Facial palsy, characterized by weakness or paralysis of facial muscles, can significantly impact a person's ability to express themselves and perform essential functions. This article delves into the causes, symptoms, diagnosis, and various treatment approaches for facial palsy, providing a comprehensive overview for individuals seeking information on this condition.
Understanding Facial Palsy
Facial palsy affects the ability to move muscles on one or both sides of the face. Patients may experience difficulties with blinking, swallowing, eating, and showing emotions through facial expressions. Bell's palsy is the most common form of facial paralysis. It involves sudden, temporary weakness or paralysis of the muscles on one side of the face. The exact cause is unknown, but it's often associated with viral infections. While most cases of facial paralysis are due to Bell's palsy, many other causes can lead to similar symptoms.
Causes of Facial Paralysis
Facial paralysis occurs when cranial nerve number 7, also known as the facial nerve, is injured. The facial nerve is responsible for stimulating:
- The muscle responsible for motions in the face
- The gland responsible for producing tears
- The small muscle in the ear responsible for dampening certain noises
- The taste gland in the tongue
- Sensation in a small portion of the skin of the ear
Injury to the facial nerve may affect several aspects of the face, depending on the degree and location of facial nerve injury.
The common causes of facial paralysis include the following:
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Bell's Palsy
Bell's palsy is the most common form of facial paralysis in the United States, with approximately 15,000 to 40,000 cases a year. The condition is actually a diagnosis of exclusion - meaning the true reason for the facial palsy is unknown. Bell palsy is an unexplained episode of facial muscle weakness or paralysis. It begins suddenly and can get worse over 48 hours.
The most common symptom of Bell's palsy is a sudden onset of paralysis on one side of the face, which is often associated with ear pain. It has been reported to occur more frequently with some other conditions, namely pregnancy and diabetes. During pregnancy, facial paralysis tends to occur most commonly in the third trimester and usually resolves itself after delivery. In other cases, facial paralysis may occur in the immediate postpartum period.
Bell palsy can affect anyone at any age. It occurs most often in pregnant women, and in people who have diabetes, influenza, a cold, or another upper respiratory ailment. Bell palsy affects men and woman equally. Bell palsy is not considered permanent. But in rare cases, it doesn't disappear. Currently, there's no known cure for Bell palsy. But recovery usually begins 2 weeks to 6 months from the start of the symptoms.
The cause of Bell palsy is not known. It's thought that it may be due to inflammation that is directed by the body's immune system against the nerve controlling movement of the face. Infection, especially following a viral infection with Herpes simplex virus. The symptoms of Bell palsy may look like other health problems, such as Guillain-Barre syndrome, myasthenia, and multiple sclerosis.
Congenital Facial Palsy
Babies may be born with facial paralysis and often the cause is unclear. In the past when delivery was performed with forceps, sometimes facial nerve injuries could occur. Congenital facial palsy may appear also as part of a syndrome and involve one or both sides of the face.
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Moebius Syndrome
Moebius Syndrome is a rare form of bilateral facial paralysis in which the sixth cranial nerve (abducens nerve) responsible for lateral motion of the eye is also involved. Moebius Syndrome has varying symptoms and may be difficult to diagnose at birth. Often, additional cranial nerves are involved and sometimes extremities may have abnormalities, chest muscles may be involved, and eyelids, ear, and lip deformities may be seen. Still, many patients are healthy. The cause of this syndrome is not clearly known.
Surgery or Medical Procedures
Facial paralysis may be caused inadvertently by medical intervention or may at times be an inseparable part of a procedure in which the facial nerve must be removed. This includes:
- Cosmetic procedures, such as facelifts
- Dental procedures
- Mastoid or parotid surgery
- Nerve blocks in the face
- Skull base surgery
Not all facial paralysis after procedures is permanent. Procedures in the area of the nerve will often cause temporary paralysis (neuropraxia) and recovery can be seen over several months. If the nerve has been transected during surgery, it is necessary to reconstruct the nerve either by direct suturing or by grafting, and in certain cases, other procedures are needed.
