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Facial Plastic and Reconstructive Surgery

(076) Case Series: Facial Nerve Neoplasms Misdiagnosed as “Permanent” Bell’s Palsy

Monday, October 2, 2023
2:45 PM – 3:45 PM East Coast USA Time
Has Audio

    Presenting Author(s)

  • Shreya Mandava, BS

    MS4
    University of Virginia School of Medicine
    Charlottesville, Virginia, United States

    • Co-Author(s)

  • CG

    Claudia Gutierrez, MD

    PGY-4
    Department of Otolaryngology - Head and Neck Surgery, University of Virginia
    Charlottesville, Virginia, United States

    • Senior Author(s)

  • Samuel L. Oyer, MD

    Associate Professor
    Department of Otolaryngology - Head and Neck Surgery, University of Virginia
    Charlottesville, Virginia, United States

Disclosure(s):
Shreya Mandava, BS: No relevant relationships to disclose.
Claudia Gutierrez, MD: No relevant relationships to disclose.
Samuel L. Oyer, MD: No relevant relationships to disclose.


Introduction: Facial nerve tumors, such as parotid gland tumors, vascular tumors, and cutaneous squamous cell carcinomas (SCC) with neurotrophic spread can be misdiagnosed as “permanent Bell’s palsy.”

Methods: Patients originally referred for surgical management of facial paralysis with a diagnosis of Bell’s palsy were found to have occult tumors with facial nerve involvement on imaging. Their medical records, imaging studies, audiology reports, and operative notes were reviewed.

Results: Three patients were identified: one 66 year-old male, one 70 year-old male, and one 82 year-old female. It was found that 2/3 (67%) patients had SCC with perineural extension and 1/3 (33%) had a facial nerve hemangioma per imaging. All 3/3 (100%) presented with progressive-onset complete facial paralysis (House-Brackmann Grade VI) and had associated facial pain and paresthesias/dysesthesias. 2/3 (67%) experienced sialorrhea and the 2/3 (67%) patients with SCC had previous precancerous/cancerous skin neoplasms. The one patient with hearing loss and tinnitus is suspected to have a hemangioma. Notably, one patient with SCC was responsive to medical therapy consistently of antivirals, steroids, and IVIG.

The mean diagnostic delay time for these patients was 32.7 months. All three had negative findings on their initial diagnostic imaging study. However, given the persistence of their paralysis, additional studies were undertaken at varying time intervals to evaluate for alternative causes of the paralysis.

Conclusions: Bell’s palsy is a diagnosis of exclusion characterized by acute onset facial paralysis with complete or partial recovery by six months. This series presents patients with progressive onset complete facial paralysis along with facial pain and dysesthesias with an average diagnostic delay of almost three years. Given the known time course of Bell’s palsy, this series highlights the importance of paralysis history and repeat interval surveillance imaging for occult masses in patients with unresolved unilateral facial paralysis, especially in those with coexisting cranial neuropathies or a history of facial skin cancers.