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Facial Nerve Palsy: Causes, Symptoms & Treatment

Facial nerve palsy is a paralysis of the seventh cranial nerve (facial nerve), causing weakness or complete loss of movement on one or both sides of the face.

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Things worth knowing about "Facial Nerve Palsy"

Facial nerve palsy is a paralysis of the seventh cranial nerve (facial nerve), causing weakness or complete loss of movement on one or both sides of the face.

What Is Facial Nerve Palsy?

Facial nerve palsy refers to a paralysis or weakness of the seventh cranial nerve, known as the facial nerve (nervus facialis). This nerve controls the muscles responsible for facial expressions, eye closure, and partly for taste sensation as well as the production of tears and saliva. Damage to this nerve results in partial or complete loss of movement on the affected side of the face.

There are two main types: peripheral facial nerve palsy, where the nerve itself is damaged, and central facial nerve palsy, where the cause lies in the brain (for example, following a stroke).

Causes

The causes of facial nerve palsy vary depending on the type:

Idiopathic (Bell palsy): The most common form of peripheral facial nerve palsy with no identifiable cause, thought to be triggered by viral inflammation of the nerve.
Viral infections: Particularly herpes simplex virus or varicella-zoster virus (herpes zoster oticus / Ramsay Hunt syndrome).
Bacterial infections: Such as Lyme disease (borreliosis) or otitis media (middle ear infection).
Tumors: Acoustic neuroma or other space-occupying lesions near the nerve.
Trauma: Head injuries or fractures of the temporal bone.
Neurological conditions: Stroke, multiple sclerosis, or Guillain-Barre syndrome.
Rare causes: Sarcoidosis, parotid gland tumors, or congenital malformations.

Symptoms

Symptoms depend on the severity of the nerve damage and the type of palsy:

One-sided weakness or complete paralysis of the facial muscles
Drooping of the corner of the mouth, difficulty speaking or chewing
Inability or difficulty closing the eyelid (lagophthalmos)
Reduced or absent blink reflex, with risk of corneal damage
Loss of forehead wrinkling on the affected side (in peripheral palsy)
Taste disturbances in the front two-thirds of the tongue
Increased sensitivity to sounds (hyperacusis)
Reduced tear production or dry eye

In central facial palsy, the forehead is usually spared, as the forehead muscles receive input from both sides of the brain.

Diagnosis

Facial nerve palsy is diagnosed through:

Clinical examination: Assessment of facial symmetry, expressions, eye closure, and forehead wrinkling.
Medical history: Evaluation of prior illnesses, infections, or trauma.
Imaging: MRI or CT of the skull to rule out tumors, stroke, or other structural causes.
Electrophysiological testing: Electromyography (EMG) and electroneurography (ENG) to assess the degree of nerve damage.
Laboratory tests: Blood count, Borrelia antibodies, and herpes serology to identify the underlying cause.
House-Brackmann Scale: A standardized grading system (Grade I to VI) used to assess the severity of facial nerve palsy.

Treatment

Treatment depends on the underlying cause and severity of the condition:

Medication

Corticosteroids (e.g., prednisolone): First-line treatment for idiopathic Bell palsy to reduce nerve inflammation; ideally started within 72 hours of symptom onset.
Antiviral medications (e.g., aciclovir, valaciclovir): Used in combination with corticosteroids when herpes zoster involvement (Ramsay Hunt syndrome) is suspected.
Antibiotics: Prescribed when a bacterial cause such as Lyme disease is identified.

Eye Care

Since eyelid closure is often impaired, artificial tear drops, eye gels, and protective eyewear or an eye patch may be necessary to prevent dryness and corneal injury.

Physiotherapy and Rehabilitation

Targeted facial exercises and physiotherapy can support nerve regeneration and help prevent muscle atrophy. Biofeedback therapy may also be beneficial in recovery.

Surgical Treatment

In severe or chronic cases, surgical interventions such as facial nerve reconstruction, nerve grafting, or nerve decompression surgery may be considered.

Prognosis

The prognosis depends greatly on the cause and extent of nerve damage. In idiopathic Bell palsy, approximately 70 to 80 percent of patients recover fully or almost fully within weeks to months. Early treatment significantly improves recovery outcomes. In rare cases, permanent deficits or abnormal nerve regeneration (known as synkinesis) may persist.

References

Deutsche Gesellschaft fur Neurologie (DGN) - Clinical Guideline on Facial Nerve Palsy, 2023. Available at: https://www.dgn.org
Gilden DH. - Bell's Palsy. New England Journal of Medicine, 2004; 351(13): 1323-1331.
Baugh RF et al. - Clinical Practice Guideline: Bell's Palsy. Otolaryngology-Head and Neck Surgery, 2013; 149(3 Suppl): S1-S27.

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