Synopsis
Localise facial weakness using the complete neurological and ear examination, protect the cornea immediately, and recognise when an apparent Bell palsy needs another diagnostic pathway.
- Compare forehead movement, gentle and forceful eye closure, smile and lip seal.
- Relative forehead sparing suggests a supranuclear lesion but is not an absolute rule.
- Whole-face weakness can arise in the facial nucleus, fascicle or peripheral nerve.
Key red flags
Facial weakness with diplopia, gaze disturbance, dysarthria, limb findings or severe ataxia needs urgent assessment for a central lesion.
Investigation priorities
Determine whether facial weakness is isolated and identify an urgent central pattern.
Management branches
New facial weakness has associated neurological findings or threatened corneal protection.
- Activate the stroke pathway when sudden neurological features suggest a cerebral or brainstem event, documenting onset and associated deficits.
- Begin ocular lubrication and safe closure support when needed while obtaining urgent ophthalmic advice for an unprotected or symptomatic cornea.
Key medicines
Prednisolone for an appropriately diagnosed Bell palsyThe NHS Highland adult regimen is 60 mg orally once daily for five days, then 50 mg on day six, 40 mg on day seven, 30 mg on day eight, 20 mg on day nine and 10 mg on day ten, then stop. Start within seventy-two hours when indicated.
Simple Eye Ointment BP, product 3538Place a thin line inside the lower eyelid as required; night-time application can supplement daytime lubrication in an agreed eye-protection plan. Continue protection until blink and closure are adequate, with earlier reassessment for ocular symptoms. Discard the opened tube after one month.