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[1]                                                                                                                                                                                                                                                 AJDHS.COM 

 

 

Available online at ajdhs.com 

Asian Journal of Dental and Health Sciences 
Open Access to Dental and Medical Research 

Copyright  © 2023 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 
which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided 

the original author and source are credited  

 

 

Facial Nerve Paralysis After Dental Extraction 

Chia Earn Sun1*, Irfan Mohamad 2, Khairul Bariah Noh3, Fei Ming Ong 4 

1 KPJ Healthcare University, Lot PT 17010, Persiaran Seriemas Utama, Kota Seriemas, 71800 Nilai, Negeri Sembilan, Malaysia. 

2 Department of Otorhinolaryngology, Head & Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 15200 Kota Bharu, 
Kelantan, Malaysia. 

3 Department of Otorhinolaryngology, Head & Neck Surgery, Hospital Sultanah Bahiyah, Km 6, Jln Langgar, Bandar, 05460 Alor Setar, Kedah, Malaysia. 

4 Bagan Specialist Centre, Jalan Bagan 1, Taman Bagan, 13400 Butterworth, Pulau Pinang, Malaysia. 

Article Info: 
_____________________________________________ 
Article History: 

Received 06 September 2023     
Reviewed  09 October 2023 
Accepted 02 November 2023 
Published 15 December 2023 

_____________________________________________ 
Cite this article as:  

Sun CE, Mohamad I, Noh KB, Ong FM, Facial Nerve 
Paralysis After Dental Extraction, Asian Journal of 
Dental and Health Sciences. 2023; 3(4):1-3 

DOI: http://dx.doi.org/10.22270/ajdhs.v3i4.59         

Abstract 
_________________________________________________________________________________________________________________ 

Parotitis is inflammation of the parotid gland caused by infection, either virus or bacteria. Facial 
nerve palsy with an associated parotid mass should always be investigated for underlying neoplasm. 
Facial nerve palsy is an unusual symptom of inflammation of the parotid gland. We report two cases 
of unilateral facial paralysis associated with acute parotitis. The patients experience ipsilateral facial 
paralysis, accompanied by additional symptoms that varied between cases. Infective causes of facial 
nerve palsy usually have good prognosis.  

Keywords: Parotid gland, Facial nerve, Facial paralysis; Parotitis, Neoplasm 

*Address for Correspondence:   

Chia Earn Sun, KPJ Healthcare University, Lot PT 17010, Persiaran Seriemas Utama, Kota Seriemas, 71800 Nilai, Negeri Sembilan, Malaysia. 

 

INTRODUCTION  

Facial paralysis due to parotid pathology is almost always 
associated with malignant lesion of the gland. Although there 
has been reported facial nerve palsy secondary to benign 
parotid gland pathology such as benign tumours, sarcoidosis 
and parotid cysts, the incidence of facial nerve palsy secondary 
to infective pathology of the parotid gland is exceedingly rare1,2.  

CASE SUMMARY  

Case 1 

A 36-year-old gentleman presented with one-week history of 
right parotid swelling and pain. He also complained of right 
sided facial nerve palsy for 5 days. He had history of dental 
procedure done 2 weeks prior to his symptoms. No preceding 
upper respiratory tract symptoms. He has no odynophagia, 
dysphagia or respiratory compromise. There was no fever.  

Clinical examination revealed diffuse swelling over right 
parotid which was erythematous and tender. There was no 
trismus. Intraoral examination was unremarkable. No pus on 
milking of Stenson duct. No medialization of lateral pharyngeal 
wall. No neck nodes were palpable. There was presence of 
right-sided facial nerve palsy, with House-Brackmann grade III. 
Other cranial nerves were intact. Otoscopy examination were 
unremarkable. Pure tone audiometry showed normal hearing 
bilaterally. Topodiagnostic test revealed absent ipsilateral 
stapedial reflex, normal Schimer test bilaterally. Flexible 
endoscopic examination was unremarkable.  

A clinical diagnosis of acute right parotitis was made. He was 
treated with intravenous Co-Amoxiclav, oral Methylcobalamin, 
tablet Prednisolone, artificial eye drops and advised on eye care. 
Right-sided facial swelling and pain resolved in response to 
antibiotic. He was discharged after 3 days of hospitalization and 
completed total 10 days of antibiotics and tapering dose of 
prednisolone. Follow-up outpatient visit at one month showed 
improvement of right sided facial nerve palsy House-Brackman 
grade II and resolved right parotid swelling. Facial nerve palsy 
resolved completely at subsequent follow-up 6 months post 
initial presentation.  

 

Figure 1. Right facial nerve palsy at initial presentation. 

