Differentiate supranuclear facial palsy from peripheral (nuclear) facial palsy. Supranuclear palsy involves predominantly the lower part of the face. Emotional responses may be intact (e.g., the patient may not be able to show you his teeth but will smile in response to a joke). Peripheral, or nuclear facial, palsy affects all ipsilateral muscles of facial expression, resulting in paralysis of the entire ipsilateral side. The mouth is pulled at an angle to the normal side and may droop on the affected side, facial creases are effaced, and the eyelid may not close.
* Lyme disease * Tumors that invade the temporal bone (e.g., cholesteatoma, carotid body tumor) * Ramsay Hunt's syndrome –Association of facial palsy with herpes zoster eruption in the pharynx and external auditory canal –Eighth cranial nerve often affected as well
* Bell's palsy –IV acyclovir and corticosteroids may lead to better recovery and less neuronal degeneration –Tape eye and use eye shade to protect the eye during sleep –Massage of weakened muscles –Electrical stimulation of paralyzed muscles in cases with delayed recovery * In other cases, treat the inciting causes (e.g., control of blood pressure and hyperlipidemia in patients with CVA, antibiotics for patients with Lyme disease, antivirals in Ramsay Hunt's syndrome, steroids for sarcoidosis) * Consider neurologic referral