Facial paralysis

Background

• Key to distinguish between central and peripheral facial nerve palsy

Causes

• Central
  • CVA
• Peripheral
  • Idiopathic (Bell's palsy)
  • Lyme disease
  • Varicella zoster
  • HSV
  • Facial trauma

Clinical Features

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.

Central Process

• Forehead "sparing" or normal muscle tone of the forehead

Peripheral Process

• Weakness of forehead muscles

Central and Peripheral

• Unable to close eye
• Loss of nasolabial fold
• Asymmetric smile

Differential Diagnosis

Facial paralysis

• Bell's palsy
• CVA
• Trigeminal neuralgia
• Tick paralysis
  • Lyme disease
• Herpes zoster oticus (Ramsay Hunt syndrome)
• CNS tumor
  • Acoustic neuroma or other cerebellopontine angle lesions
  • Meningioma
  • Cerebellar pontine angle
  • Facial nerve schwannoma
  • Parotid
  • Sarcoma
• Anesthesia nerve blocks
• Cerebral Aneurysms (vertebral, basilar, or carotid)

Evaluation

Central Process

• CT

Peripheral Process

• No labs or imaging routinely necessary
• Consider lyme serologies if endemic area

Management

Central Process

Peripheral Process

• Prednisone (unless diagnosed Lyme disease)
• Empiric doxycycline if high suspicion for Lyme disease
• Consider valacyclovir for severe presentation if Lyme is negative
• Artificial tears
• Consider neurology follow-up

See Also

• Facial swelling