Facial Palsy


Flowchart

Red flags requiring urgent ENT referral

  • Facial nerve palsy associated with severe otalgia may be a result of necrotising otitis externa

  • Facial nerve palsy associated with long-term history of otorrhoea may be a sign of advanced cholesteatoma or a temporal bone malignancy

  • Facial palsy with parotid swelling in an elderly patient may represent parotid malignancy (rare presentation)

  • Facial palsy associated with trauma may require urgent decompression.

  • Other associated neurological symptoms may suggest a central cause such as stroke.

 

Assessment and recognition

History

  • When did it happen?

  • Was it sudden or gradual?

  • Did it involve the entire half of the face or just the lower half (forehead sparing)?

  • Any ear pain, discharge, hearing loss or vertigo?

  • Any new lumps or bumps in the head and neck region?

  • Any other neurological symptoms or signs?

  • Any recent trauma?

  • Any history of ear problems or operations?

  • How has the facial weakness affected them (eg. can they close their eyes, can they chew adequately?)

  • Relevant past medical history would include previous ear operations

  • Comorbidities (diabetes, autoimmune)

 

Examination

  • Assess facial movements. First ensure the lesion is lower motor neurone (forehead should be weak). If not, refer to stroke team. Facial weakness can be graded based on the House-Brackmann scale. Functionally the most important criterion is eye closure.

 

Grade I: Normal

Grade II: Mild asymmetry on movement

Grade III: Marked asymmetry on movement, complete eye closure

Grade IV: Marked asymmetry on movement, incomplete eye closure

Grade V: Asymmetry at rest, incomplete eye closure

Grade VI: No facial movement.

  • Otoscopy looking for infection, discharge or cholesteatoma

  • Neck examination for masses (parotid)

  • Examine the rest of the cranial nerves

 

Differential diagnosis and primary care management

ENT surgeons manage LMN facial palsies; forehead-sparing indicates urgent referral to neurology/stroke. The LMN causes are idiopathic, otological or cervical. It is worth starting most patients on 1 mg/kg prednisolone (max 60 mg) for a minimum of 1 week (with PPI cover) and give advice on eye taping at night (eye patches are not as safe).

Idiopathic

  • Bell's palsy - this is a diagnosis of exclusion, and the commonest cause of facial palsy in a patient with normal ENT and neurological examination. It is presumed to be viral in origin but this is unproven. The prognosis is generally very good with 90% recovering in a year. Start patients on 1 mg/kg prednisolone (max 60 mg) for a minimum of 1 week (with PPI cover) and give advice on eye taping at night (eye patches are not as safe). Refer to ENT on a semi-urgent basis / emergency ENT clinic. Aciclovir has not been shown to be beneficial.

Otological causes 

  • Ramsay-Hunt syndrome - this is shingles (VZV reactivation) in the distribution of the geniculate ganglion. Patients present with otalgia followed by a LMN facial nerve palsy. Examination may show vesicles in the external auditory meatus and/or ear canal skin. These patients generally recover with time although the prognosis is not as good as Bell's palsy. Treat patients identically to Bell’s palsy, with the addition of 800 mg aciclovir tds for 1 week.  Refer to ENT on a semi-urgent basis / emergency ENT clinic. 

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  • Squamous chronic otitis media / cholesteatoma - The presence of a facial nerve palsy in a patient with a chronically discharging (usually foul-smelling) ear generally indicates a cholesteatoma has eroded the facial nerve. This scenario is rare, and these patients should be referred to ENT on the same day. Patients are treated with steroids and antibiotics and potentially mastoidectomy and facial nerve decompression.

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  • Acute otitis media - AOM can rarely cause facial nerve palsy, usually because the patient’s facial nerve canal is dehiscent. In a very unwell patient intracranial spread should be considered. In all cases where there is a bulging red tympanic membrane and new facial weakness, the patient should be sent to ED and referred to ENT immediately.

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  • Lateral skull base osteomyelitis / “malignant” otitis externa - this should be suspected in elderly or immunocompromised individuals (including diabetics) with persistent painful otitis externa. Patients present with severe, deep-seated otalgia, and may have granulations of the ear canal skin on otoscopy (although ear examination is often misleadingly mild). Associated facial nerve palsy indicates a high risk of mortality.  These patients should be sent to ED and referred to ENT immediately. The diagnosis is confirmed on a CT scan of their temporal bone showing bony erosion. Management is typically prolonged intravenous and oral antibiotics.

Otitis Externa.jpg

Otitis Externa

 

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  • Trauma - LMN facial palsy can be a result of blunt or penetrating trauma. Blunt trauma can result in fractures of the temporal bone, which can also result in hearing loss, vertigo and CSF otorrhoea. Penetrating injuries to the upper neck and parotid region can also damage the facial nerve. All patients with traumatic facial nerve palsy need to be referred to ED on the same day for exclusion of other injuries, with ENT involvement.  

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  • Vestibular schwannoma/acoustic neuroma - These are benign slow-growing tumours that impinge on the vestibulocochlear and facial nerve and can cause hearing loss, tinnitus and dizziness. Rarely, a large tumour can cause facial palsy, cerebellar symptoms and hydrocephalus.  An MRI IAM is diagnostic and the patients can either be treated conservatively (serial scans) or actively (surgery, radiosurgery, gamma knife). Patients with a known CPA tumour presenting with a facial nerve palsy should be referred on the same day for consideration of decompression.

 

Cervical causes

  • Parotid malignancy - a parotid lump with associated with facial palsy is likely to be malignant (rare presentation). Refer under cancer-wait pathway.

  • Trauma (presents to ED) - penetrating neck trauma can cause LMN paralysis of the facial nerve if involving the parotid gland or lateral skull base.

  • Paragangliomas - these are rare, benign tumours of the middle ear, lateral skull base and neck. They can very rarely cause facial nerve palsies.

 

Referral pathways to ENT

Same day

  • Facial palsy due to acute or chronic otitis media

  • Traumatic facial palsy - refer to ED

 

Cancer pathway

  • Parotid / neck lump with facial nerve palsy

 

ENT emergency clinic

  • Ramsay-Hunt syndrome

  • Bell's palsy

 

Routine

  • Known facial nerve palsy patients who require further secondary care interventions.

Author: Mr Ananth Vijendren BM MRCS MRCS (ENT) FRCS (ORL-HNS) PhD, Consultant Otologist/ENT Surgeon, Lister Hospital, Stevenage