Acute Facial Palsy Management

Facial Palsy is a debilitating condition that affects over 20,000 people annually in the UK, with an incidence of 70 cases per 100,000 population (Norris, 2019). It is unknown how many people are affected by Facial Palsy in Ireland, but if we apply the UK incidence rate here, it would equate to almost 3,500 people annually.

Facial Palsy is a general medical term that refers to weakness of facial expression, usually on one side of the face, as a result of damage to the facial nerve, caused by either swelling or pressure on the nerve.

There are many causes of Facial Palsy. This includes:

Viral sources:

– Bell’s Palsy is the most common cause of facial palsy, leading to almost 80% of all cases. Bell’s Palsy is due to the herpes simplex (cold sore) virus. Roughly 70% of people with Bell’s Palsy will make a full recovery. Bell’s Palsy has the best prognosis out of all the causes of facial palsy.

– Ramsay Hunt Syndrome is another type of viral infection. This is due to the herpes zoster (shingles) virus. The prognosis for a full recovery from Ramsay Hunt Syndrome is much lower at 20%.

Bacterial sources:

– Ear infection
– Lyme’s Disease
– Tumour:
– A type of benign tumour called a vestibular schwannoma is a common example or the nerve may be injured following surgery to remove a tumour in the head or neck area


– Although this type of Facial Palsy is slightly different as the issue is within the brain, not an injury to the facial nerve. It also presents slightly differently as the facial weakness usually does not affect the eye or forehead.


– Guillian Barre Syndrome

Autoimmune conditions:

– Sarcoidosis


Following a cut to the soft tissues of the face or a break to a bone in that area of the skull the facial nerve may be injured.

Congenital causes:

– Some children are born with an absent or altered facial nerve

** There are many other sources of facial nerve palsy and these are just some of the more common causes.

“Treat Me Right”

The theme of this year’s Facial Palsy Awareness Week March 1st – 7th is “Treat Me Right”. I feel the cornerstone of this campaign is the “right” to access accurate and timely medical treatment and information.

If you or someone you know has Facial Palsy, is it likely that you simply didn’t know what to do or what medical profession you should seek help from? In Ireland there is a no national guideline regarding the management of Facial Palsy. As a result, treatment and information given is variable.

A google search will do nothing to further your knowledge on this condition either as the information is often wildly misleading and has no scientific basis for many treatments suggested. I will direct you at this point to a fantastic site that has up-to-date scientifically supported advice.

The information below is gathered from international guidelines, research papers and best practice from Facial Palsy Specialist Centres.

What should you do if you suspect you have Facial Palsy?

If you or someone you know develops a sudden onset of facial paralysis/weakness then you should visit your GP or attend A & E as soon as possible. Firstly, it is important to establish the cause of Facial Palsy. Although Bell’s Palsy is the most common cause, it is important that the medical team do a thorough examination and remain suspicious of all causes of Facial Palsy, as Bell’s palsy is a diagnosis of exclusion.

For example, sometimes the rash that helps diagnose Ramsay Hunt Syndrome (RHS) might not be present or obvious immediately, and a thorough ear nose and throat exam should be performed. It is important to establish the exact cause, as the prognosis for RHS is much poorer than Bell’s Palsy and closer follow-up and monitoring should occur. The diagnosis for the cause of Facial Palsy can be given following a complete medical exam and sometimes, if indicated, following blood tests or imaging.

What is the recommended treatment for Facial Palsy?

If it is determined that the cause of Facial Palsy is indeed Bell’s Palsy it is important to receive medical treatment within 72 hours of onset, as research indicates that this is the optimum period of time in which Bell’s palsy will successfully respond. This is also true for someone with RHS.

Treatment consists (in both Bell’s Palsy and RHS) of high dose steroids and anti-viral treatment for 10 days.


Oral Prednisolone at 1mg/kg (to a max of 80mg) * 5 days tapering 10mg/d from day 5


Famciclovir 500mg/8h * 7 days (updated from acyclovir at the 6th International Course: An update on Facial Paralysis, Madrid 2023)

Although the evidence for the use of antivirals in Bell’s Palsy is weak, RHS can often mimic Bell’s in the absence of the rash, so it is best to treat with both in case it is RHS.

There is an exception to this. In pregnancy it is safe to treat with steroids but the use of antivirals is unknown and not recommended.

This medical treatment is widely known as it is recommended in the international medical guidelines known as NICE guidelines. (May 2019, An update on Bell’s Palsy Management).

Other than the initial medical management, what other treatment is recommended for Facial Palsy in those initial few weeks following onset?

Unfortunately, as there are no standardised guidelines in Ireland, the information or advice given regarding further management of Facial Palsy is inconsistent and often of poor quality.

