What is Facial Palsy?

The theme of this year’s awareness week is “The Little Things”. If you are someone who has been affected by Facial Palsy you already know that “The Little Things” are in fact quite big things and very disruptive to your daily life. If you do not have Facial Palsy, read below to gain a little understanding of this condition.

Facial Palsy

Facial Palsy is a debilitating condition that affects over 20,000 people annually in the UK, with an incidence of 70 cases per 100,000 population (Norris, 2019). It is unknown how many people are affected by Facial Palsy in Ireland, but if we apply the UK incidence rate here, it would mean almost 3,500 people are affected annually.

What is Facial Palsy?

Facial Palsy is a general medical term that refers to weakness of facial expression, usually on one side of the face, as a result of damage to the facial nerve caused by either swelling or pressure on the nerve.

How does the Facial Nerve work?

There is a facial nerve (electrical cable) on each side of your face. If you damage the one on the left it will affect the left side of your face and the same to the right. The facial nerve (cranial nerve VII) forms in the brain (the electrical generator) and leaves the brain via a small bony channel through the skull. At this point the facial nerve is vulnerable to swelling as this channel is very narrow and pressure can build with even minimal swelling. After it enters the face just in front of the ear it divides into 5 branches (in yellow) to supply the different muscles (light bulbs) for facial expression.

The facial nerve is also responsible for the production of tears, saliva and taste for part of the tongue.

facial muscles side view

There are 23 muscles on each side of the face and one muscle that encircles the mouth. Each of these muscles is responsible for a specific movement, but rarely, if ever, do they work in isolation. In order to create an expression, such as a smile for example, at least 9 muscles on each side of the face work in a very precise coordinated manner.

So, if you were to think about it, the brain or generator creates the signal, it is then carried via the nerve or cable to the muscle or light bulb and the light bulb switches on. If the generator is out, no signal or a faulty signal is created. If the cable is pinched/kinked or cut, it cannot carry the signal to the light bulb. And finally, if the bulb was broken, then no light would come on. In Facial Palsy the damage occurs at the level of the cable, in that it is pinched so much that it cannot transmit the electrical signal.

muscles in our face

What can cause Facial Palsy?

Any condition that can cause swelling or pressure on the nerve can result in Facial Palsy.

The most common cause of Facial Palsy is Bell’s Palsy, accounting for 80% of all cases of Facial Palsy. This is thought to be due to a reactivation of a dormant viral infection. It can affect anyone of any gender and age, but its incidence seems to be highest in those in the 15- to 45-year-old age group. Risk factors for Bell’s palsy include pregnancy, preeclampsia, obesity, hypertension, diabetes, and upper respiratory ailments.

Another viral illness, the Herpes Zoster virus causes a more aggressive form of Facial Palsy known as Ramsay Hunt Syndrome.

*Of note, following the emergence of the pandemic, associations were being made with increased rates of Facial Palsy and SARS Co V-2 infection. However, according to more robust and larger scale data, this link appears to be unfounded (Martin-Villares et al, 2021).

Bacterial conditions such as Lyme disease or following a middle ear infection.

Surgery to remove a benign acoustic nerve tumour (vestibular schwannoma) can cause Facial Palsy. The facial nerve lies very close to the acoustic nerve, so in the process of removing these tumours the facial nerve can be damaged.

Surgery to the parotid gland. The facial nerve runs through this salivary gland and can be damaged during surgery.

Neurological conditions such as Guillian-Barre syndrome.

Traumatic injuries, such as fractures or deep cuts to the brain, skull or face.
Congenital causes, meaning a baby is born with Facial Palsy.

**Stroke can cause Facial Palsy but this injury occurs in the brain (the electrical generator), and is different to the other causes above which have injury at the level of the nerve (electrical cable).

What does Facial Palsy look like?

Following the onset of Facial Palsy, if the facial nerve is not transmitting the signal correctly then some or all of these muscles on the affected side of the face will not be able to work. This often gives the face a drooping appearance and the affected eye may appear quite large, and is unable to close. Over time the face may appear tight and frozen, with the eyebrow raised and the eye smaller on the affected side.

facial nerve paralysis

The question “what does Facial Palsy look like?” is deceiving, as many consider Facial Palsy purely a cosmetic problem. Whilst there certainly are cosmetic issues associated with Facial Palsy, it is actually mainly a communicative disorder. “The face is the image of the soul” …. Cicero, 46BC. Our face identifies us and expresses our thoughts and feelings. Our face communicates with people. Eighty percent or more of our interpersonal communication is through facial gestures or expression.

Without being able to smile, frown, snarl etc it is almost as if the person is “locked in” and they need to verbalise their emotions or often they simply say nothing at all as the spontaneity is lost and the effort required is too great. This is incredibly distressing for many people with Facial Palsy.

