Facial Nerve Palsy

Facial nerve palsy refer to isolated dysfunction of the facial nerve. This typically presents with a unilateral facial weakness. It is important to understand some basics about the pathway of the facial nerve and the function of the facial nerve to consider the causes and management.


Facial Nerve Pathway

The facial nerve exits the brainstem at the cerebellopontine angle. On its journey to the face it passes through the temporal bone and parotid gland.

It then divides into five branches that supply different areas of the face:

  • Temporal
  • Zygomatic
  • Buccal
  • Marginal mandibular
  • Cervical


Facial Nerve Function

There are three functions of the facial nerve: motor, sensory and parasympathetic.

Motor: Supplies the muscles of facial expression, the stapedius in the inner ear and the posterior digastric, stylohyoid and platysma muscles in the neck.

Sensory: carries taste from the anterior 2/3 of the tongue.

Parasympathetic: it provides the parasympathetic supply to the submandibular and sublingual salivary glands and the lacrimal gland (stimulating tear production).


Upper vs Lower Motor Neurone Lesion

A very common exam question is to distinguish between an upper motor neurone and lower motor neurone facial nerve palsy. It is essential to be able to make this distinction, because in a patient with a new onset upper motor neurone facial nerve palsy you should be referring urgently with a suspected stroke, whereas patients with lower motor neurone facial nerve palsy can be reassured and managed in the community.

Each side of the forehead has upper motor neurone innervation by both sides of the brain. Each side of the forehead only has lower motor neurone innervation from one side of the brain.

In an upper motor neurone lesion, the forehead will be spared and the patient can move their forehead on the affected side.

In a lower motor neurone lesion, the forehead will NOT be spared and the patient cannot move their forehead on the affected side.

Upper Motor Neurone Lesions

Unilateral upper motor lesions occur in: 

  • Cerebrovascular accidents (strokes)
  • Tumours


Bilateral upper motor neurone lesions are rare. They may occur in:

  • Pseudobulbar palsies 
  • Motor neurone disease


Bell’s Palsy

Bell’s palsy is a relatively common condition. It is idiopathic, meaning there is no clear cause. It presents as a unilateral lower motor neurone facial nerve palsy. The majority of patients fully recover over several weeks but recovery may take up to 12 months. A third are left with some residual weakness.

If patients present within 72 hours of developing symptoms, NICE guidelines recommend considering prednisolone as treatment, either:

  • 50mg for 10 days
  • 60mg for 5 days followed by a 5-day reducing regime of 10mg a day


The NICE Clinical Knowledge Summaries do not recommend using antivirals but say an antiviral plus steroids may offer a “small benefit” (this should be discussed with a specialist).

Patients also require lubricating eye drops to prevent the eye on the affected drying out and being damaged. If they develop pain in the eye they need an ophthalmology review for exposure keratopathy. Tape can be used to keep the eye closed at night.


Ramsay-Hunt Syndrome

Ramsay-Hunt syndrome is caused by the varicella zoster virus (VZV). It presents as a unilateral lower motor neurone facial nerve palsy. Patients stereotypically have a painful and tender vesicular rash in the ear canal, pinna and around the ear on the affected side. This rash can extend to the anterior 2/3 of the tongue and hard palate.

Treatment should ideally be initiated within 72 hours. Treatment is with:

  • Prednisolone
  • Aciclovir


Patients also require lubricating eye drops.

TOM TIP: Ramsay-Hunt syndrome is a very popular presentation in your MCQ exams. Look out for that patient with a vesicular rash around their ear and a facial nerve palsy.


Other Causes of Lower Motor Neurone Facial Nerve Palsy


  • Otitis media
  • Malignant otitis externa
  • HIV
  • Lyme’s disease


 Systemic disease:

  • Diabetes
  • Sarcoidosis
  • Leukaemia
  • Multiple sclerosis
  • Guillain–Barré syndrome



  • Acoustic neuroma
  • Parotid tumours
  • Cholesteatomas



  • Direct nerve trauma
  • Damage during surgery
  • Base of skull fractures


Last updated April 2019
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