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CDHB

Facial Nerve (VII) Palsy

Common Causes

• Bell's Palsy (idiopathic).
• Herpes zoster (Ramsay Hunt syndrome).
• Middle ear infection.
• Trauma.
• Tumour: if there has been no recovery of facial nerve function after 3 months a tumour of the temporal bone / parotid must be excluded.

Clinical Assessment

• Thorough clinical assessment is required.
• Neurological assessment:
  • Confirm that upper and lower facial muscles are involved. Lower facial weakness only is more suggestive of a central nervous system (upper motor neurone) disorder.
  • Complete cranial nerve examination to detect/exclude any other abnormality.
  • Confirm no neurological abnormality in the limbs.
• ENT assessment:
  • Examine for vesicles including pharynx, pinna, ear canal.
  • Otoscopy for middle-ear disorder.
  • Parotid gland examination to exclude clinical evidence of tumour.
  • Examination for cervical and cranial lymphadenopathy.

Bell's Palsy

• Consider alternative explanation for unilateral facial weakness: UMN lesion, zoster infection (see below), sarcoid, compression.
• The weakness is usually maximal on the first day.
• The prognosis is usually favourable, however aberrant reinnervation can result in synkinesis (e.g., movement of the mouth when the eye is closed) or 'crocodile tears'.
• Provided no contraindications, a 10-day course of steroids if commenced within 72 hours, improves an already favourable prognosis. Prednisone 60 mg/day for 5 days, then taper over the next 5 days.
• Bilateral VII palsy: this is not "Bell's palsy". Suspect: sarcoidosis, Guillain Barre syndrome, myasthenia, myopathy. Neurological opinion advised.

Ramsay Hunt syndrome

• Herpes zoster infection of the geniculate ganglion or VII nerve.
• Vesicles/scabs may be present on the face, pinna, ear canal, pharynx, upper neck
• Facial palsy is common with worse prognosis than idiopathic (Bell's) palsy.
  • Untreated with complete palsy: 10% complete recovery.
  • Untreated with partial palsy: 68% complete recovery.
• Maximum palsy usually occurs within 1 week but there is evidence that late denervation occurs up to 14 days after the onset of the palsy.
• Other cranial nerves may also be involved: e.g., VIII, IX, X.
  • Check for swallowing impairment - further management may be indicated.
• Treatment: aciclovir 800 mg 5 times a day PO for 7-10 days. Check renal function.
• If facial palsy also treat with prednisone as for Bell's palsy (above).

Progression / failure to improve

• Patients should be instructed to seek further medical attention and investigation if no improvement occurs within 6-12 weeks or if there is any evidence of involvement of other cranial nerves.

Topic Code: 3568