Bilateral Facial Palsy


Original Editor - Wendy Walker

Top Contributors - Wendy Walker and Kim Jackson

One Page Owner - Wendy Walker as part of the One Page Project


Bilateral facial palsy, AKA Facial Diplegia, is defined as facial paralysis or paresis affection both sides of the face, with onset being either completely simultaneous or the second side being affected within 30 days of the first side.

Bilateral facial palsy is a rare condition, with an incidence of between 0.2% and 2%[1][2].

Clinically Relevant Anatomy

For details of anatomy of the Facial Nerve, the seventh Cranial Nerve, please see the Facial Nerve page.

Causes of Bilateral Facial Palsy

Idiopathic Bell's Palsy can be the cause of bilateral facial palsy, but other causes such as Lyme Disease[3], neurosarcoidosis, Guillain-Barre Syndrome, Melkerssohn-Rosenthal Syndrome, meningitis, leukaemia, tumours and basilar skull fractures must be considered and excluded as causes before a diagnosis of Bilateral Bell's Palsy is given[4].

Although unilateral facial palsy most commonly idiopathic or a result of viral infection, bilateral facial palsy presents more of a diagnostic challenge as some of the causes can be potentially fatal[5].

All patients presenting with bilateral facial palsy should undergo thorough investigations as a matter of urgency[4][5].

Clinical Presentation

Bilateral facial palsy is characterised by paralysis or weakness of the muscles in both sides of the face. In many cases the onset of paralysis is not completely simultaneous, and one side of the face may be affected several days before the other.

This frequently results in an inability to close the eyes fully, and reduced ability or even complete inability to move the mouth/lips.

Functional Issues

Eye Problems

Both eyes are generally unable to close, or unable to close fully, and also likely to have a significant reduction in tear production, which means that both eyes are at risk of develping a corneal ulcer.

Mouth Problems

Inability to move the lips eg. into smile, pucker, cause severe difficulties with non-verbal communication, and patients often report social problems as they are unable to convey their emotions through facial expression.

Eating and drinking are both affected, as lack of lip seal makes it difficult to keep fluids and food in the oral cavity.

There is also reduced clarity of speech as the "labial consonents" (ie. b, p, m, v, f) all require lip seal.

Diagnostic Procedures

Tests recommended[4][5]:

  • MRI or CT to brain: to involve the internal auditory meatus, cerebrobellopontine angle and mastoid - aim = pimarily to exclude tumours
  • Blood testing for Borrelia (for Lyme Disease), syphilis antibody, Epstein-Barr virus, antinuclear antibody, HIV, serum angiotensin converting enzyme levels (to exclude sarcoidosis)
  • Lumbar puncture, with CSF testing

Outcome Measures

add links to outcome measures here (see Outcome Measures Database)

Management / Interventions

Initial management will depend upon the cause of the palsy.

Long term management will be the same as for unilateral facial palsy: see the Facial Palsy page for more details.


References will automatically be added here, see adding references tutorial.

  1. Keane JR, Bilateral seventh nerve palsy: analysis of 43 cases and review of the literature. Neurology. 1994 Jul;44(7):1198-202
  2. Teller DC1, Murphy TP, Bilateral facial paralysis: a case presentation and literature review. J Otolaryngol. 1992 Feb;21(1):44-7
  3. Clark JR, Carlson RD, Sasaki CT, et al. Facial paralysis in Lyme disease. Laryngoscope. Nov 1985;95(11):1341-5
  4. 4.0 4.1 4.2 Oosterveer DM1, Bénit CP, de Schryver EL. Differential diagnosis of recurrent or bilateral peripheral facial palsy. J Laryngol Otol. 2012 Aug;126(8):833-6
  5. 5.0 5.1 5.2 Gaudin RA1, Jowett N, Banks CA, Knox CJ, Hadlock TA. Bilateral Facial Paralysis: A 13-Year Experience. Plast Reconstr Surg. 2016 Oct;138(4):879-87