Trauma
Trauma that causes facial nerve paralysis generally occurs in one of two locations:
Intracranial Trauma
The facial nerve courses through the temporal bone between where the nerve leaves the brainstem and where it exits the skull and enters the face. Any trauma strong enough to cause a fracture of this temporal bone may cause facial nerve paralysis. This is often seen after motor vehicle accidents or blast injuries and is more common in adults, although it may occur in children. If the paralysis occurs immediately after the accident, surgery involving decompression of the nerve via the skull base is performed by neurosurgeons and otolaryngologists. Close monitoring of the condition, rather than active treatment, is chosen when the paralysis progresses slowly.
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Extracranial/Facial Trauma
This type of injury is most commonly penetrating, either from a knife cut or projectile. Dental procedures or nerve blocks rarely cause this type of injury. Recovery can sometimes be seen without surgical intervention if the injury is close to the middle of the face, where the nerve branches are very small but also interconnect with other branches. If the injury is more to the side of the face, surgical repair of the nerve is usually needed, preferably within the first 72 hours of injury. The decision of whether to repair the nerve and the choice of surgical technique is usually made by an experienced plastic and reconstructive surgeon who has advanced training in facial nerve surgery and microsurgery.
Tumors
Facial nerve paralysis can be caused by tumors. Acoustic neuroma, cholesteatoma, schwannoma, and invasive carcinomas are among the more common tumors. Symptoms may vary, from an acute paralysis that shows no improvement over several months to a slowly progressive paralysis that’s often accompanied by synkinesis (abnormal twitching or motion in the face). Early diagnosis is critical, and imaging studies, such as computed tomography (CT) scans and magnetic resonance imaging (MRIs), are usually needed to identify the extent of the tumor. Based on the imaging findings, the treatment plan may involve surgery, radiation, or both. The removal of tumors itself may cause facial paralysis. However, inadvertent injury to the facial nerve is uncommon in the hands of experienced skull base surgeons, usually otolaryngologists and neurosurgeons. When a tumor is very close to the facial nerve or even surrounding the facial nerve, temporary or permanent facial paralysis may occur after tumor removal. In some cases, especially if cancerous tumors are involved, the facial nerve may be altered to obtain clear removal of the tumor.
Viruses
Several viruses, including varicella-zoster, herpes simplex, and Epstein-Barr (EBV) may cause facial paralysis. The varicella-zoster virus causes Ramsay Hunt syndrome, in which patients often have a history of ear pain, peripheral facial paralysis, and a rash located in the ear canal. Ramsay Hunt syndrome is also characterized by hearing loss, painful sensitivity to noise, and reduced tearing. Full recovery is usually less common than in Bell’s palsy, and more patients end up with complete nerve loss and synkinesis. Ear infections, infectious mononucleosis, and AIDS may also cause facial paralysis.
Lyme Disease
Another known infectious cause for facial paralysis is Lyme disease, seen more on the East Coast and caused by ticks commonly found on deer. Approximately 11 percent of patients with Lyme disease develop facial paralysis.
Other Causes
Other conditions and factors can also contribute to facial paralysis, including:
- Stroke
- Infections
- Inflammatory conditions
Symptoms of Facial Paralysis
Though there are many causes of facial paralysis, the signs and symptoms are often similar and include:
- Inability to smile: Smile asymmetry may range from being nearly unnoticeable to severe asymmetries with obvious deformities, even when the face is at rest. In its more severe forms, patients are unable to create a symmetric smile and the paralyzed side is droopier, even at rest.
- Inability to close the eye: Because one of the muscles surrounding the eye assists in eye closure, patients with partial or complete facial nerve paralysis often have difficulty closing the eye. Incomplete closure of the upper eyelid, in combination with decreased production of tears due to facial nerve injury, may expose the eye to dryness and corneal irritation, often resulting in pain (especially after waking), abrasions, ulcerations, and rarely blindness. This condition is also known as exposure keratopathy.