It is not uncommon to hear that a person with Facial Palsy has been advised to “chew gum” or “follow this sheet of exercises” or use an “electrical muscle stimulator”. In all instances, this advice is outdated and research shows these can actually be detrimental to the nerve healing and recovery. (Farragher et al, 2017)

Facial therapy

Facial therapy delivered by trained Facial Therapy Specialists (a Physiotherapist or Speech and Language Therapist with specialist post graduate training in Facial Palsy) is the cornerstone of rehabilitation following facial palsy. A recent study from Queen Victoria Hospital in the UK demonstrated that early Specialist Facial Therapy results in better outcomes and a shorter treatment course. (Neville et al, 2022).

It is important to note that a general Chartered Physiotherapist may not have the specialist skills required to treat Facial Palsy. It is important to seek a trained Facial Therapy Specialist. Here in PMC Physiotherapy Caitriona is a Facial Therapy Specialist and following a thorough assessment will guide a person with Facial Palsy through the most appropriate bespoke treatment for the particular phase of healing they are at.

    In the early stages, when there is no power going to the facial muscles, due to injury to the facial nerve, no amount of facial “exercises” will make them move. Instead, you are teaching the brain to use abnormal patterns of movement which negatively impacts facial expressions when the nerve does recover.

    Functional challenges

    A Facial Therapy Specialist understands the many functional challenges a person with Facial Palsy faces, including eating/drinking/speech etc and will guide you to practical solutions to help.


    Eyecare is a crucial component of early Facial Palsy management. Many people are unable to close their eye fully and this can in turn lead to an extremely dry eye that could become prone to ulceration if left untreated. A Facial Therapy Specialist can teach you how to tape your eye, what type of drops to use, how to use glasses or goggles etc.

    Does everyone need this care or what is the prognosis?

    Unfortunately, it seems that most people with Facial Palsy are told that they will make a full recovery in 6 weeks to 3 months, and whilst it is true that 70% of patients with Bell’s Palsy make a full recovery with no treatment other than that initial medical intervention, the remaining 30% of people do not and the other causes of Facial Palsy do not have as favourable a prognosis.

    A person who has not made a full recovery within this time frame is often left in limbo and endures an exhausting medical journey through many individual specialist areas such as Neurology; ENT; Opthamology; Plastic Surgery; Physiotherapy; Speech and Language Therapy and multiple return visits to GP/A+E, before arriving at an appropriate treatment regime.

    The following table should help understand at what time and to whom a person with Facial Palsy should be referred to following their initial management in A+E or at the GP.

    Facial Palsy Referral Table

    It is never too late to seek treatment

    What do you do if you are well over 3 months (now it could be years) since your onset of Facial Palsy and want to seek treatment? Is it too late?

    The answer is it is never too late to seek treatment. The type of treatment will probably be slightly different compared to that you would have received in the early weeks or months when there was no power going to the muscles via the facial nerve.

    Usually in the months to years following Facial Palsy, for people who don’t make that full recovery, the nerve recovers to some extent. The nerve and muscles can now work a little abnormally together (synkinesis) and treatment is aimed at controlling this unwanted movement.

    The treatment at this point from a Facial Therapy Specialist is a concept called facial Neuromuscular Retraining (fNMR). This bespoke programme of facial expressions must be supervised by a skilled Facial Therapy Specialist to ensure success (Diels J, 2022).

    In addition, a combination of Botox treatment may be used also and it is essential to combine it with fNMR to ensure best long-term outcomes.

    For those that have not recovered any movement there are some surgical procedures which can improve function.

    PMC Physio Dunboyne recommendation

    If you have been affected by Facial Palsy or wish to gain more information regarding this condition book your appointment or call us on 018253997. Caitriona is our Facial Therapy Specialist and is a member of Facial Therapy Specialists International.


    • Butler DP, Morales DR, Johnson K, Nduka C. Facial palsy: when and why to refer for specialist care. Br J Gen Pract. 2019 Oct 31;69(688):579-580. doi: 10.3399/bjgp19X706541. PMID: 31672833; PMCID: PMC6808583.
    • Katie A Fargher & Susan E Coulson (2017) Effectiveness of electrical stimulation for rehabilitation of facial nerve paralysis, Physical Therapy Reviews, 22:3-4, 169-176, DOI: 10.1080/10833196.2017.1368967
    • Neville, Catriona & Gwynn, Tamsin & Young, Karen & Jordan, Elizabeth & Malhotra, Raman & Nduka, Charles & Kannan, Ruben. (2022). Comparative Study of Multimodal Therapy in Facial Palsy Patients. Archives of Plastic Surgery. 49. 633-641. 10.1055/s-0042-1756352.
    • NICE guidelines Bell’s Palsy Management. An update May 2019.


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