Part 2 Facial Palsy – Recognise when to refer for specialist treatment

If symptoms don’t fully resolve, recognise when and where to refer for specialist treatment.

When you present to your GP or A+E with Facial Palsy, a thorough exam should be completed and testing/imaging completed as appropriate, with onward referrals also made as appropriate to specialist services such as Neurology / ENT / Opthamology.

If your Facial Palsy was deemed suitable for management by your GP or in A+E, you should be given a review appointment for 2-3 weeks later. At this review, your progress, or lack of, should be assessed and onward referrals made as appropriate, including Specialist Facial Therapy.

The following table should help understand at what time and to whom a person with Facial Palsy should be referred to following their initial management in A+E or at the GP.

Multiple studies now highlight the importance of early intervention with Specialist Facial Therapy. This is usually provided by a Chartered Physiotherapist who has completed specific Post Graduate Facial Therapy training.

The therapy involves specific rehabilitation called Facial Neuromuscular Retraining and differs greatly to rehabilitation involving other parts of the body.

A specialist Facial Therapist can assist with treatment from the very acute phase, and for those that do not gain full spontaneous recovery, all the way into the chronic phase years later.

It is true that many people with Bell’s Palsy (~ 70%) will make a complete spontaneous recovery with no treatment other than the initial medical management. However, for those that will not, it is important to keep the timeframes below in mind.

• If you have had facial palsy for 4 weeks and have had no recovery at all you should start Specialist Facial Therapy.

• If you are slowly recovering but are not fully recovered by 6-8 weeks, then you should start Specialist Facial Therapy.

(The Facial Rehabilitation Centre, Queen Victoria Hospital, NHS 2024).

**Many years following the onset of Facial Palsy, Specialist Facial Therapy has been shown to improve symptoms and function, especially when used in conjunction with other medical treatments such as botox**

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.

Until someone has experience of Facial Palsy, the devastating effects associated with it are often underestimated.

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.

There is a significantly higher prevalence of anxiety & depression in those with chronic facial nerve palsy than the normal population. Questions such as: “What will I do if people ask me what has happened to my face? How will I cope without my smile? Will surgery ‘fix me’? What if surgery doesn’t fix me? Returning to work/socializing will be awful. Will I ever get/keep a relationship? What are my friends/colleagues/family thinking about me? People are talking about me. How SHOULD I be coping? What did I do to deserve this? What’s the point?” It is really important to stress at this point that whilst we don’t normally see our own faces (other than now on zoom or teams work calls) someone with Facial Palsy, also feels or is aware of the abnormal muscle function in their face all day long. There is no escape. You simply can’t “just forget about it”.

Studies highlight high levels of appearance related distress, poor social wellbeing and low quality of life (Hotton, 2020). The level of how severe the Facial Palsy is deemed by the medical professional or general public is irrelevant. With any degree of ongoing or chronic Facial Palsy there is the possibility of psychological distress.

There are also 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 vulnerable 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 taste production, 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.

The muscle around our mouth also helps us to make a seal for snorkelling/kissing/blowing up balloons etc.

Breathing through the nose can be difficult as the muscles in the sides of the nose are not working correctly to open it.

Speech is affected, with difficulty pronouncing 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.

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.

When the Facial nerve takes a long time to recover, a condition called synkinesis can occur. This can result in stiffness and overactivity in the facial muscles, which can be quite painful.

If you or someone you know is experiencing symptoms related to Facial Palsy please contact us and make an appointment with Caitriona, our Specialist Facial Therapist and Chartered Physiotherapist.