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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, 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.



  • 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).

Herpes Zoster Oticus (Ramsay Hunt syndrome)
  • 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.

General Considerations

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.

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