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Facial nerve dysfunction can dramatically affect a patient's quality of life. The human face is a focal point for expression and interpersonal communication, whereas facial motor movement contributes to eye protection, speech articulation, chewing and swallowing, and emotional expression. Thus, the patient with a facial palsy suffers not only the functional consequences of impaired facial motion but also the psychological impact of a skewed facial appearance.

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Essentials of Diagnosis

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Bell's Palsy

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  • Acute onset, with unilateral paresis or paralysis of the face in a pattern consistent with peripheral nerve dysfunction (all branches affected).
  • Rapid onset and evolution (<48 hours).
  • Facial palsy may be associated with acute neuropathies affecting other cranial nerves (particularly, cranial nerves V–X).

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Herpes Zoster Oticus (Ramsay Hunt syndrome)

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  • Acute peripheral facial palsy associated with otalgia and varicella-like cutaneous lesions that involve the external ear, skin of the ear canal, or the soft palate.
  • Involvement often extends to cranial nerves V, IX, and X, and cervical branches that have anastomotic communications with the facial nerve.
  • Differentiated from Bell's palsy by characteristic cutaneous ulcers and a higher incidence of hearing loss or balance dysfunction.

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General Considerations

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There are a variety of disorders that may be associated with unilateral facial palsies (Table 70–1). Bilateral facial palsy is much less frequent and occurs in less than 2% of patients presenting with an acute facial palsy (Table 70–2). Bilateral involvement typically reflects a systemic disorder with multiple manifestations. Because of their overlapping clinical presentation and treatment paradigms, Bell's palsy and herpes zoster oticus (also known as Ramsay Hunt syndrome) will be considered together.

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Table Graphic Jump Location
Table 70–1. Differential Diagnoses of Facial Paralysis.

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