What are the differential diagnoses for a patient presenting with unilateral facial weakness (hemifacial paresis)?

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Last updated: March 19, 2025 • View editorial policy

Differential Diagnosis for Unilateral Facial Weakness

Single Most Likely Diagnosis

  • Bell's Palsy: This is the most common cause of unilateral facial weakness, accounting for approximately 70% of cases. It is an idiopathic condition characterized by inflammation of the facial nerve, leading to weakness or paralysis of the facial muscles on one side of the face. The diagnosis is often made clinically, based on the presentation of sudden onset unilateral facial weakness without other neurological symptoms.

Other Likely Diagnoses

  • Stroke or Transient Ischemic Attack (TIA): While less common than Bell's Palsy, a stroke or TIA can cause unilateral facial weakness. However, this is usually accompanied by other neurological deficits such as limb weakness, speech difficulties, or sensory changes.
  • Lyme Disease: Neuroborreliosis, the neurological manifestation of Lyme disease, can cause facial nerve palsy, among other symptoms. This is particularly considered in endemic areas or in patients with a history of tick exposure.
  • Ramsay Hunt Syndrome: This condition, caused by the varicella-zoster virus (the same virus that causes chickenpox and shingles), can lead to facial weakness, ear pain, and vesicles in the ear. It is less common than Bell's Palsy but should be considered, especially in older adults or those with a history of shingles.

Do Not Miss Diagnoses

  • Brain Tumors: Although rare, tumors affecting the facial nerve or its nucleus can cause unilateral facial weakness. Early diagnosis is crucial for treatment and prognosis, making this a "do not miss" diagnosis.
  • Multiple Sclerosis: This demyelinating disease can present with a wide range of neurological symptoms, including unilateral facial weakness. Identifying multiple sclerosis early can significantly impact management and quality of life.
  • Cerebellopontine Angle Tumors: Tumors in this location, such as acoustic neuromas, can compress the facial nerve, leading to weakness. These tumors are rare but can have significant implications if not diagnosed and treated appropriately.

Rare Diagnoses

  • Sarcoidosis: This autoimmune disease can cause facial nerve palsy among its myriad presentations. It is rare but should be considered in patients with other systemic symptoms suggestive of sarcoidosis.
  • Guillain-Barré Syndrome: Although primarily known for causing ascending paralysis, Guillain-Barré Syndrome can occasionally present with facial weakness. It is a rare condition but one that requires prompt recognition and treatment due to its potential for rapid progression and respiratory compromise.
  • Melkersson-Rosenthal Syndrome: A rare neurological disorder characterized by recurrent, often unilateral, facial paralysis or weakness, along with swelling of the face and lips (usually the upper lip) and the development of folds and furrows in the tongue (fissured tongue).

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.