EN4.16 | Facial Nerve Palsy — Summary & Reflection

KEY TAKEAWAYS

Facial nerve palsy requires systematic assessment from the first moment:

• UMN vs LMN: Forehead spared = UMN (stroke); forehead involved = LMN (peripheral/ENT causes).
• Commonest cause: Bell's palsy (~70%) — idiopathic, HSV-1 reactivation, diagnosis of exclusion.
• Red flags requiring imaging: slow-progressive onset, vesicles (Ramsay Hunt), ear discharge (CSOM/cholesteatoma), parotid mass, bilateral palsy, other cranial nerve signs.
• Ramsay Hunt syndrome: VZV reactivation, geniculate ganglion; vesicles in ear, severe palsy, worse prognosis (~50% recovery); treat with steroids + antivirals.
• Immediate priority: Eye care — lubricating drops, ointment, tape at night; corneal exposure = emergency.
• Bell's palsy treatment: Prednisolone 50 mg/day (within 72h) ± antivirals; recovery in 70–85%.
• Topognostic testing: Schirmer's (GSPN/lacrimation), stapedial reflex, taste testing — localise lesion level.
• Grading: House-Brackmann I (normal) to VI (complete paralysis).

REFLECT

The patient in the opening scenario needed two questions answered in 2 minutes. You should now be able to answer both clearly. Reflect on the clinical reasoning process: what features of her history and examination would make you confident this is Bell's palsy versus suspicious of another cause? What would you say to reassure her about the prognosis while still being honest that ~15–30% of patients do not fully recover? Consider also the psychological impact of waking up with half your face paralysed — what communication and counselling skills are required to support this patient through what is often a frightening and socially isolating experience?