Bell’s Palsy / Ramsay Hunt Syndrome

7th (facial) nerve palsy. Bell’s palsy is usually idiopathic, from swelling of the facial nerve within its bony canal. Ramsay Hunt syndrome is the same presentation caused by herpes zoster reactivation — vesicles may be seen in the ear on the affected side.

Demographics: age 15–45; a GP typically sees one case every 2–3 years.

Presentation

Abrupt onset over 2–5 days: facial weakness, pain in/behind the ear (particularly in Ramsay Hunt), impaired blinking; sometimes loss of taste (anterior 2/3 of tongue), difficulty eating, hyperacusis.

Examination

Look for frontalis/eye sparing — sparing indicates a central cause (stroke, MS), since the forehead receives bilateral cortical innervation. Patients with a central facial weakness from stroke usually also have peripheral limb weakness. Bell’s palsy/Ramsay Hunt cause full unilateral facial weakness including the forehead, with impaired eye closure on the affected side.

Management

• Symptoms <72 hours: prednisolone 1mg/kg (max 75mg) daily for 5 days.
• Ramsay Hunt features (pain, vesicles): add an antiviral to the prednisolone — valaciclovir 1g TDS for 7 days, or aciclovir 800mg 5×/day for 7 days.
• Non-pharmacological: cover the affected eye if closure is impaired, tape closed for sleeping, liberal artificial tears for eye irritation.
• Ophthalmology review if the facial palsy is severe.
• Usually resolves over 3–4 weeks; if no recovery by then, full recovery may take months as the nerve regrows. Severe initial symptoms carry a higher risk of residual deficit. If an ongoing deficit doesn’t improve, arrange an MRI brain.