Facial Paralysis

UT Southwestern Medical Center offers comprehensive, multidisciplinary treatment for many of the most complex facial paralysis problems. We understand that confronting facial paralysis is very difficult. Our goal is to help.

What Is Facial Paralysis (Bell’s Palsy)?

This condition affects someone’s ability to move the muscles on one or both sides of their face. It may be caused by damage to the facial nerve due to injury, infection, or a brain condition such as a stroke. Patients may have 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. That’s why it’s essential to seek a proper diagnosis and understand the underlying cause of the condition.

What Causes Facial Paralysis?

It 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:

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. Named after a 19th-century Scottish surgeon, the condition is actually a diagnosis of exclusion – meaning the true reason for the facial palsy is unknown.

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.

Most patients fully recover from Bell's palsy. A primary care physician, neurologist, or otolaryngologist usually diagnoses and treats the condition.

Congenital (at Birth) 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.

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 (Trauma Within the Skull)

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.

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. Paralysis is on both sides of the face in 30 percent of cases.

What Are the 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.

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.

Our facial paralysis specialists not only diagnose and treat complex problems but also do so efficiently and conveniently in one location. Most patients can be evaluated in minimal time, and care is efficiently coordinated if several surgical teams are required for treatment.

Are There Warning Signs of Bell’s Palsy?

Bell's palsy typically does not have clear warning signs, as the condition usually develops rapidly. However, some people may experience subtle symptoms before the onset of facial weakness or paralysis, such as:

• Cold or slight fever
• Pain or discomfort behind the ear on the affected side of the face before weakness is noticed
• Weakness on one side of the face, including a feeling of stiffness or pulling

It’s important to note that Bell's palsy symptoms typically develop over 24 to 72 hours. A person might go to bed feeling fine and wake up with noticeable facial weakness.

Can the Risk of Facial Paralysis Be Reduced?

Many cases of facial paralysis, particularly Bell's palsy, occur without any clear cause or warning. 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. Using insect repellent and checking for ticks after outdoor activities in high-risk areas may help prevent Lyme disease.

Lifestyle Modifications

• Maintain a healthy diet: Eating a balanced diet rich in nutrients supports overall health and may contribute to a stronger immune system.
• Exercise regularly: Physical activity promotes cardiovascular health, which may help reduce the risk of stroke-related facial paralysis.
• Avoid smoking: Smoking is a risk factor for stroke, so quitting or avoiding tobacco use may lower the risk of stroke-related facial paralysis.
• Limit alcohol consumption: Excessive alcohol intake can increase the risk of certain health conditions that may lead to facial paralysis.

While these preventive measures may help reduce the risk for some types of facial paralysis, they cannot guarantee prevention.

How Is Facial Paralysis Diagnosed?

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, we may order certain tests 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.
• Blood tests: Blood tests may be conducted to rule out other infections or conditions.

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. The key physical finding that differentiates Bell's palsy is a partial or complete weakness of the forehead muscles.

How Is Facial Paralysis Treated?

Our facial paralysis specialists offer treatments for all areas of the face, as well as associated conditions.

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.

Postoperative Rehabilitation

UT Southwestern Medical Center's facial paralysis specialists expect you to be committed to your recovery and invest in yourself in order to maximize the results of your treatment.

The importance of pre- and postoperative rehabilitation is paramount.

Prior to surgery you will meet with an experienced therapist who specializes in facial nerve rehabilitation. During this visit, exercises may be prescribed based on the type of reconstruction that’s planned. In certain types of reconstruction, exercise is key to a satisfactory final result and success.

After surgery, you will need to come to UT Southwestern every three months for an evaluation during the first year and every six months during the second year. If you are from out of state or country, we will help locate a therapist in your home area.

Working Together

Your meeting with a rehabilitation expert is for initial and continued guidance but is not a substitute for continued work at home or elsewhere – alone or with family and friends.

During the visitation we will decide with you the most appropriate treatment and start the journey of rehabilitation together.

At UT Southwestern, every patient has our commitment and dedication to reach our common goals.