Acute Facial Palsy: ED Assessment & Management Guide
Clinical guide for evaluating acute facial palsy in the ER, covering UMN vs LMN signs, Bell's palsy, Ramsay Hunt syndrome, and prednisolone dosing.
Acute Facial Palsy
Emergency Department Assessment & Management
RCEM Learning Reference | Emergency Medicine
Learning Objectives
Identify upper vs lower motor neuron facial palsy
Recognise and exclude dangerous differentials
Apply the House-Brackmann grading scale
Initiate appropriate ED management
Know when to refer and how to follow up
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What is Acute Facial Palsy?
DEFINITION
Sudden onset weakness/paralysis of facial muscles due to facial nerve (CN VII) dysfunction.
<strong>Bell's Palsy</strong> = idiopathic LMN facial palsy (most common cause ~75%)
<strong>Incidence:</strong> ~20 per 100,000 per year in UK
<strong>Peaks:</strong> ages 15–45, equal sex distribution
<strong>Viral reactivation (HSV-1)</strong> most likely aetiology
20/100,000
Annual UK Incidence
75%
Spontaneous Recovery
CN VII
Facial Nerve Affected
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UMN vs LMN Facial Palsy
UMN — Central
LMN — Peripheral
CRITICAL EXAM: TEST FOREHEAD WRINKLING AND EYE CLOSURE
RCEM Learning Reference | Clinical Assessment
Differential Diagnosis
Ramsay Hunt & Stroke must not be missed
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Bell's Palsy
Most common, idiopathic LMN, viral
Ramsay Hunt Syndrome
VZV reactivation, painful vesicles in ear canal, poorer prognosis
Stroke / TIA
UMN, forehead sparing, other neuro signs — RED FLAG
Otitis Media / Mastoiditis
Ear pain, fever, discharge
Parotid Tumour
Slow onset, parotid mass on exam
Lyme Disease
Tick exposure, erythema migrans, bilateral possible
Clinical Assessment in the ED
History
Examination
Investigations
Onset and time course <span style="color: #00E5FF; font-weight: 600;">(within 72h?)</span>
Associated symptoms: <span style="opacity: 0.95;">ear pain, vesicles, hearing loss, taste change</span>
Risk factors: <span style="opacity: 0.95;">diabetes, hypertension, pregnancy, immunosuppression</span>
Recent viral illness, tick exposure, trauma
Full cranial nerve examination
Forehead wrinkling <span style="color: #00E5FF; font-weight: 600;">(UMN vs LMN)</span>
Eye closure — can patient close eye fully?
Examine ear canal for vesicles <span style="color: #00E5FF; font-weight: 600;">(Ramsay Hunt)</span>
Parotid palpation
Check for other neurological deficits
Blood glucose <span style="color: #00E5FF; font-weight: 600;">(routine)</span>
No imaging required for typical Bell's palsy
<strong style="color: white; font-weight: 600;">CT/MRI</strong> if UMN signs, trauma, or atypical features
<strong style="color: white; font-weight: 600;">Lyme serology</strong> if endemic area exposure
RCEM Learning Reference | Emergency Medicine
House-Brackmann Grading Scale
Emergency Medicine Facial Palsy
RCEM Learning Reference | Emergency Medicine
Higher grades = poorer prognosis; Grade IV-VI needs urgent eye care
Grade I
Normal
Normal symmetric function
Grade II
Mild
Slight weakness; complete eye closure with minimal effort
Grade III
Moderate
Obvious asymmetry; eye closure with effort; HB movement visible
Grade IV
Moderately Severe
Disfiguring asymmetry; incomplete eye closure
Grade V
Severe
Barely perceptible movement; incomplete eye closure
Grade VI
Total Paralysis
No movement whatsoever
ED Management
— Bell's Palsy
STEROIDS
Primary Treatment
Prednisolone 50mg OD for 10 days
OR 60mg OD x5 days then taper by 10mg/day
Start within 72 hours of onset
NNT = 6 for full recovery at 3 months
Do NOT delay — even mild cases benefit
EYE CARE
Essential
Lubricating eye drops hourly during day
Viscotears or hypromellose drops
Eye ointment at night
Tape eye closed at night if incomplete closure
Refer ophthalmology if corneal concerns
Prevents exposure keratitis
ANTIVIRALS
Not Routinely Recommended
No proven benefit in Bell's palsy alone
NOT recommended routinely (RCEM/NICE)
Consider only in severe cases or Ramsay Hunt
Ramsay Hunt: Aciclovir 800mg 5x/day x7 days + high-dose steroids
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Ramsay Hunt Syndrome
(CN VII + VIII)
VZV reactivation in geniculate ganglion
More severe than Bell's palsy — poorer prognosis
Facial palsy + ear pain + vesicles in ear canal
Painful vesicular rash in external auditory meatus
Facial palsy (more complete)
Sensorineural hearing loss
Vertigo/tinnitus possible
Rash may be absent in 15% ("zoster sine herpete")
Aciclovir 800mg 5 times/day for 7 days
High-dose prednisolone (same as Bell's)
Eye care as for Bell's palsy
ENT referral
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Prognosis & Follow-Up
Prognosis & Outcomes
85%
near-complete recovery with treatment
75%
full recovery without treatment
9 Months
typical timeline for full recovery
30%
may experience sequelae (synkinesis, contracture, taste changes)
Poor Prognostic Factors
Complete palsy (Grade V-VI)
Older age
Hypertension / Diabetes
Ear pain and taste disturbance
Ramsay Hunt (worse than Bell's)
Follow-up Pathways
In 1 week
If no improvement at 4 weeks, recurrent palsy, bilateral palsy, or atypical features
If eye complications
If vesicular rash appears (Ramsay Hunt?)
Has no proven benefit
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Safety Netting & Red Flags
Emergency Medicine • Acute Facial Palsy
Red Flags (Requires Urgent Action)
Signs of Stroke (UMN, forehead sparing)
CT HEAD + Stroke pathway
Bilateral Facial Palsy
Consider GBS, Lyme, sarcoid, lymphoma
Progressive Palsy > 72h
Neoplastic cause until proven otherwise
Recurrent Ipsilateral Palsy
Exclude parotid tumour
Associated Parotid Mass
Malignancy — urgent ENT
Systemic Features (Fever, neck stiffness)
Meningitis / encephalitis
Safety Net Advice (For Discharged Patients)
Eye protection instructions given (verbal + written)
Return if eye becomes red, painful, or vision changes
Return if new neurological symptoms develop
Return if vesicular rash appears in ear
Follow-up confirmed with GP within 1 week
Steroid prescription given with instructions
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Key Takeaways
ALWAYS exclude UMN (stroke)
Test forehead wrinkling
Bell's Palsy = idiopathic LMN palsy
Diagnosis of exclusion
Steroids within 72h (NNT=6)
Prednisolone 50mg OD x10 days
Eye care is ESSENTIAL
Prevent exposure keratitis
Check for Ramsay Hunt
Vesicles in ear + treat with aciclovir + steroids
Safety net and GP follow-up
ENT if no improvement at 4 weeks
RCEM Learning — Acute Facial Palsy module | NICE CKS Bell's Palsy | Sullivan FM et al. NEJM 2007 | Gagyor I et al. BMJ 2015
- bell's-palsy
- emergency-medicine
- neurology
- ramsay-hunt-syndrome
- clinical-guidelines
- facial-nerve
- medical-education