Facial nerve dysfunction can dramatically affect a patient’s quality of life. The human face is a focal point for expression and interpersonal communication, as 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.
ESSENTIALS OF DIAGNOSIS Bell Palsy
Herpes Zoster Oticus (Ramsay Hunt syndrome)
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).
Acute peripheral facial palsy associated with otalgia and varicellalike 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 palsy by characteristic cutaneous ulcers and a higher incidence of hearing loss or balance dysfunction.
A variety of disorders may be associated with unilateral facial palsies (Table 73–1). Bilateral facial palsy is much less frequent and occurs in less than 2% of patients presenting with an acute facial palsy (Table 73–2). Bilateral involvement typically reflects a systemic disorder with multiple manifestations. Because of their overlapping clinical presentation and treatment paradigms, Bell palsy and herpes zoster oticus (also known as Ramsay Hunt syndrome) will be considered together.
Table 73–1Differential diagnoses of facial paralysis. |Favorite Table|Download (.pdf) Table 73–1 Differential diagnoses of facial paralysis.
Möebius syndrome (facial diplegia associated with other cranial nerve deficits)
Basilar skull fractures
Penetrating injury to middle ear
Altitude paralysis (barotrauma)
Scuba diving (barotrauma)
Opercular syndrome (cortical lesion in facial motor area)
Millard-Gubler syndrome (abducens palsy with contralateral hemiplegia due to lesion in base of pons involving corticospinal tract)
Malignant otitis externa
Acute or chronic otitis media
Cholesteatoma (acquired and congenital)
Herpes zoster oticus (Ramsay Hunt syndrome)
Poliomyelitis (type I)
HIV and AIDS
Genetic and metabolic
Oculopharyngeal muscular dystrophy
Anomalous sigmoid sinus
Benign intracranial hypertension
Intratemporal aneurysm of internal carotid artery
Embolization for epistaxis (external carotid artery branches)
Glomus jugulare tumor
Hydradenoma (external canal)
Facial nerve neuroma
von Recklinghausen disease
Carcinomatous encephalitis (Bannworth syndrome)
Carcinoma (invasive or metastatic, from breast, kidney, lung, stomach, larynx, prostate, thyroid)