- Impaired speech: Due partially to the paralysis of muscles of the lips and those surrounding the mouth, patients frequently complain about impaired speech.
- Forehead paralysis: If the frontal branch of the facial nerve is involved, patients lose the ability to raise their forehead. In younger patients, it is sometimes less noticeable, but regardless of age, this causes significant impairment in both form and function. Patients lose the ability to lift the eyebrow - an important action of facial expression - and frequently have a droopy brow, which causes both asymmetry and may cover the eye and interfere with vision.
- Inability to clear food from the mouth: Due to paralysis of the Buccinator muscle, patients may complain about food remaining stuck in the cheek on the paralyzed side. Patients will often have difficulty advancing the food and will commonly use the tongue or fingers to mobilize the food.
- Drooling: Often in cases of severe paralysis, drooling of solids or fluids from the corner of the mouth may occur.
- Difficulty breathing from the nose: Often the sidewall of the nose is collapsed on the paralyzed side, causing difficult nasal breathing.
- Facial dyskinesias (involuntary facial movements): With synkinesis, when a person voluntarily moves one muscle, another muscle is also involuntarily and simultaneously moved. It occurs when the facial nerve has degenerated and then partially recovers. Common examples include the closing of the eyes and the simultaneous twitching or partial elevation of the lip or the opening between the upper and lower eyelid when one attempts to smile. With hyperkinesis, the resting state or activity of the muscle is exaggerated. It is not uncommon that the paralyzed side of the face is contracted or pulled towards the injured side yet cannot produce a functional smile. Very often, even in the resting state, the opening between the eyelids (palpebral fissure) is narrower on the paralyzed side compared to the normal side and may contribute to the asymmetry of the face.
- Drooping of the face
- Difficulty making facial expressions, such as closing an eye or smiling
- Drooling
- Pain around the jaw or in or behind the ear on the affected side
- Increased sensitivity to sound on the affected side
- Headache
- A loss of taste
- Changes in tear and saliva production
Medical attention is needed when facial paralysis only partially recovers or does not recover at all, is progressive, exists from birth, or has been of long-standing duration.
Symptoms of Bell's Palsy
The main sign of Bell’s palsy is facial muscle paralysis - usually on one side of your face. It looks like one side of your face is drooping. This includes your:
- Forehead.
- Eyebrow.
- Eye and eyelid.
- Corner of your mouth.
Symptoms of Bell’s palsy tend to come on suddenly and reach peak severity within 48 to 72 hours. Some people develop mild facial muscle weakness. Others experience total muscle paralysis in their face. It’s difficult to make full expressions with Bell’s palsy. Wrinkling your forehead, blinking and grimacing may be difficult or impossible on the affected side. Your face may feel numb or heavy. But you can still feel touch and temperatures (like heat and coolness) on the affected side of your face.
Other symptoms of Bell’s palsy may include:
- Drooling.
- Dry eyes.
- Difficulty speaking, eating or drinking.
- Facial or ear pain.
- Headache.
- Loss of taste.
- Ringing in your ears (tinnitus).
- Sensitivity to sounds (hyperacusis).
Early symptoms of Bell’s palsy - or warning signs - may include a slight fever and pain behind your ear. However, there’s nothing you can do to stop Bell’s palsy from developing once it begins. In addition, you could have these symptoms for another reason and not develop Bell’s palsy.
Diagnosis of Facial Paralysis
UT Southwestern physicians primarily use clinical evaluation to diagnose facial paralysis. The doctor will:
- Check for weakness or paralysis on one or both sides of the face
- Assess the patient's ability to make facial expressions, such as smiling or raising eyebrows
- Examine forehead, eyelid, and mouth movements
They’ll also ask the patient:
- When symptoms started and how quickly they developed
- Any recent illnesses or potential triggers
- Accompanying symptoms such as pain or changes in taste
While not always necessary, certain tests may be ordered to confirm the diagnosis or rule out other conditions:
- Imaging studies: MRI or CT scans may be used to eliminate other potential causes of facial paralysis, such as tumors.
