Current Neurology and Neuroscience Reports

, Volume 10, Issue 6, pp 448–458 | Cite as

Neuro-ophthalmologic Complications and Manifestations of Upper and Lower Motor Neuron Facial Paresis

  • M. Tariq Bhatti
  • Jade S. Schiffman
  • Anastas F. Pass
  • Rosa A. Tang


The facial nerve (cranial nerve VII) courses a long pathway beginning in the precentral gyrus and ending at the facial muscles, lacrimal and salivary glands, and structures of the inner ear. Lesions along this pathway, clinically divided into upper and lower motor neuron lesions, present with unique characteristics that assist the physician in identifying the lesion site. The sequelae particularly of peripheral CN VII palsies, may result in significant and chronic damage to the cornea that may be challenging for the physician and patient.


Bell’s palsy Corticosteroids Facial nerve paresis Tumors Strokes Acyclovir Prednisolone 



The authors thank Liat Gantz for assistance in preparing this manuscript.


No potential conflicts of interest relevant to this article were reported.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Anderson CA, Sandberg E, Filley CM, et al.: One and one-half syndrome with supranuclear facial weakness: magnetic resonance imaging localization. Arch Neurol 1999, 56(12):1509–1511.CrossRefPubMedGoogle Scholar
  2. 2.
    Gilden DH: Clinical practice. Bell’s palsy. N Engl J Med 2004, 351(13):1323–1331.CrossRefPubMedGoogle Scholar
  3. 3.
    Rahman I, Sadiq SA: Ophthalmic management of facial nerve palsy: a review. Surv Ophthalmol 2007, 52(2):121–144.CrossRefPubMedGoogle Scholar
  4. 4.
    Razfar A, Afifi AM, Manders EK, et al.: Ocular outcomes after gold weight placement and facial nerve resection. Otolaryngol Head Neck Surg 2009, 140(1):82–85.CrossRefPubMedGoogle Scholar
  5. 5.
    Hoffman WY: Reanimation of the paralyzed face. Otolaryngol Clin North Am 1992, 25(3):649–667.PubMedGoogle Scholar
  6. 6.
    Conley J, May M: Perspectives in facial reanimation. In The Facial Nerve. edn 2. Edited by May M, Schaitkin BM. New York: Thieme Medical Publishers; 2000:551–570.Google Scholar
  7. 7.
    van de Graaf RC, IJpma FF: Remarks on the early history of Bell’s palsy. Eur Arch Otorhinolaryngol 2008, 265(11):1433–1434.CrossRefPubMedGoogle Scholar
  8. 8.
    Schirm J, Mulkens PS: Bell’s palsy and herpes simplex virus. APMIS 1997, 105(11):815–823.CrossRefPubMedGoogle Scholar
  9. 9.
    Devriese PP, Schumacher T, Scheide A, et al.: Incidence, prognosis and recovery of Bell’s palsy. A survey of about 1,000 patients (1974–1983). Clin Otolaryngol Allied Sci 1990, 15(1):15–27.CrossRefPubMedGoogle Scholar
  10. 10.
    Hauser WA, Karnes WE, Annis J, Kurland LT: Incidence and prognosis of Bell’s palsy in the population of Rochester, Minnesota. Mayo Clin Proc 1971, 46(4):258–264.PubMedGoogle Scholar
  11. 11.
    Adour KK, Byl FM, Hilsinger RL Jr, et al: The true nature of Bell’s palsy: analysis of 1,000 consecutive patients. Laryngoscope 1978, 88(5):787–801.PubMedGoogle Scholar
  12. 12.
    Yanagihara N, Mori H, Kozawa T, et al.: Bell’s palsy. Nonrecurrent v recurrent and unilateral v bilateral. Arch Otolaryngol 1984, 110(6):374–377.PubMedGoogle Scholar
  13. 13.
    Gilden D: Treatment of Bell’s palsy—the pendulum has swung back to steroids alone. Lancet Neurol 2008, 7(11):976–977.CrossRefPubMedGoogle Scholar
  14. 14.
    House JW, Brackmann DE: Facial nerve grading system. Otolaryngol Head Neck Surg 1985, 93(2):146–147.PubMedGoogle Scholar
  15. 15.
    Schaitkin BM, May M: Reporting recovery of facial function. In The Facial Nerve. edn 2. Edited by May M, Schaitkin BM. New York: Thieme Medical Publishers; 2000:275–294.Google Scholar
