Facial paralysis - Revision history

Danbot: Add verified PubMed references (PMIDs 37918298, 31097197)

2026-03-22T10:43:49Z

Add verified PubMed references (PMIDs 37918298, 31097197)

← Older revision		Revision as of 10:43, 22 March 2026
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	==Background==		==Background==
	[[File:Cranial nerve VII.png\|thumb\|Bilateral course of facial nerve. Note that the forehead muscles receive innervation from both hemispheres of the brain, which is why there is forehead sparing for [[stroke]] but not [[Bell's palsy]] (or other peripheral facial nerve injury).]]		[[File:Cranial nerve VII.png\|thumb\|Bilateral course of facial nerve. Note that the forehead muscles receive innervation from both hemispheres of the brain, which is why there is forehead sparing for [[stroke]] but not [[Bell's palsy]] (or other peripheral facial nerve injury).]]
	*Facial paralysis (CN VII palsy) is a common ED presentation requiring distinction between central and peripheral causes		*Facial paralysis (CN VII palsy) is a common ED presentation requiring distinction between central and peripheral causes<ref>DeBord K, et al. Clinical application of physical therapy in facial paralysis treatment: A review. J Plast Reconstr Aesthet Surg. 2023 Dec;87:217-223. PMID 37918298</ref>
	*Key distinction: central (upper motor neuron) vs. peripheral (lower motor neuron) — determines urgency of workup		*Key distinction: central (upper motor neuron) vs. peripheral (lower motor neuron) — determines urgency of workup
	*Central cause = forehead sparing (bilateral cortical input to forehead muscles) → evaluate for [[stroke]]		*Central cause = forehead sparing (bilateral cortical input to forehead muscles) → evaluate for [[stroke]]
	*Peripheral cause = forehead involvement (entire ipsilateral face) → [[Bell's palsy]] most common		*Peripheral cause = forehead involvement (entire ipsilateral face) → [[Bell's palsy]] most common<ref>Lassaletta L, et al. Facial paralysis: Clinical practice guideline of the Spanish Society of Otolaryngology. Acta Otorrinolaringol Esp (Engl Ed). 2020 Mar-Apr;71(2):99-118. PMID 31097197</ref>
	*[[Bell's palsy]] is a diagnosis of exclusion — consider other peripheral causes before labeling as idiopathic		*[[Bell's palsy]] is a diagnosis of exclusion — consider other peripheral causes before labeling as idiopathic

Danbot: Strip excess bold

2026-03-22T09:26:17Z

Strip excess bold

Danbot: Expanded with EM-focused content: central vs peripheral distinction, red flags, Lyme/Ramsay Hunt, eye protection, disposition

2026-03-20T23:29:04Z

Expanded with EM-focused content: central vs peripheral distinction, red flags, Lyme/Ramsay Hunt, eye protection, disposition

← Older revision		Revision as of 23:29, 20 March 2026
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	==Background==		==Background==
	[[File:Cranial nerve VII.png\|thumb\|Bilateral course of facial nerve. Note that the forehead muscles receive innervation from both hemispheres of the brain, which is why there is forehead sparing for [[stroke]] but not [[Bell's palsy]] (or other peripheral facial nerve injury).]]		[[File:Cranial nerve VII.png\|thumb\|Bilateral course of facial nerve. Note that the forehead muscles receive innervation from both hemispheres of the brain, which is why there is forehead sparing for [[stroke]] but not [[Bell's palsy]] (or other peripheral facial nerve injury).]]
	*~~Key to distinguish~~ between central and peripheral ~~facial nerve~~ palsy		*Facial paralysis (CN VII palsy) is a common ED presentation requiring distinction between central and peripheral causes
			*Key distinction: '''central (upper motor neuron) vs. peripheral (lower motor neuron)''' — determines urgency of workup
			*Central cause = '''forehead sparing''' (bilateral cortical input to forehead muscles) → evaluate for [[stroke]]
			*Peripheral cause = '''forehead involvement''' (entire ipsilateral face) → [[Bell's palsy]] most common
			*[[Bell's palsy]] is a diagnosis of exclusion — consider other peripheral causes before labeling as idiopathic