- Electromyography (EMG): This test can assess nerve activity and provide information about the severity of the condition. This test can confirm the presence of nerve damage and determine how serious it is. An EMG measures the electrical activity of a muscle in response to stimulation.
- Blood tests: Blood tests may be conducted to rule out other infections or conditions. There is no blood test for Bell's palsy.
A healthcare provider will ask about your symptoms and review your medical history. They’ll perform a physical examination and ask you to try to make various facial movements, like:
- Opening and closing your eyes.
- Raising your eyebrows.
- Smiling.
- Frowning.
In addition to a physical examination, your healthcare provider may request imaging tests.
It's crucial to distinguish Bell's palsy from other conditions that can cause facial weakness, such as stroke, middle ear infections, or multiple sclerosis.
Treatment of Facial Paralysis
Facial paralysis treatments can vary based on the type and location of the paralysis, the elapsed time from when the paralysis occurred to the time of seeking treatment, the patient’s age, and patient preference. Treatment of Bell palsy should be conservative and guided by the severity and probable prognosis in each particular case.
Addressing the Underlying Cause
Facial paralysis treatment depends on the underlying cause. For example:
- If you develop facial paralysis as a result of stroke, your healthcare provider will focus on treating stroke.
- If facial paralysis is a result of a tumor, your provider will discuss options to remove the tumor.
- If the cause is Bell’s palsy, then your provider may prescribe medications and recommend facial strengthening exercises.
Nonsurgical Treatments
Nonsurgical treatments may include:
- Corticosteroids: Corticosteroids, such as prednisone (Rayos, Prednisone Intensol) to reduce inflammation and swelling in your facial nerve. These are powerful anti-inflammatory agents. If they can reduce the swelling of the facial nerve, the nerve can fit more comfortably within the bony corridor that surrounds it. Corticosteroids may work best if they're started within several days of when symptoms start. The most widely accepted treatment for Bell palsy is corticosteroid therapy. However, the use of steroids is still controversial because most patients recover without treatment. The guidelines recommend use of corticosteroids within 72 hours from the onset of symptoms. The recommended dose of prednisone for the treatment of Bell palsy is 1 mg/kg or 60 mg/day for 6 days, followed by a taper, for a total of 10 days.
- Antivirals: Antivirals to fight possible infection. The role of antivirals is not certain. Antivirals alone have shown no benefit compared with placebo. Antiviral agents (eg, acyclovir, valacyclovir) may be considered if a viral etiology is suspected, but only in combination with corticosteroids. Acyclovir (Zovirax) is administered at a dosage of 400 mg orally 5 times daily for 10 days. Valacyclovir (Valtrex), taken orally in doses of 500 mg twice daily for 5 days, may be used instead of acyclovir. If VZV is the cause of Bell palsy, higher doses may be needed (1000 mg orally 3 times daily).
- Botox injections: OnabotulinumtoxinA (Botox). This medicine may help manage symptoms such as facial spasms and tearing. Botox injections to treat synkinesis - a secondary condition that results in involuntary muscle movements. (This is common with Bell’s palsy.)
- Physical therapy: Physical therapy to improve facial symmetry, increase muscle strength and regain facial coordination. Paralyzed muscles can shrink and shorten, which may be permanent. Physical therapy (eg, facial exercises, neuromuscular retraining )
- Speech therapy: Speech therapy to help you regain your speech and swallow function.
- Occupational therapy: Occupational therapy to help you improve functions like facial expressions and interpersonal communication.
- Taking pain relievers.
- Doing physical therapy exercises.
- Acupuncture.
- Biofeedback training.
- Applying moist heat.
Surgical Treatments
Surgical treatments may include:
Eyelid surgery: In order to help your eye close, various procedures may be performed to support your eye and make blinking more efficient.