  16. 16.
    de Ru JA, van Benthem PP, Hordijk GJ: Arguments favouring the pharmacotherapy of Bells’ palsy [in Dutch]. Ned Tijdschr Geneeskd 2005, 149(26):1454.PubMedGoogle Scholar
  17. 17.
    Kang TS, Vrabec JT, Giddings N, Terris DJ: Facial nerve grading systems (1985–2002): beyond the House-Brackmann scale. Otol Neurotol 2002, 23(5):767–771.CrossRefPubMedGoogle Scholar
  18. 18.
    Salinas RA, Alvarez G, Ferreira J: Corticosteroids for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2004, CD001942.Google Scholar
  19. 19.
    Allen D, Dunn L: Aciclovir or valaciclovir for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2004, CD001869.Google Scholar
  20. 20.
    Sullivan FM, Swan IR, Donnan PT, et al.: Early treatment with prednisolone or acyclovir in Bell’s palsy. N Engl J Med 2007, 357(16):1598–1607.CrossRefPubMedGoogle Scholar
  21. 21.
    •• Engström M, Berg T, Stjernquist-Desatnik A, et al.: Prednisolone and valaciclovir in Bell’s palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol 2008, 7(11):993–1000. This study included 839 BP patients treated within 72 h of onset of symptoms in a double-blind protocol. It found that patients receiving prednisolone alone achieved a significantly shorter time to full recovery compared with those receiving combination therapy. At 6 months, full recovery was achieved in 71% (n = 150) of the prednisolone/placebo group (P < 0.003), 58% (n = 120) of the valacyclovir/placebo group (P < 0.0001), 72% (n = 149) of the prednisolone/valacyclovir group (P < 0.0001), and 62% (n = 127) of the double-placebo group (P < 0.0001). Further, use of antiviral treatment did not provide any additional benefit. CrossRefPubMedGoogle Scholar
  22. 22.
    Minnerop M, Herbst M, Fimmers R, et al: Bell’s palsy: combined treatment of famciclovir and prednisone is superior to prednisone alone. J Neurol 2008, 255(11):1726–1730.CrossRefPubMedGoogle Scholar
  23. 23.
    Hato N, Yamada H, Kohno H, et al.: Valacyclovir and prednisolone treatment for Bell’s palsy: a multicenter, randomized, placebo-controlled study. Otol Neurotol 2007, 28(3):408–413.CrossRefPubMedGoogle Scholar
  24. 24.
    Kawaguchi K, Inamura H, Abe Y, et al: Reactivation of herpes simplex virus type 1 and varicella-zoster virus and therapeutic effects of combination therapy with prednisolone and valacyclovir in patients with Bell’s palsy. Laryngoscope 2007, 117(1):147–156.CrossRefPubMedGoogle Scholar
  25. 25.
    Yeo SG, Lee YC, Park DC, Cha CI: Acyclovir plus steroid vs steroid alone in the treatment of Bell’s palsy. Am J Otolaryngol 2008, 29(3):163–166.CrossRefPubMedGoogle Scholar
  26. 26.
    • de Almeida JR, Al Khabori M, Guyatt GH, et al.: Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA 2009, 302(9):985–993. The authors performed a meta-analysis of 18 clinical trials totaling 2,786 patients with BP to determine the effect of corticosteroids and antiviral agents on the risk of unsatisfactory facial recovery. Corticosteroids were found to reduce the risk of an unsatisfactory recovery outcome, whereas antiviral agents were found to have no beneficial effect. The combination of corticosteroids and antiviral agents had a borderline effect in reducing the risk of an unsatisfactory recovery outcome. CrossRefPubMedGoogle Scholar
  27. 27.