	===Causes===		===Causes===
	*Central		*'''Central (upper motor neuron)'''
	**[[~~CVA~~]]		**[[Stroke]]/[[TIA]] — most critical to identify
	*Peripheral		**Intracranial mass/tumor
	**Idiopathic ([[Bell's palsy]])		*'''Peripheral (lower motor neuron)'''
	**[[Lyme disease]]		**Idiopathic ([[Bell's palsy]]) — accounts for ~60-75% of acute unilateral facial paralysis
	**[[Varicella-zoster]]		**[[Lyme disease]] — most common identifiable infectious cause in endemic areas; can be bilateral
	**[[HSV]]		**[[Varicella-zoster]] (Ramsay Hunt syndrome) — vesicles in ear canal, severe pain
	**[[Facial trauma]]		**[[HSV]] reactivation
			**[[Otitis media]] (with or without cholesteatoma)
			**[[Facial trauma]] / temporal bone fracture
			**Parotid gland tumor
			**Guillain-Barré syndrome (can be bilateral)
			**[[Sarcoidosis]] (Heerfordt syndrome)

	==Clinical Features==		==Clinical Features==
	[[File:Bellspalsy.jpg\|thumb\|A person attempting to show his teeth and raise his eyebrows with [[Bell's palsy]] on his right side; notice how the forehead is NOT spared).]]		[[File:Bellspalsy.jpg\|thumb\|A person attempting to show his teeth and raise his eyebrows with [[Bell's palsy]] on his right side; notice how the forehead is NOT spared.]]
	[[File:DOAeXAmWsAAAp5g.jpg\|thumb\|Patient with [[stroke]] (forehead sparing).]]		[[File:DOAeXAmWsAAAp5g.jpg\|thumb\|Patient with [[stroke]] (forehead sparing).]]

	===Central Process===		===Central Process (Forehead Sparing)===
	* ~~Forehead "sparing" or normal~~ muscle tone of ~~the forehead~~		*Normal forehead muscle tone — patient can raise eyebrow and wrinkle forehead on affected side
			*Weakness of lower face (nasolabial fold flattening, asymmetric smile)
			*Often accompanied by other neurologic deficits (hemiparesis, speech changes, sensory loss)

	===Peripheral Process===		===Peripheral Process (Forehead Involved)===
	* Weakness of forehead ~~muscles~~		*Weakness of entire ipsilateral face including forehead
			*Unable to close eye (risk of corneal exposure and injury)
			*Loss of nasolabial fold
			*Asymmetric smile
			*May have associated symptoms depending on etiology:
			**Ear pain/vesicles ([[Ramsay Hunt syndrome]])
			**Hyperacusis (stapedius muscle involvement)
			**Decreased taste (chorda tympani involvement)
			**Dry eye (greater petrosal nerve involvement)

	===~~Central and Peripheral~~===		===Red Flags===
	* ~~Unable to close eye~~		*Forehead sparing → consider [[stroke]] (activate stroke protocol)
	* ~~Loss of nasolabial fold~~		*Bilateral facial weakness → consider Lyme disease, [[Guillain-Barré syndrome]], sarcoidosis
	* ~~Asymmetric smile~~		*Slowly progressive (>3 weeks) → consider tumor
			*Vesicles in ear canal → Ramsay Hunt syndrome (requires antivirals)
			*Recent tick exposure or erythema migrans → [[Lyme disease]]
			*Recurrent episodes → consider tumor, sarcoidosis, or Melkersson-Rosenthal syndrome

	==Differential Diagnosis==		==Differential Diagnosis==
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	==Evaluation==		==Evaluation==
	===Central Process===		===Central Process===
	*[[~~head~~ CT\|CT]]		*Activate [[stroke]] protocol if acute onset with forehead sparing
			*[[Head CT\|CT head]] emergently; CT angiography
			*Consider [[MRI]] brain
			*Standard stroke workup

	===Peripheral Process===		===Peripheral Process===
	*No labs or imaging routinely necessary		*No labs or imaging routinely necessary for classic Bell's palsy presentation
	*Consider ~~lyme~~ serologies if endemic area		*Examine ear canal for vesicles (Ramsay Hunt syndrome)
			*Consider Lyme serologies if endemic area, bilateral involvement, recent tick exposure, or erythema migrans
			*Consider [[CBC]], [[ESR]], [[CRP]], [[BMP]] if atypical features
			*Consider MRI with gadolinium if: atypical course, slowly progressive, no improvement at 3 weeks, recurrent episodes
			*[[CT temporal bone]] if history of trauma

