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We present a case of a 69-year-old male who presented with acute left facial nerve palsy, serous bloody otorrhea, otalgia, and exposed necrotic bone on the floor of his left ear canal. His medical history revealed a left canal wall-down (CWD) mastoidectomy thirty years ago. Subsequently, twenty years later, he received primary chemoradiotherapy for tonsil cancer on the same side. The patient’s medical history, the typical clinical picture, and a comprehensive diagnostic workup, including imaging modalities and electrophysiology, finally led to a diagnosis of osteoradionecrosis of the temporal bone (ORNTB), with secondary facial nerve palsy. The facial nerve, unfortunately, did not recover and treatment remained conservative, as per the patient’s preference. ORNTB is a rare, delayed complication after radiotherapy for head and neck cancer, which occurs after about 8 years and a minimum of 41.8 Gray of radiation to the affected area. Facial nerve palsy in ORNTB is rare, with only 2.9% of patients experiencing it, but, in our particular case, the patient had undergone an additional CWD mastoidectomy. The treatment options need to be personalized and aimed at symptom control. There should be awareness of the condition among ENT specialists, especially during head and neck cancer follow-ups, and in patients who have had mastoidectomy and radiotherapy affecting the ipsilateral temporal bone.