    • Goudakos JK, Markou KD: Corticosteroids vs corticosteroids plus antiviral agents in the treatment of Bell palsy: a systematic review and meta-analysis. Arch Otolaryngol Head Neck Surg 2009, 135(6):558–564. Five randomized controlled studies published from 1996 to 2007 totaling 738 patients were analyzed. The authors found no benefit from adding an antiviral agent to corticosteroids in increasing the recovery rate of FNP in patients with BP. CrossRefPubMedGoogle Scholar
  28. 28.
    Hato N, Matsumoto S, Kisaki H, et al.: Efficacy of early treatment of Bell’s palsy with oral acyclovir and prednisolone. Otol Neurotol 2003, 24(6):948–951.CrossRefPubMedGoogle Scholar
  29. 29.
    Gilden DH, Tyler KL: Bell’s palsy—is glucocorticoid treatment enough? N Engl J Med 2007, 357(16):1653–1655.CrossRefPubMedGoogle Scholar
  30. 30.
    Murakami S, Mizobuchi M, Nakashiro Y, et al.: Bell palsy and herpes simplex virus: identification of viral DNA in endoneurial fluid and muscle. Ann Intern Med 1996, 124(1 Pt 1):27–30.PubMedGoogle Scholar
  31. 31.
    Madhok V, Falk G, Fahey T, Sullivan FM: Prescribe prednisolone alone for Bell’s palsy diagnosed within 72 h of symptom onset. BMJ 2009, 338:b255.CrossRefPubMedGoogle Scholar
  32. 32.
    Tyler KL: Prednisolone—but not antiviral drugs—improves outcome in patients with Bell’s palsy. Nat Clin Pract Neurol 2009, 5(2):74–75.CrossRefPubMedGoogle Scholar
  33. 33.
    Davenport RJ, Sullivan F, Smith B, et al.: Treatment for Bell’s palsy. Lancet 2008, 372(9645):1219–1220; author reply 1220–1211.CrossRefPubMedGoogle Scholar
  34. 34.
    Lockhart P, Daly F, Pitkethly M, et al.: Antiviral treatment for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2009, CD001869.Google Scholar
  35. 35.
    Frueh BR, Preston RA, Musch DC: Facial nerve injury and hemifacial spasm. Am J Ophthalmol 1990, 110(4):421–423.PubMedGoogle Scholar
  36. 36.
    Jordan DR, Patrinely JR, Anderson RL, Thiese SM: Essential blepharospasm and related dystonias. Surv Ophthalmol 1989, 34(2):123–132.CrossRefPubMedGoogle Scholar
  37. 37.
    Cramer H, Otto K: Meige’s syndrome: clinical findings and therapeutic results in 50 patients. Neuroophthalmology 1986, 6(1):3–15.CrossRefGoogle Scholar
  38. 38.
    Koutsis G, Kokotis P, Sarrigiannis P, et al.: Spastic paretic hemifacial contracture in multiple sclerosis: a neglected clinical and EMG entity. Mult Scler 2008, 14(7):927–932.CrossRefPubMedGoogle Scholar
  39. 39.
    Andermann F, Lloydsmith DL, Gloor P, et al.: Facial myokimia in multiple sclerosis. Brain 1961, 84(1):31.CrossRefGoogle Scholar
  40. 40.
    Tenser RB, Corbett JJ: Myokymia and facial contraction in brain stem glioma. An electromyographic study. Arch Neurol 1974, 30(6):425–427.PubMedGoogle Scholar
  41. 41.
    Waybright EA, Gutmann L, Chou SM: Facial myokymia. Pathological features. Arch Neurol 1979, 36(4):244–245.PubMedGoogle Scholar
  42. 42.
    Bettoni L, Bortone E, Ghizzoni P, Lechi A: Myokymia in the course of Bell’s palsy. An electromyographic study. J Neurol Sci 1988, 84(1):69–76.CrossRefPubMedGoogle Scholar
  43. 43.
    Brackmann DE, Fetterman BL: Cranial nerve VII. In Textbook of Clinical Neurology. edn. 3. Edited by Goetz CG. Oxford, UK: Saunders Elsevier; 2003:1392.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • M. Tariq Bhatti
    • 2
  • Jade S. Schiffman
    • 1
  • Anastas F. Pass
    • 3
  • Rosa A. Tang
    • 4
  1. 1.The University of Texas, MD Anderson Cancer CenterHoustonUSA
  2. 2.Departments of Ophthalmology and Medicine (Division of Neurology)Duke University Eye Center and Duke University Medical CenterDurhamUSA
  3. 3.University of Houston—University Eye Institute, MS Eye CARE CenterHoustonUSA
  4. 4.MS Eye CARE Center, University of HoustonHoustonUSA

Personalised recommendations