			===Eye Examination===
			*Assess corneal closure — inability to fully close eye requires eye protection measures
			*Fluorescein stain to evaluate for corneal abrasion/exposure keratopathy

	==Management==		==Management==
	===Central Process===		===Central Process===
	*Treat underlying pathology		*Treat underlying pathology ([[stroke]] protocol, neurosurgical consultation for mass)

			===Peripheral Process (Bell's Palsy)===
			*'''[[Prednisone]]''' 60-80mg daily x 7 days (started within 72 hours of onset) — strongest evidence for improved recovery
			*'''Eye care''': artificial tears during day, lubricating ointment at night, tape or patch eyelid closed during sleep
			*'''Consider [[valacyclovir]]''' 1g TID x 7 days for severe facial paralysis (House-Brackmann grade IV-VI) — evidence is mixed but may provide modest benefit when combined with steroids
			*Empiric '''[[doxycycline]]''' if high suspicion for [[Lyme disease]] (do NOT give steroids alone if Lyme suspected)

	===~~Peripheral Process~~===		===Ramsay Hunt Syndrome===
	* [[~~Prednisone~~]] ~~(unless diagnosed Lyme disease)~~		*'''[[Valacyclovir]]''' or [[acyclovir]] + [[prednisone]]
	* Empiric [[~~doxycycline~~]] ~~if high suspicion for Lyme disease~~		*Has worse prognosis than Bell's palsy — ENT/neurology follow-up
	* Consider [[~~valacyclovir~~]] ~~for severe presentation if Lyme is negative~~
	* Artificial tears
	* ~~Consider~~ neurology follow-up

	==Disposition==		==Disposition==
			===Discharge (Most Patients)===
			*Most patients with peripheral facial paralysis can be discharged
			*Ensure adequate eye protection education (corneal desiccation is the main complication)
			*Follow-up with primary care in 1-2 weeks; neurology or ENT if no improvement in 3-4 weeks
			*Return precautions: worsening symptoms, new neurologic deficits, vision changes

			===Admit===
			*Central process (stroke protocol)
			*Bilateral facial paralysis (evaluate for Guillain-Barré, Lyme, sarcoidosis)
			*Ramsay Hunt syndrome with severe involvement (consider IV antivirals)

	==See Also==		==See Also==
			*[[Bell's palsy]]
			*[[Stroke]]
			*[[Ramsay Hunt syndrome]]
			*[[Lyme disease]]
	*[[Facial swelling]]		*[[Facial swelling]]

Rossdonaldson1: /* Clinical Features */

2020-02-03T17:40:45Z

Clinical Features

← Older revision		Revision as of 17:40, 3 February 2020
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	==Clinical Features==		==Clinical Features==
	[[File:Bell's palsy.png\|thumb\|[[Bell's palsy]] with right-sided peripheral facial nerve palsy with inability to wrinkle the forehead and nose, unequal lid fissures, and inability to lift the corner of the mouth.]]
	[[File:Bellspalsy.jpg\|thumb\|A person attempting to show his teeth and raise his eyebrows with [[Bell's palsy]] on his right side; notice how the forehead is NOT spared).]]		[[File:Bellspalsy.jpg\|thumb\|A person attempting to show his teeth and raise his eyebrows with [[Bell's palsy]] on his right side; notice how the forehead is NOT spared).]]
	[[File:DOAeXAmWsAAAp5g.jpg\|thumb\|Patient with [[stroke]] (forehead sparing).]]		[[File:DOAeXAmWsAAAp5g.jpg\|thumb\|Patient with [[stroke]] (forehead sparing).]]

Rossdonaldson1 at 16:49, 3 February 2020

2020-02-03T16:49:30Z

← Older revision		Revision as of 16:49, 3 February 2020
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	==Clinical Features==		==Clinical Features==
	[[File:Bell's palsy.png\|thumb\|~~Right~~-sided peripheral facial nerve palsy with inability to wrinkle the forehead and nose, unequal lid fissures, and inability to lift the corner of the mouth.]]		[[File:Bell's palsy.png\|thumb\|[[Bell's palsy]] with right-sided peripheral facial nerve palsy with inability to wrinkle the forehead and nose, unequal lid fissures, and inability to lift the corner of the mouth.]]
	[[File:Bellspalsy.jpg\|thumb\|A person attempting to show his teeth and raise his eyebrows with Bell's palsy on his right side; notice how the forehead is NOT spared).]]		[[File:Bellspalsy.jpg\|thumb\|A person attempting to show his teeth and raise his eyebrows with [[Bell's palsy]] on his right side; notice how the forehead is NOT spared).]]
			[[File:DOAeXAmWsAAAp5g.jpg\|thumb\|Patient with [[stroke]] (forehead sparing).]]

