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.
Essentials of Diagnosis
- 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 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.
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.
Table Graphic Jump Location Table 70–1. Differential Diagnoses of Facial Paralysis. ||Download (.pdf)
Table 70–1. Differential Diagnoses of Facial Paralysis.
- Forceps delivery
- Myotonic dystrophy
- MÃ¶ebius syndrome (facial diplegia associated with other cranial nerve deficits)
- Cortical injuries
- Basilar skull fractures
- Brainstem injuries
- Penetrating injury to middle ear
- Facial injuries
- 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
- Coxsackie virus
- Lyme disease
- Genetic and Metabolic
- Diabetes mellitus
- Alcoholic neuropathy
- Bulbopontine paralysis
- Oculopharyngeal muscular dystrophy
- Anomalous sigmoid sinus
- Benign intracranial hypertension
- Intratemporal aneurysm of internal carotid artery
- Embolization for epistaxis (external carotid artery branches)
- Acoustic neuroma
- Glomus jugulare tumor
- Pontine glioma
- Hydradenoma (external canal)
- Facial nerve neuroma
- Fibrous dysplasia
- von Recklinghausen disease
- Carcinomatous encephalitis (Bannworth syndrome)
- Cholesterol granuloma
- Carcinoma (invasive or metastatic, from breast, kidney, ...