Facial Palsy

Original Editor - Wendy Walker.

Top Contributors - Wendy Walker, Muhammad Umar, Evan Thomas, Naomi O'Reilly and Darine Mohieldeen

Topic Expert - Wendy Walker

Clinically Relevant Anatomy

For more detail on the anatomy of the facial nerve, please see the Facial Nerve page.

The VIIth cranial Nerve has its nucleus in the Pons, and takes a rather winding route before exiting the skull through the stylomastoid foramen. It then passes through the parotid gland, splitting into 5 branches: Temporal, zygomatic, buccal, mandibular and cervical.

Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist. http://creativecommons.org/licenses/by/2.5/Cranial Nerve V11.jpg

See Facial Muscles Video :facial Muscles

Causes of Facial Palsy:


Bell's Palsy - cause not known [1] but likely to be linked to Herpes Simplex infection [2]

Bell’s palsy accounts for approximately 60 per cent of all cases of sudden onset facial paralysis. It affects between 20 to 40 per 100,000 people per year.


A tumour compressing the facial nerve can result in facial paralysis, but more commonly the facial nerve is damaged during surgical removal of a tumour. The most common tumour to result in facial palsy during surgical removal is the Acoustic Neuroma (AKA Vestibular Schwannoma). Less commonly, cholesteatoma, hemangioma, Facial Schwannoma or parotid gland tumours (or the surgery to remove them) are the cause.


Ramsay Hunt Syndrome

Caused by Herpes Zoster infection = a syndromic occurrence of facial paralysis, herpetiform vesicular eruptions, and vestibulocochlear dysfunction. Patients presenting with Ramsay Hunt syndrome generally have a greater risk of hearing loss than do patients with Bell palsy, and the course of disease is more painful. Moreover, a lower recovery rate is observed in these patients.

Lyme Disease

Infection with Borrelia burgdorferi via tick bites is another cause of facial paralysis. Of patients affected with Lyme disease, 10% develop facial paralysis, with 25% of these patients presenting with bilateral facial palsy.[3] 

Iatrogenic Facial Nerve Damage

Iatrogenic facial nerve injury occurs most commonly in temporomandibular joint replacement, mastoidectomy, and parotidectomy[4].

Rare causes

These include:

Neurosarcoidosis, ototis media, Multiple Sclerosis, Moebius Syndrome, Melkersson-Rosenthal syndrome, Guillain-Barre Syndrome, Millard-Gubler Syndrome AKA Ventral Pontine Syndrome (Ipsilateral facial palsy with contralateral hemiplegia caused by involvement of the corticospinal tract along with paralysis of lateral rectus on the ipsilateral side due to the involvement of the abducent nerve), Foville Syndrome AKA Inferior Medial Pontine Syndrome (ipsilateral facial palsy, contralateral hemiplegia with ipsilateral conjugate gaze effects), Eight-and-a-half syndrome (facial palsy with  Internuclear ophthalmoplegia and horizontal gaze palsy)

Trauma, especially temporal bone fractures

Clinical Presentation

Paralysis of the muscles supplied by the Facial Nerve presents on the affected side of the face as follows:

Appearance and range of movement:

Inability to close the eye

Inability to move the lips eg. into smile, pucker

At rest, the affected side of the face may "droop"

The lower eyelid may drop and turn outward - "ectroprian"

Functional effects:

Difficulty eating and drinking as lack of lip seal makes it difficult to keep fluids and food in the oral cavity

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

Dryness of the affected eye - see the Dry Eye page for more details

Somatic effects:

The facial nerve  supplies the lachrymal glands of the eye, the saliva glands, and to the muscle of the stirrup bone in the middle ear (the stapes). It also transmits taste from the anterior 2/3 of the tongue.

Facial palsy often involves:

  • Lack of tear production in the affected eye, causing a dry eye, with risk of corneal ulceration.

In Facial Nerve palsy there are 2 problems which contribute towards making the eye dry:
1. The greater petrosal nerve, derived from the facial nerve, supplies the parasympathetic autonomic component of the lacrimal gland. - controlling production of moisture/tearing in eyes.
2. The zygomatic branch of the Facial Nerve supplies Orbicularis Oculi, and the resulting paralysis causes inability(or reduced ability) to close the eye or blink, so the tears (or indeed artificial lubrication in the form of drops, gel or ointment) are not spread across the cornea properly.

  • Hyperacusis = sensitivity to sudden loud noises
  • Altered taste sensation

Differential Diagnosis, UMN versus LMN:

If the forehead is not affected (ie the patient is able to raise fully the eyebrow on the affected side) then the facial palsy is likely to be a result of a lesion in the Upper Motor Neuron (UMN). Paralysis which includes the forehead, such that the patient is unable to raise the affected eyebrow, is a Lower Motor Neuron (LMN)lesion.

However, caution is advised in using preservation of forehead function to diagnose a central lesion. Patients may have sparing of forehead function with lesions in the pontine facial nerve nucleus, with selective lesions in the temporal bone, or with an injury to the nerve in its distribution in the face. It is worth remembering that a cortical lesion that produces a lower facial palsy/paresis is usually associated with a motor deficit of the tongue and weakness of the thumb, fingers, or hand on the ipsilateral side[5].

Diagnostic Procedures

Laboratory investigations include an audiogram, nerve conduction studies (ENoG), computed tomography (CT) or magnetic resonance imaging (MRI), electromyography (EMG)[6].

Management / Interventions

Medical and surgical management depends on the cause of the facial palsy.