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Sun et al                                                                                                                                            Asian Journal of Dental and Health Sciences. 2023; 3(4):1-3 

[2]                                                                                                                                                                                                                                                 AJDHS.COM 

Case 2 

A 58-year old gentleman with underlying Diabetes Mellitus 
presented with two-day history of right parotid swelling, 
restricted mouth opening and reduced oral intake. He had a 
dental procedure done about a week prior to initial 
presentation. He denied odynophagia, dysphagia or airway 
symptoms. There was no history of preceding upper 
respiratory tract infection or fever.  

Initial clinical assessment showed diffuse, tender swelling over 
right parotid region. Overlying skin is warm and erythematous. 
He also had trismus with mouth opening of one finger-breadth. 
Intra-oral examination revealed bulging of the right 
peritonsillar region. No neck nodes palpable. Further flexible 
nasopharyngo-laryngoscopy examination showed right 
peritonsillar bulge with slight extension of the right lateral 
pharyngeal wall. Cranial nerves were intact on initial 
assessment. Otoscopy examination was unremarkable. 
Contrast-enhanced computed topography of the neck revealed 
small collection inferior to right alveolar process of right 
maxillary bone, swollen right masseter and right parotid glands. 
Diagnosis of acute peritonsillar abscess with acute parotitis was 
made.  

Incision and drainage was done over right peritonsillar region, 
which drained 10cc of pus. Pus culture and sensitivity showed 
mixed growth of 1 gram positive cocci and 2 gram negative rods. 
He was treated with intravenous Cefuroxime and 
Metronidazole. On Day 6 of admission, patient developed right-
sided facial nerve palsy, House-Brackmann grade III. Other 
cranial nerves were intact.  

Fine needle aspiration cytology done over right parotid 
swelling showed benign salivary acini, no malignant cell seen. 
Right sided facial swelling and pain resolved with antibiotics, 
with improved mouth opening and good oral intake. He 
completed 2 weeks of intravenous antibiotics. He was referred 
for facial exercises. On his follow-up outpatient visit at one 
month, right parotid swelling resolved, with persistent right 
facial nerve paralysis House-Brackmann grade II.  

DISCUSSION 

Inflammation of salivary gland such as parotitis is usually 
caused by salivary stasis. Predisposing factors include 
sialolithiasis, duct stricture, dehydration, poor oral hygiene, 
immunosuppression, diabetes mellitus, autoimmune disorders 
and congenital sialectasis3. In both patients, there was a history 
of dental procedure prior to presentation, suggesting dental 
origin of infection. Poor oral hygiene was predisposing factors 
in both patients. Index patient in the second case had 
underlying diabetes mellitus.  

Acute suppurative sialadenitis commonly involved the parotid 
glands as the serous property of the saliva has less 
antimicrobial activity, as compared to the mucinous saliva of 
the submandibular gland. Common organisms that are 
responsible for sialadenitis include Staphylococcus aureus 
followed by Streptococcus viridans, and anaerobes4. In the 
second case, pus culture showed mixed growth of a gram-
positive cocci and 2 gram negative rods. 

Majority of the patient presented with acute onset of local pain 
and swelling, erythema, trismus, usually accompanied by fever, 
malaise and poor oral intake. Clinical examination will reveal 
tenderness, warmth and induration of the overlying skin. In 
parotid abscess, fluctuancy may not be elicited due to the 
overlying capsule formed by the fascia superficial to it1. 
Bimanual palpation occasionally demonstrates pus from 
Stenson duct opening4. 

In the first case, the patient came with typical presentation of 
right acute parotitis with involvement of facial nerve, which 

was unusual. Both parotid swelling and facial paralysis 
responded well to antibiotics. The second patient presented 
with acute right peritonsillar abscess with inflammation of 
ipsilateral parotid gland. Facial paralysis developed later at Day 
6 of admission. Fine needle aspiration was thus essential to 
exclude possibility of parotid neoplasm, in which cytology 
revealed benign salivary acini. Computed tomography did not 
show parotid neoplasm.  

Facial nerve palsy secondary to parotitis is extremely rare. In 
cases where facial nerve palsy is associated with parotid 
pathology, malignant neoplasm of the gland has to be highly 
suspicious especially high grade mucoepidermoid carcinoma 
and adenoid cystic carcinoma of parotid because of perineural 
invasion4. Other than that, benign conditions of the parotid 
gland such as Warthin tumour, and sarcoidosis has also been 
shown to affect the facial nerve3. The etiology of facial nerve 
paralysis in acute parotitis remains unknown. Involvement of 
the facial nerve has been suggested to be secondary to 
compression of the seventh nerve in association with local 
inflammation; perineuritis due to the virulence of the offending 
organisms or ischemic neuropathy arising from the local toxic 
effects of infection1,2,5. 

