Facial Palsy, Radiographic and Other Workup Negative: FROWN

Objectives: Slow-onset peripheral facial palsy is far less common than acute-onset peripheral facial palsy and necessitates diagnostic evaluation for a benign or malignant tumors, or other less common etiologies. In the rare scenario when no clarifying etiology is discovered following long-term evaluation (no radiographic or hematologic abnormalities and an otherwise unremarkable evaluation), a diagnostic and management dilemma occurs. We present a series of patients with this possible new clinical entity: facial palsy, radiographic and other workup negative (FROWN), and propose a management strategy for this diagnosis of exclusion.

Methods: A series of 3,849 patients presenting with facial palsy to a tertiary Facial Nerve Center was retrospectively assessed to identify those with progressive loss of facial function over at least 1 month. Exclusion criteria included history, physical or hematologic findings indicative of known diseases associated with facial palsy, and radiographic studies demonstrating a benign or malignant tumor.

Results: Patients with slow-onset facial palsy constituted 5% (190 patients) of the cohort and were ultimately diagnosed with either a benign or malignant neoplasm or other facial nerve pathology. Fourteen patients with slow-onset facial palsy remained without a diagnosis following long-term evaluation and serial imaging. Eleven patients underwent dynamic facial reanimation surgery and facial nerve and muscle biopsy, with no clear histopathologic diagnosis.

Conclusion: Patients with slow-onset facial palsy with negative radiographic and medical evaluations over several years may be characterized as having FROWN, an idiopathic and as yet poorly understood condition, which appears to be amenable to facial reanimation, but which requires further investigation as to its pathophysiology.