This webpage describes an alarming situation where the face suddenly and inexplicably stops moving without any other symptoms. One moment the face is moving fine, and the next, it suddenly has stopped moving on one side (rarely even both sides). Stroke should be considered IF associated with ability to still move the forehead (but not the cheek or lip) and other symptoms including paralysis involving other parts of the body and/or inability to speak.
Otherwise, this situation is known as isolated facial paralysis or Bell's Palsy. The paralysis may be complete with utter inability to smile, pucker the lips, or close the eye. It can also be partially paralyzed.
There is a more serious condition of Bell's palsy known as Ramsay Hunt Syndrome which involves not only facial paralysis, but other inner ear symptoms including ear pain, hearing loss, shingles skin rash around the ear.
Why Does This Occur?
Surgery involving the mastoid or parotid gland may result in facial paralysis as the nerve goes thru these anatomic areas before innervating the facial muscles. Beyond the obvious surgical injury, it is not precisely known why this occurs, but there are several theories. The most common theory is a viral infection of the facial nerve (cranial nerve number 7). This situation is akin to the loss of smell when the smell nerve is infected during a cold or sudden sensorineural hearing loss causing a sudden profound hearing loss.
When a nerve becomes infected, it tends to swell. Unfortunately, the facial nerve (along with the hearing nerve) goes through a bony canal called the Internal Auditory Canal (arrow in picture) which is a passageway for the nerve to go through the skull to get to the face. This bony passage does not enlarge to accomodate the nerve as it swells leading to the nerve becoming "strangulated" and therefore becoming non-functional leading to facial paralysis.
To use an analogy, if your foot is the nerve and your shoe is the bony canal, imagine what would happen to your foot if it starts to swell, but you keep wearing the same size shoe. Ouch!
In this swollen and entrapped state, the nerve only has so much time before it potentially starts to die. As such, the only medication found to be helpful is steroids... lots of it and at high doses. Just as steroids decreases swelling of an inflamed arthritic knee, it seems to decrease sweling of the hearing nerve allowing it to recover more quickly before permanent damage settles in.
The nerve only has so much time of being strangulated inside its bony canal before it starts to die.
High doses of prednisone is the treatment of choice, typically tapered over a 3 week course (start at 20mg 3X per day for 5 days than taper the dose slowly every 3 days). Depending on the severity, the dosage may be adjusted.
Although controversial, anti-viral antibiotics (valtrex and acyclovir) can also be prescribed though studies have suggested no difference in outcome whether it is given or not.
As a basic rule of thumb... if the face DOES move, albeit not very well, the chance of recovery fully back to normal is excellent. If the face is utterly paralyzed, the risk of partial or no recovery is present.
Please note that treatment for facial paralysis is an area of controversy and different doctors may have different opinions on how to approach this condition. The following is an opinion of how a treatment course may occur:
- Visit #1 (ideally within days of facial paralysis)
- Examination of the ear (yes... the facial nerve goes through the ear to get to the face!!!) as well as the parotid gland to ensure no other physical pathology that may cause the facial paralysis
- Prescription for prednisone burst and taper
- Lyme titres (Lyme disease can cause facial paralysis). If positive, treatment for Lyme disease must start.
- Try exercises for facial paralysis.
- Visit #2 (within 2 weeks later)
- If no improvement of complete facial paralysis, nerve conduction studies can be obtained (helps determine likelihood of facial nerve function return). Obtain MRI scan of the head to ensure no brain / nerve pathology.
- If there is partial facial paralysis (there is some movement, even if small), continue to monitor.
- Consider staring a calcium channel blocker.
- Visit #3 (another 2-3+ weeks later)
- If face is still completely paralyzed, prognosis is poor based on nerve conduction studies, and MRI is normal, consider surgical options.
While undergoing treatment, basic care needs to be provided for the eye as the patient will not be able to close the eye completely resulting in a dry eye and at worst, corneal damage from the dryness. Ophthalmic lubricant needs to be applied in regular intervals and at night, the eye taped shut, but never covered with an eye patch or gauze due to risk of corneal scratching (if the eye inadvertently opens under the patch, the overlying material may scracth the cornea). Such care needs to be provided until the eyelid is able to close completely.
If you have suffered a facial paralysis, call for an appointment ASAP or go to the emergency room!!!
Permanent Facial Paralysis
Unfortunately, if the facial paralysis has not resolved after 6+ months and especially if still present after 1 year, the facial paralysis may be considered permanent. At this point, surgical options can be considered to address incomplete eye closure with either a platinum or gold weight to the upper eyelid to help close the eye.
If a lower eyelid ectropion (droopy eyelid) is present, a lateral tarsal strip procedure can be performed.
In certain specialized tertiary care centers, a facial reanimation procedure can be pursued to attempt to bring back normal facial movement. This complex surgery involves creating nerve bridges from the working side to the paralyzed side, or utilizing other functioning nerves (like the nerves that go to the tongue/jaw muscles) to provide nerve stimulation. The earlier this procedure is performed after facial paralysis onset, the better the outcomes... so a variety of testing (ENoG, EMG, etc) must be performed to determine whether permanent facial paralysis is present or not.
Do either corticosteroids or antiviral agents reduce the risk of long-term facial paresis in patients with new-onset Bell's palsy? J Emerg Med. 2010 May;38(4):518-23. Epub 2009 Oct 21.
Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001869.
Clinical Practice Guideline: Bell’s Palsy. Otolarngol Head Neck Surg. 149(5) Supp S1-S27. Nov 2013.
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