Clinical approach should begin with a full history and clinical 
examination. Detailed examination of the head and neck and 
cranial nerves should be done to exclude any malignancy. Acute 
signs of infection such as redness, tenderness and warmth with 
documented fever should be treated with intravenous 
antibiotics. If there is a purulent discharge, swab for culture and 
sensitivity has to be taken to determine the offending organism 
and its antibiotic sensitivity. For our second patient, pus culture 
grew mixed growth of 1 gram positive and 2 gram negative rods. 
Other adjuvant measures include sialogouges, hydration and 
good oral hygiene are advocated3 

When diagnostic doubt exists, patients should be investigated 
for an underlying neoplasm. Imaging is indicated in patients 
who do not respond to medical therapy or if there is suspicion 
of underlying malignancy4. Ultrasound scan is the initial 
imaging modality of choice for the assessment of parotid gland, 
as it is able identify any collection, mass or calculi; and will be 
able to detect features of malignant lesion such as irregular 
shape, speculated or ill-defined margin, heterogeneous 
echotexture, punctate calcification and vascularization6. 
Further imaging modalities such as CT (computed tomography) 
or MRI (magnetic resonance imaging) will be needed if there is 
further suspicion of malignancy to see the extension of tumour, 
any nodal metastasis and for staging purpose. Further 
evaluation of a parotid mass can be done by means of fine 
needle aspiration, biopsy or histological evaluation of the mass 
by surgical excision4. 

In our cases, the patient responded to initial medical treatment 
and the parotid swelling resolved rapidly. The first patient 
showed complete resolution of facial paralysis. As for the 
second patient, further follow-up visit at one month showed 
persistent facial nerve paralysis despite resolution of his right 
parotid swelling.   

CONCLUSION  

Facial nerve palsy accompanying benign parotid pathology is 
uncommon. Acute parotitis causing facial nerve palsy is even 
rare. In cases of facial nerve palsy associated with parotid 
swelling, malignancy has to be excluded. Infective causes of 
facial nerve palsy have a good prognosis, with likely resolution 
of the facial nerve palsy.  

Conflict of interest: There is no conflict of interest in this work.  

 



Sun et al                                                                                                                                            Asian Journal of Dental and Health Sciences. 2023; 3(4):1-3 

[3]                                                                                                                                                                                                                                                 AJDHS.COM 

Patient’s consent: Verbal consent was obtained from patient 
in agreement of data publication. 

What is new in this case report compared to previous 
literature? 

- Parotitis/ infective pathology is an unusual cause of facial 
nerve palsy. 

- We highlighted the possibility of dental origin of infection 
progressing to involve parotid and other neck spaces. 

Learning points and implications to patients 

- Full examination of the head and neck and relevant 
investigations must be undertaken to rule out the 
possibility of malignancy. 

- Management of patient should be focused on treating the 
underlying cause to reduce perineural inflammation. 

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1. Mohamad I, Ahmad MZ, Mohamad H. Parotid abscess with facial 
nerve paralysis in a young healthy female. Bangladesh J 

Otorhinolaryngol. 2011;17(2):147-
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2. Alam M, Hasan S, Hashmi S, Singh P. Facial Palsy due to Parotid 
Abscess: An Unusual Complication. Turk Arch Otorhinolaryngol. 
2017;54(4):168-171. https://doi.org/10.5152/tao.2016.1671 

3. Lowe E, Singh C, Birdi S. What lies beneath a facial nerve palsy? 
Case report of a facial palsy caused by non-suppurative parotitis. 
Case Studies in Surgery. 2016;2(4):17-21. 
https://doi.org/10.5430/css.v2n4p17 

4. Hajiioannou J, Florou V, Kousoulis P et al. Reversible facial nerve 
palsy due to parotid abscess Int J Surg Case Rep. 2013;4(11):1021-
1024. https://doi.org/10.1016/j.ijscr.2013.08.016 

5. Pitz CC, Duurkens VA, Goossens DJ, et al. Tetraplegia after a 
tracheal resection procedure. Chest. 1994;106(4):1264-5. 
https://doi.org/10.1378/chest.106.4.1264 

6. Wu S, Liu G, Chen R, Guan Y. Role of ultrasound in the assessment 
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https://doi.org/10.3329/bjo.v17i2.8858
https://doi.org/10.5152/tao.2016.1671
https://doi.org/10.5430/css.v2n4p17
https://doi.org/10.1016/j.ijscr.2013.08.016
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https://doi.org/10.1259/dmfr/60907848

