Face your weakness – can you confidently assess facial droop?

Author: Jay Park / Editor: Sarah Edwards / Codes: EC4, NeuC10, NeuC12, NeuP5, NeuP8, SLO1, SLO2 / Published: 03/10/2025

A 60-year-old male with background of hypertension presents with a 1 day history of sudden onset left-sided facial drooping, loss of taste to left side of tongue, and left-sided otalgia and post-auricular pain (nil discharge /tinnitus/vertigo/ hearing changes). This was preceded by 4 days of sore throat, muscle aches and fatigue. He denies head trauma, fever/rigors, syncope, headache, photophobia, neck stiffness, nausea and vomiting, seizures and weight loss. This is his first presentation of facial weakness. He denies any recent travel, including to grassy or wooded areas in UK.

On examination:

There is an obvious left-sided facial droop compared to the right on inspection. He can slightly raise his left eyebrow with lots of effort and cannot wrinkle his left forehead. He manages to close his left eye with effort and can only weakly resist forced eye opening. When asked to smile with maximum effort, he has slight left-sided mouth drooping still visible, and you also notice that his left eye winks slightly at the same time.

Throat exam – tonsils normal appearance, no vesicles

Ear exam – left ear shows small amount of wax, normal appearances of tympanic membrane and auditory canal, no vesicles/rash, no mastoid tenderness.

No parotid masses palpated

Other cranial nerves and peripheral nerves test normally.

No evidence of rash or bites on top-to-toe exam

Observations:

• SpO2 – 99% on air
• RR – 18
• HR – 57
• BP – 125/60
• Temp – 36.5C GCS 15/15, PEARL 3mm bilaterally