	===Central Process===		===Central Process===

Rossdonaldson1: /* Clinical Features */

2020-02-03T16:24:49Z

Clinical Features

← Older revision		Revision as of 16:24, 3 February 2020
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	==Clinical Features==		==Clinical Features==
	[[File:Bell's palsy.png\|thumb\|Right-sided peripheral facial nerve palsy with inability to wrinkle the forehead and nose, unequal lid fissures, and inability to lift the corner of the mouth.]]		[[File:Bell's palsy.png\|thumb\|Right-sided peripheral facial nerve palsy with inability to wrinkle the forehead and nose, unequal lid fissures, and inability to lift the corner of the mouth.]]
			[[File:Bellspalsy.jpg\|thumb\|A person attempting to show his teeth and raise his eyebrows with Bell's palsy on his right side; notice how the forehead is NOT spared).]]

	===Central Process===		===Central Process===
	* Forehead "sparing" or normal muscle tone of the forehead		* Forehead "sparing" or normal muscle tone of the forehead

Rossdonaldson1: /* Background */

2020-02-03T16:24:22Z

Background

← Older revision		Revision as of 16:24, 3 February 2020
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	==Background==		==Background==
			[[File:Cranial nerve VII.png\|thumb\|Bilateral course of facial nerve. Note that the forehead muscles receive innervation from both hemispheres of the brain, which is why there is forehead sparing for [[stroke]] but not [[Bell's palsy]] (or other peripheral facial nerve injury).]]
	*Key to distinguish between central and peripheral facial nerve palsy		*Key to distinguish between central and peripheral facial nerve palsy

ClaireLewis at 23:36, 1 October 2019

2019-10-01T23:36:22Z

← Older revision		Revision as of 23:36, 1 October 2019
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	**Idiopathic ([[Bell's palsy]])		**Idiopathic ([[Bell's palsy]])
	**[[Lyme disease]]		**[[Lyme disease]]
	**[[Varicella zoster]]		**[[Varicella-zoster]]
	**[[HSV]]		**[[HSV]]
	**[[Facial trauma]]		**[[Facial trauma]]
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	==Evaluation==		==Evaluation==
	===Central Process===		===Central Process===
	*CT		*[[head CT\|CT]]

	===Peripheral Process===		===Peripheral Process===
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	==Management==		==Management==
	===Central Process===		===Central Process===
			*Treat underlying pathology

	===Peripheral Process===		===Peripheral Process===
	* Prednisone (unless diagnosed Lyme disease)		* [[Prednisone]] (unless diagnosed Lyme disease)
	* Empiric doxycycline if high suspicion for Lyme disease		* Empiric [[doxycycline]] if high suspicion for Lyme disease
	* Consider valacyclovir for severe presentation if Lyme is negative		* Consider [[valacyclovir]] for severe presentation if Lyme is negative
	* Artificial tears		* Artificial tears
	* Consider neurology follow-up		* Consider neurology follow-up
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	[[Category:Symptoms]]		[[Category:Symptoms]]
			[[Category:Neurology]]

Rossdonaldson1: /* Management */

2018-09-22T04:00:12Z

Management

← Older revision		Revision as of 04:00, 22 September 2018
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	==Management==		==Management==
	Central Process		===Central Process===


	Peripheral Process		===Peripheral Process===
	* Prednisone (unless diagnosed Lyme disease)		* Prednisone (unless diagnosed Lyme disease)
	* Empiric doxycycline if high suspicion for Lyme disease		* Empiric doxycycline if high suspicion for Lyme disease

Rossdonaldson1: /* Evaluation */

2018-09-22T03:59:58Z

Evaluation

← Older revision		Revision as of 03:59, 22 September 2018
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	==Evaluation==		==Evaluation==
	Central Process		===Central Process===
	*CT		*CT

	Peripheral Process		===Peripheral Process===
	*No labs or imaging routinely necessary		*No labs or imaging routinely necessary
	*Consider lyme serologies if endemic area		*Consider lyme serologies if endemic area