Reanimation surgery: There are various types of reanimation surgery. For some procedures, a surgeon takes muscles and/or nerves from other areas of your body (some nearby and some from remote sites) and uses them to restore facial movement. Facial reanimation may involve nerve transfers, tendon transfers or muscle transplants, depending on the specific goals of treatment. Facial reanimation surgery helps make the face look more even and may restore facial movement. Examples of this type of surgery include an eyebrow lift, an eyelid lift, facial implants and nerve grafts.
Surgery to remove a tumor: If facial paralysis is the result of a tumor, a surgeon may perform surgery to remove it and take pressure off your facial nerve.
Cosmetic surgery: There are several cosmetic surgery procedures that can restore balance and symmetry to your face. These procedures may include brow lifts, facelifts, facial slings and eyelid surgery.
Decompression surgery: In the past, decompression surgery was used to relieve the pressure on the facial nerve by opening the bony passage that the nerve passes through. Today, decompression surgery isn't recommended.
Tarsorrhaphy: Tarsorrhaphy decreases horizontal lid opening by fusing the eyelid margins together, increasing support of the precorneal lake of tears and improving coverage of the eye during sleep. The procedure can be done in the office and is particularly suitable for patients who are unable or unwilling to undergo other surgery. It can be completed as either a temporary or a permanent measure. Tarsorrhaphy can be performed laterally, centrally, or medially.
Each case is unique and each person has their own set of specific needs. Your healthcare provider will talk to you in detail about a treatment option that’s right for you.
Eye Care
If face paralysis affects your eyes, it can lead to chronic dry eyes and other complications. In these cases, your healthcare provider will recommend treatment to prevent your eyes from drying out too much. This might include:
- Eye drops and ointments.
- Taping your eyelids.
- Eye patches.
- Temporary closure of your eyelid with sutures.
- Surgery to place small weights in your eyelids to help them close.
It is universally accepted that eye care is imperative in Bell palsy. In most cases, topical ocular lubrication (with artificial tears during the day and lubricating ophthalmic ointment at night, or occasionally ointment day and night) is sufficient to prevent the complications of corneal exposure.
Can the Risk of Facial Paralysis Be Reduced?
Many cases of facial paralysis, particularly Bell's palsy, occur without any clear cause or warning. In many cases, you can’t prevent the conditions or situations that may result in facial paralysis - particularly in cases of trauma. However, some steps may help reduce the risk of certain types of facial paralysis:
Preventive Measures
- Manage underlying health conditions: Controlling conditions like diabetes and high blood pressure may help reduce the risk of facial paralysis related to stroke or other vascular issues.
- Reduce stress: A link may exist between stress and the onset of Bell's palsy, possibly due to stress weakening the immune system. Managing stress through relaxation techniques may be beneficial.
- Practice good hygiene: Since some cases of facial paralysis are linked to viral or bacterial infections, maintaining good hygiene habits may help reduce exposure to potential pathogens.
- Protect against tick bites: Lyme disease, transmitted by tick bites, can cause facial paralysis.
Prognosis for Bell's Palsy
Bell palsy usually resolves in time and causes no long-term complications. Most people with Bell's palsy recover fully - with or without treatment. Symptoms often get better on their own in a few weeks. Your face should return to normal movement. Recovery from Bell’s palsy can take up to a full year. But for most people, it goes away after a few months. Bell palsy usually starts to improve in 2 weeks. But it may take 3 to 6 months to return to normal.
But during the illness, most people are unable to close their eye on the affected side of their face. So it's important to protect the eye from drying at night or while working at a computer. Eye care may include eye drops during the day, ointment at bedtime, or a moisture chamber at night. A small number of people continue to have some weakness of the face. They may need surgery if the weakness greatly affects the eyelids. It's also crucial that you protect the affected eye from drying.
In certain cases, some symptoms of Bell's palsy don’t go away. You may have lasting weakness, tightening, or spasming in your face muscles. Complications can also occur 3-4 months after you first get Bell’s palsy. Irregular regrowth of nerve fibers. This may result in involuntary contraction of certain muscles when you're trying to move other muscles, known as synkinesis. Partial or complete blindness of the eye that won't close.