OBJECTIVEThis study reviewed patients with unilateral facial paralysis and normal clinical and imaging findings who underwent diagnostic facial nerve exploration.STUDY DESIGN AND SETTINGFifteen patients with facial paralysis and normal findings were seen in the Mayo Clinic Department of Otorhinolaryngology.RESULTSEleven patients were misdiagnosed as having Bell palsy or idiopathic paralysis. Progressive facial paralysis with sequential involvement of adjacent facial nerve branches occurred in all 15 patients. Seven patients had a history of regional skin squamous cell carcinoma, 13 patients had surgical exploration to rule out a neoplastic process, and 2 patients had negative exploration. At last follow‐up, 5 patients were alive.CONCLUSIONSPatients with facial paralysis and normal clinical and imaging findings should be considered for facial nerve exploration when the patient has a history of pain or regional skin cancer, involvement of other cranial nerves, and prolonged facial paralysis.SIGNIFICANCEOccult malignancy of the facial nerve may cause unilateral facial paralysis in patients with normal clinical and imaging findings. (Otolaryngol Head Neck Surg 2004;130:459–65.)