Medical Management

Bell's Palsy and Ramsay Hunt Syndrome are treated with corticoteroids (prednisone), given within 72 hours of onset,[7]and this can be accompanied by antiviral medication[8].

Surgical Management

Acoustic Neuromas or Facial Schannomas are frequently resected surgically. See Acoustic Neuroma page for more details.

Patients at high risk of corneal ulcer may be offered oculoplastic surgery to protect the eye.

For patients with dense facial palsy and no nerve function, a number of surgical interventions may be used. These fall into the following categories:

  1. Facial reanimation surgeries which involve nerve graft or anastomosis
  2. Facial reanimation surgeries which involve muscle transposition
  3. Static surgeries, ie. plastic surgery to improve symmetry at rest but no improvement in movement


  • Neuromuscular Retraining (NMR) [9]
  • Electromyography (EMG) biofeedback [10]
  • Trophic Electrical Stimulation (TES) [11]
  • Proprioceptive Neuro Muscular Facilitation Techniques


Synkinesis (AKA aberrant regeneration) occurs after injurty to the facial nerve.

For more information on this, see the dedicated Synkinesis page.

Effects on Quality of Life

A large retrospective study [920 patients] published in September 2018 looked into the correlation between facial palsy severity and quality of life[12]; it concluded "A correlation between facial palsy severity and quality of life was found in a large cohort of patients comprising various etiologies. Additionally, novel factors that predict quality of life in facial palsy were revealed".

Key Evidence

jama.jamanetwork.com/article.aspx Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis.  de Almeida JR, Al Khabori M, Guyatt GH, Witterick IJ, Lin VY, Nedzelski JM, Chen JM.

onlinelibrary.wiley.com/doi/10.1002/14651858.CD001942.pub4/abstract Cochrane Review: Corticosteroids for Bell's palsy (idiopathic facial paralysis)  Rodrigo A Salinas, Gonzalo Alvarez, Fergus Daly, Joaquim Ferreira

onlinelibrary.wiley.com/doi/10.1002/14651858.CD006283.pub3/abstract Cochrane Review: Physical therapy for Bell's palsy (idiopathic facial paralysis)  Lázaro J Teixeira1, Juliana S Valbuza, Gilmar F Prado


www.facialpalsy.org.uk/ Charity for Facial Palsy from any cause

bellspalsy.org.uk/links.html Bell's Palsy Association, Charity

www.nhs.uk/Conditions/Bells-palsy/Pages/Introduction.aspx Information web-site on Bell's Palsy

Here's a link to the Facebook group for Facialpalsy.org

This link is to an introductory video about the effects of facial palsy: http://www.facialpalsy.org.uk/about-facial-palsy/facial-palsy-uk-information-video/322


  1. Peiterson,E. Bell's Palsy; the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Oto-Laryngologica. Supplementum 2002;549:4-30
  2. Holland NJ, Weiner GM. Recent developments in Bell's Palsy. BMJ 2004; 329(7465):553-7
  3. Clark JR, Carlson RD, Sasaki CT, et al. Facial paralysis in Lyme disease. Laryngoscope. Nov 1985;95(11):1341-5.
  4. Hohman MH, Bhama PK, Hadlock TA. Epidemiology of iatrogenic facial nerve injury: a decade of experience. Laryngoscope. 2014 Jan;124(1):260-5.
  5. Jenny AB, Saper CB. Organization of the facial nucleus and corticofacial projection in the monkey: a reconsideration of the upper motor neuron facial palsy. Neurology. Jun 1987;37(6):930-9. [Medline].
  6. Kumar A, Mafee MF, Mason T. Value of imaging in disorders of the facial nerve. Top Magn Reson Imaging. Feb 2000;11(1):38-51. [Medline].
  7. ^ Gronseth, GS; Paduga, R (2012 Nov 7). "Evidence-based guideline update: Steroids and antivirals for Bell palsy: Report of the Guideline Development Subcommittee of the American Academy of Neurology". Neurology 79 (22): 2209–13.
  8. Daniel P Butler and Adriaan O Grobbelaar. Facial palsy: what can the multidisciplinary team do? J Multidiscip Healthc. 2017; 10: 377–381. Published online 2017 Sep 25. doi:  10.2147/JMDH.S125574
  9. Manikandan N. Effect of facial neuromuscular re-education on facial symmetry in patients with Bell's palsy: a randomized controlled trial. Clin Rehabil. 2007 Apr;21(4):338-43.fckLR*Electromyography (EMG) Biofeedback <ref>Bossi D, Buonocore M et al. Usefulness of BFB/EMG in facial palsy rehabilitation. Disabil Rehabil. 2005 Jul 22;27(14):809-15.
  10. Bossi D, Buonocore M et al. Usefulness of BFB/EMG in facial palsy rehabilitation. Disabil Rehabil. 2005 Jul 22;27(14):809-15
  11. Targan R S, Alon G, Kay SL. Effect of long-term electrical stimulation on motor recovery and improvement of clinical residuals in patients with unresolved facial nerve palsy Otolaryngol Head Neck Surgery February 2000 vol. 122 no. 2 246-252
  12. Tavares-Brito J, van Veen MM, Dusseldorp JR, Bahmad F Jr, Hadlock TA Facial Palsy-Specific Quality of Life in 920 Patients: Correlation With Clinician-Graded Severity and Predicting Factors. Laryngoscope. 2018 Sep 12. doi: 10.1002/lary.27481. [Epub ahead of print]