Facial palsy

Background: Facial palsy can be classifies as being upper motor neurone or lower motor neurone.

• Upper motor neurone facial palsy spares the forehead i.e. forehead movement remains intact
• Lower motor neurone facial palsy involves the forehead i.e. the patient cannot raise their eyebrow on the affected side

Lower motor neurone facial palsy normally presents as a sudden weakness of all divisions of the face.

Often, facial palsy is incorrectly labelled as “Bells palsy”. Bells palsy is considered a diagnosis of exclusion. It is therefore required to exclude lesions of the facial nerve throughout its course in the head.

Causes include:

• Central: CVA, tumours, Multiple sclerosis, Vestibular schwannoma
• Otological: Acute otitis media with dehiscent facial nerve, cholesteatoma, malignant otitis externa, ramsay hunt syndrome, temporal bone fracture, iatrogenic
• Parotid: Tumour

How to assess:

Check for forehead sparing - If upper motor neurone, need to exclude stroke

Check for incomplete eye closure – will require regular dry eye drops, eye ointment at night and taping eye closed at night to prevent exposure keratitis and blindness. Please provide patient information leaflet on eye care in facial palsy.  

Cranial nerve examination – to exclude other ipsilateral cranial deficits

Ear examination – to exclude acute otitis media or ramsay hunt syndrome

Neck examination with palpation of the parotid – to exclude malignancy

Referral guidance:

If upper motor neurone (forehead sparing), manage as per possible stroke

Multiple cranial nerve abnormalities – referral to Neurology / Neurosurgery / ENT as appropriate

Acute otitis media – discuss with ENT as an emergency

Ramsay Hunt – Oral anti-viral and short course oral steroid

Parotid tumour – referral to ENT Head & Neck as USOC

Bell’s Palsy (Idiopathic LMN facial palsy) – Short course oral steroid