← Older revision		Revision as of 09:26, 22 March 2026
Line 2:		Line 2:
	[[File:Cranial nerve VII.png\|thumb\|Bilateral course of facial nerve. Note that the forehead muscles receive innervation from both hemispheres of the brain, which is why there is forehead sparing for [[stroke]] but not [[Bell's palsy]] (or other peripheral facial nerve injury).]]		[[File:Cranial nerve VII.png\|thumb\|Bilateral course of facial nerve. Note that the forehead muscles receive innervation from both hemispheres of the brain, which is why there is forehead sparing for [[stroke]] but not [[Bell's palsy]] (or other peripheral facial nerve injury).]]
	*Facial paralysis (CN VII palsy) is a common ED presentation requiring distinction between central and peripheral causes		*Facial paralysis (CN VII palsy) is a common ED presentation requiring distinction between central and peripheral causes
	*Key distinction: ~~'''~~central (upper motor neuron) vs. peripheral (lower motor neuron)~~'''~~ — determines urgency of workup		*Key distinction: central (upper motor neuron) vs. peripheral (lower motor neuron) — determines urgency of workup
	*Central cause = ~~'''~~forehead sparing~~'''~~ (bilateral cortical input to forehead muscles) → evaluate for [[stroke]]		*Central cause = forehead sparing (bilateral cortical input to forehead muscles) → evaluate for [[stroke]]
	*Peripheral cause = ~~'''~~forehead involvement~~'''~~ (entire ipsilateral face) → [[Bell's palsy]] most common		*Peripheral cause = forehead involvement (entire ipsilateral face) → [[Bell's palsy]] most common
	*[[Bell's palsy]] is a diagnosis of exclusion — consider other peripheral causes before labeling as idiopathic		*[[Bell's palsy]] is a diagnosis of exclusion — consider other peripheral causes before labeling as idiopathic

	===Causes===		===Causes===
	*~~'''~~Central (upper motor neuron)~~'''~~		*Central (upper motor neuron)
	**[[Stroke]]/[[TIA]] — most critical to identify		**[[Stroke]]/[[TIA]] — most critical to identify
	**Intracranial mass/tumor		**Intracranial mass/tumor
	*~~'''~~Peripheral (lower motor neuron)~~'''~~		*Peripheral (lower motor neuron)
	**Idiopathic ([[Bell's palsy]]) — accounts for ~60-75% of acute unilateral facial paralysis		**Idiopathic ([[Bell's palsy]]) — accounts for ~60-75% of acute unilateral facial paralysis
	**[[Lyme disease]] — most common identifiable infectious cause in endemic areas; can be bilateral		**[[Lyme disease]] — most common identifiable infectious cause in endemic areas; can be bilateral
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	===Peripheral Process (Bell's Palsy)===		===Peripheral Process (Bell's Palsy)===
	*~~'''~~[[Prednisone]]~~'''~~ 60-80mg daily x 7 days (started within 72 hours of onset) — strongest evidence for improved recovery		*[[Prednisone]] 60-80mg daily x 7 days (started within 72 hours of onset) — strongest evidence for improved recovery
	*~~'''~~Eye care~~'''~~: artificial tears during day, lubricating ointment at night, tape or patch eyelid closed during sleep		*Eye care: artificial tears during day, lubricating ointment at night, tape or patch eyelid closed during sleep
	*~~'''~~Consider [[valacyclovir]]~~'''~~ 1g TID x 7 days for severe facial paralysis (House-Brackmann grade IV-VI) — evidence is mixed but may provide modest benefit when combined with steroids		*Consider [[valacyclovir]] 1g TID x 7 days for severe facial paralysis (House-Brackmann grade IV-VI) — evidence is mixed but may provide modest benefit when combined with steroids
	*Empiric '''[[doxycycline]]''' if high suspicion for [[Lyme disease]] (do NOT give steroids alone if Lyme suspected)		*Empiric '''[[doxycycline]]''' if high suspicion for [[Lyme disease]] (do NOT give steroids alone if Lyme suspected)

	===Ramsay Hunt Syndrome===		===Ramsay Hunt Syndrome===
	*~~'''~~[[Valacyclovir]]~~'''~~ or [[acyclovir]] + [[prednisone]]		*[[Valacyclovir]] or [[acyclovir]] + [[prednisone]]
	*Has worse prognosis than Bell's palsy — ENT/neurology follow-up		*Has worse prognosis than Bell's palsy — ENT/neurology follow-up