A Case of Facial Nerve Palsy

Medical Student Clinical Pearl by Livia Clarke


MD Candidate, Class of 2024

Dalhousie University

Reviewed by Dr. M McGraw

Copy Edited by Dr. J Vonkeman

Pdf Download: EMSJ A Case of a Facial Nerve Palsy



A 45-year-old male presents to the Emergency Department with muscle paralysis of the left side of his face. That morning, he experienced some difficulty eating his breakfast and noticed that the left side of his face was immobile when looking in the mirror. He is also experiencing paresthesia of the left side of his face. He is an otherwise healthy individual with no past medical history and not taking any medications.

On examination, he is vitally stable and in no apparent distress. He has left sided facial paralysis involving the upper and lower portions of the face, suggesting impairment of cranial nerve VII, as well as paresthesia. The rest of the cranial nerve exam is normal. Upper and lower extremity muscle tone and strength are normal. Sensation is normal. Cerebellar testing with finger-to-nose, heel-to-shin, and rapid alternating movements is normal. Gait is normal.

Differential Diagnosis of Facial Nerve Palsy (1,3)

  • Peripheral Causes:
    • Lyme disease
    • Otitis media
    • Ramsey Hunt syndrome
    • Guillain-Barre syndrome
    • Cholesteatoma or tumor of parotid gland
    • Bell’s Palsy
    • Leukemia
  • Central causes:
    • MS
    • Neoplasm
    • Stroke

Bell’s Palsy

Bell’s Palsy is a common idiopathic condition that results from the peripheral paralysis of the seventh cranial nerve causing unilateral facial paralysis4. It is thought to be caused from inflammation causing compression of the facial nerve at the geniculate ganglion3,4. The exact cause of this inflammation is unknown, but suspected causes include viral infections such as Herpes simplex virus1.


Figure 1: Anatomy of the facial nerve (American Family Physician)


Patients often present with sudden onset (over several hours and up to 72 hours) of unilateral facial paralysis that involves the upper and lower face1,4. Commonly patients cannot close the affected eyelid, experience eyebrow sagging, loss of the nasolabial fold, and drooping of the affected corner of the mouth1,4. Patients may also experience impairment in taste and decreased tearing of the eye1,4.


Figure 2: Presentation of a left Bell’s Palsy. A) Inability to raise left eyebrow. B) & C) Inability to close left eye or raise left corner of mouth (UptoDate).


The involvement of both upper and lower portions of the face is important because facial weakness originating from central causes (i.e., stroke, tumor) results in a pattern of facial weakness restricted to the lower region of the face that spares the forehead3.

Figure 3: (A) a facial nerve lesion. (B) a supranuclear lesion with forehead sparing (American Family Physician).

The risk of Bell’s Palsy is three times greater during pregnancy, with the highest risk in the third trimester and during the first week postpartum. Hypertension has also been associated with an increased risk in some studies1. Other risk factors include diabetes, preeclampsia and obesity4.


Bell’s Palsy is a diagnosis of exclusion and is diagnosed clinically1. If there are atypical features, the patient should be evaluated for central causes. During the assessment of a patient presenting with Bell’s Palsy it is important to assess for a patient’s ability to completely close the affected eye.


In most cases, Bell’s Palsy will resolve without treatment4. Oral corticosteroids are often prescribed to reduce the inflammation of the facial nerve. Prednisone 60-80 mg/day for one week is recommended2. Often an antiviral will also be prescribed, but its effectiveness is not proven. Valacyclovir 1000mg three times daily for one week or acyclovir 400mg five times daily for 20 days are popular choices for those with severe symptoms2. If the patient is unable to completely close the affected eye, they must be cautioned to apply hydrating solutions (i.e. artificial tears) during waking hours as well as artificial tears ointment and taping the eyelid shut during sleep to prevent corneal injury5.


Bell’s Palsy has a favorable prognosis. Approximately 70% of patients will completely recover without treatment by 3-6 months2. With glucocorticoid treatment, 80-85% of patient are expected to completely recover2. 7-15% of patients will experience recurrent Bell’s Palsy either on the same or opposite side2.

Case Continued 

The patient’s symptoms were classic for Bell’s palsy, and he did not have any atypical features. He was provided a prescription of an oral corticosteroid and an antiviral and discharged home.


  1. Hatzenbuehler, J., & Pulling, T. J. (2011). Diagnosis and Management of Osteomyelitis.American Family Physician84(9), 1027–1033.
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  3. Yuschak, E., Chase, S., Haq, F., & Vandever, C. (2019). Demographics and Length of Stay for Osteomyelitis in Opioid Drug Users: A Unique Population with High Healthcare Costs.Cureus11(3), e4339.
  4. Calhoun, J. H., & Manring, M. M. (2005). Adult Osteomyelitis.Infectious Disease Clinics of North America19(4), 765–786.
  5. Hogan, A., Heppert, V. G., & Suda, A. J. (2013). Osteomyelitis.Archives of Orthopaedic and Trauma Surgery133(9), 1183–1196.
  6. Pichichero, M. E., & Friesen, H. A. (1982). Polymicrobial Osteomyelitis: Report of Three Cases and Review of the Literature.Clinical Infectious Diseases4(1), 86–96.
  7. Momodu, I.I., & Savaliya, V. Osteomyelitis. ]. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Updated 2023 May 31.
  8. Arnold, S. R., Elias, D., Buckingham, S. C., Thomas, E. D., Novais, E., Arkader, A., & Howard, C. (2006). Changing Patterns of Acute Hematogenous Osteomyelitis and Septic Arthritis: Emergence of Community-associated Methicillin-resistant Staphylococcus aureus.Journal of Pediatric Orthopaedics26(6), 703–708.
  9. Parikh, M. P., Octaria, R., & Kainer, M. A. (2020). Methicillin-Resistant Staphylococcus aureus Bloodstream Infections and Injection Drug Use, Tennessee, USA, 2015-2017.Emerging Infectious Diseases26(3), 446–453.
  10. Best, K., Hussien, S., Malik, A., Patel, S., & Michael, M. B. (2022). Suprapubic Osteomyelitis in an Intravenous Drug User: A Case Report. InCureus (Vol. 14, Issue 1, pp. e21312–e21312).
  11. Lauri, C., Tamminga, M., Glaudemans, A. W. J. M., Juárez Orozco, L. E., Erba, P. A., Jutte, P. C., Lipsky, B. A., IJzerman, M. J., Signore, A., & Slart, R. H. J. A. (2017). Detection of Osteomyelitis in the Diabetic Foot by Imaging Techniques: A Systematic Review and Meta-analysis Comparing MRI, White Blood Cell Scintigraphy, and FDG-PET.Diabetes Care40(8), 1111–1120.
  12. Schirò, S., Foreman, S. C., Bucknor, M., Chin, C. T., Joseph, G. B., & Link, T. M. (2020). Diagnostic Performance of CT-Guided Bone Biopsies in Patients with Suspected Osteomyelitis of the Appendicular and Axial Skeleton with a Focus on Clinical and Technical Factors Associated with Positive Microbiology Culture Results.Journal of Vascular and Interventional Radiology31(3), 464–472.
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