Functional issues associated with Facial Palsy

Imagine you have an eye that does not close. What would it feel like on a cold windy day? Or in the shower with shampoo going into it? Or when trying to sleep and it simply never shuts? A feeling of grit in your eye from lack of blinking and tear production? Constant tearing from this irritation of the eye? And much more…..The eye is incredibly vunerable to damage especially in the early stages of Facial Palsy and eye care is crucial at this point.

Simple daily tasks we take for granted such as eating and drinking can become huge tasks and socially awkward. Certain foods are often impossible to tackle such as sandwiches. As you are often unable to make a sufficient seal around your lips, drinking from a cup might be impossible, and often the food or drink can spill from your mouth also. Remember the facial nerve is also responsible for the production of taste, so often people report a metallic taste when eating or drinking. There is a decrease in the amount of saliva in the mouth and this can affect eating but certainly dental care too, so greater attention is required to remove trapped food and to ensure additional dental hygiene to protect your teeth.

Speech is affected, with difficulty prounouncing words beginning with “P” and “B” particularly. People may find it hard to be understood, especially on the phone. Yet another impact this condition has on communication.

The question “what does Facial Palsy look like?” is deceiving, as many consider Facial Palsy purely a cosmetic problem. Whilst there certainly are cosmetic issues associated with Facial Palsy, it is actually mainly a communicative disorder. “The face is the image of the soul” …. Cicero, 46BC. Our face identifies us and expresses our thoughts and feelings. Our face communicates with people. Eighty percent or more of our interpersonal communication is through facial gestures or expression.

Hearing can be affected as the muscles, to dampen down the eardrum, are not receiving input either. Noise is suddenly amplified to unbearable levels. This usually does ease over time.

And now for the tricky part. As the facial nerve recovers (and it can do!) you would assume that all of expressions and functional tasks in our face simply return to previous levels. However, it is not that simple. The facial nerve has lots of different pathways to follow as it is recovering, which unfortunately means it can often follow the incorrect one and leads to a bit of cross wires or faulty rewiring (synkinesis).

Also, you now need to learn to express your emotions. This can’t be called relearning as we never learned to express these emotions in the first place. It all happened automatically. We never had to practice a smile or think about how to show sadness, it just happened. Then when Facial Palsy occurs you now need to think about how to move your face and express these emotions, and this can be a difficult concept to grasp initially and usually people over shoot the mark and work the muscles with too much effort. This can result in a tight painful face.

So can you see all “The Little Things” can individually be disruptive but combined can have a very negative impact on a person’s quality of life and significant psychological impact.

Early Treatment and Recovery

In Bell’s Palsy the current guidelines (NICE 2019) recommend treatment with an oral long-acting steroid within 72 hours following the onset of symptoms. This does not guarantee a full recovery but certainly improves outcomes. Approximately 80-85% of people will have either a full or almost full recovery following Bell’s Palsy with no therapy or specialist intervention required.

For those with Ramsay Hunt Syndrome antivirals given in the first 72 hours are also showing benefits.

In those early days it is crucial to protect the eye, so linking in with your GP or a Facial Therapy Specialist who can refer you to appropriate services as required.

It is really important NOT to do generic facial exercises, as if there is no signal going to the muscles then how could you ever make them work? In fact, it can add to the unwanted overactivity of other muscles that we tend to see in the later stages of recovery.

A Facial Therapy Specialist can guide you through massage and soft tissue techniques to keep your muscles supple whilst waiting for the nerve to recover. This also helps to keep the brain awake to the affected side.

Recovery can take several weeks or months to occur but those that are showing signs of recovery within the first 3-6 weeks have the best prognosis. If there is no sign of recovery by 3 months, then further treatment should be sought. Again, ideally seek out a Facial Therapy Specialist or request referral to a Facial Palsy Clinic via your GP.

Therapy treatment at this point is aimed at training facial expressions. The method we use is called NeuroMuscular Retraining. It is different to “exercises”. It is bespoke for each individual. It is more attuned to learning a new skill or practicing playing a musical instrument.

Some people also require the use of BOTOX to reduce activity in some overactive muscles.

If no recovery at all has taken place, a very small proportion of people may require surgical intervention.

PMC Physiotherapy Dunboyne recommendation

If you have been affected by Facial Palsy or wish to gain more information regarding this condition book your appointment or call us on 018253997. Caitriona is our Facial Therapy Specialist and is a member of Facial Therapy Specialists International.

Diagrams and some information used with permission from facialpalsy.org.uk
Bell’s Palsy Fact Sheet
Assessment Guide
Norris, Jonathan H et al. “Exploring Patient Experience of Facial Nerve Palsy to Inform the Development of a PROM.” Plastic and reconstructive surgery. Global open vol. 7,1 e2072. 9 Jan. 2019, doi:10.1097/GOX.0000000000002072


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