Congenital Facial Nerve Palsy

Aka: Congenital Facial Nerve Palsy, Facial Nerve Injury from Birth Trauma, Congenital Cranial Nerve 7 Palsy

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II. Epidemiology

  1. Incidence: 2 in 1000 live births

III. Pathophysiology

  1. Facial Nerve (Cranial Nerve VII) injury

IV. Causes

  1. No Traumatic cause in most cases
  2. Postulated causes (birth or perinatal Trauma)
    1. Forceps blade Trauma
    2. Molding
  3. Congenital Facial Palsy
    1. Mobius syndrome
    2. Cardiofacial syndrome

V. Risk Factors

  1. Primiparous women
  2. Birth weight >3500 g
  3. Forceps Assisted Delivery
  4. Cesarean delivery
  5. Prematurity

VI. Signs

  1. Central Facial Nerve Injury
    1. Asymmetrical face with crying
    2. Forehead and Eyelid not affected
    3. Abnormal side
      1. Skin on abnormal side is smooth and swollen
      2. Nasolabial fold absent
      3. Corner of mouth droops
      4. Weakness Depressor Anguli Oris with drooping corner of mouth (e.g. especially while crying)
    4. Normal side
      1. Mouth deviated to normal side
      2. Wrinkles deeper
  2. Peripheral Facial Nerve Injury
    1. Asymmetrical face with crying
  3. Peripheral Facial Nerve branch injury
    1. Asymmetrical face with crying
    2. Affects only forehead, eye, and mouth

VII. Differential Diagnosis

  1. Brainstem motor nuclei hypoplasia or agenesis (Mobius syndrome)
  2. Arnold Chiari syndrome
  3. Genetic malformation
    1. Congenital absence of facial Muscles
    2. Orbicularis OrisMuscle absent on one side
  4. Neonatal stroke
    1. May present with Neonatal Seizure, apnea, Hemiparesis or focal weakness
    2. Incidence: 9.6 per 100,000 live births in U.S.
    3. Types
      1. Ischemic CVA (arterial territory)
      2. Intracranial Hemorrhage
      3. Periventricular venous infarction

VIII. Management

  1. Eye Protection
    1. Eye patch
    2. Methylcellulose drops (artificial tears) q4 hours
  2. Atypical presentations (or lack of improvement after first 2 weeks)
    1. See differential diagnosis above
    2. Consider pediatric neurology Consultation
    3. Consider MRI Brain
    4. Consider electrodiagnostics
  3. Persistent facial palsy (esp. >2 months)
    1. Physical therapy
    2. Surgical interventions
      1. Lid loading surgery
      2. Microneurovascular Muscle transfer

IX. Course

  1. Traumatic palsy resolves completely in most cases
    1. Recovery begins by first week of life
    2. Complete resolution anticipated over first 2 months of life
  2. Persistent facial palsy (>2 months) causes
    1. See Differential Diagnosis above

X. References

  1. Al Tawil (2010) Am J Perinatol 27(9): 711-3 [PubMed]
  2. Ciorba (2015) World J Clin Cases 3(12): 973-9 [PubMed]
  3. Williams (2026) Am Fam Physician 113(2): 189-90 [PubMed]

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