Sudden onset (usually over hours) of unilateral facial paralysis peaking withinfirst week and then gradually resolve over three weeks to three months (may be due to HSV)
With or without loss of taste on the anterior two-thirds of the tongue or altered secretion of the lacrimal and salivary glands.
DDx
Herpes zoster infection
Otitis media
Lyme disease
Guillain-Barré syndrome
HIV infection
Sarcoidosis
Sjögren syndrome
Tumor
Stroke
Melkersson-Rosenthal syndrome
Physical Exam
Facial movement
Closing the eyes, elevating the brow, frowning, showing the teeth, puckering the lips, and tensing the soft tissues of the neck to observe for platysma activation.
Sparing of the forehead muscles on the affected side of the face is suggestive of a central (upper motor neuron) lesion because of bilateral innervation to this area.
Sensation
Skin
Particular attention is directed at the external ear to look for vesicles or scabbing (which indicates zoster) and for mass lesions within the parotid gland.
Investigations
Consider CT C+ or MRI (with Gadolinium) imaging of the brain, temporal bone, and parotid gland if the physical signs are atypical, there is slow progression beyond three weeks, or if there is no improvement at four months
Consider Lyme serologies if endemic area
Management
Eye care if poor eye lid closure and reduced tearing
Artificial tears during the day, ointment at night
Protective goggles/glasses
If onset <72h, Prednisone (60 to 80 mg/day) x 1 week
If severe, consider addition of Valacyclovir 1g TID x 1 week
For persistent symptoms, consider imaging and ENT referral