About Facial Nerve Palsy

WHAT IS THE FACIAL NERVE?

The facial nerve is the 7th cranial nerve and carries nerve fibres that control facial movement and expression. The facial nerve also carries nerves that are involved in taste to the anterior 2/3 of the tongue and producing tears (lacrimal gland). It has small branches involved in moderating our sensitivity to noise volume (stapedius muscle) and several other muscles.

The cells that transmit information within the facial nerve originate in the brain stem, in a region called the pons. The nerve must therefore travel through the base of the skull in order to reach the face. Along this route, the facial nerve travels in close proximity to the eighth cranial nerve, the vestibulocochlear nerve, which is responsible for hearing and balance. The facial nerve exits the skull through an opening in the bone located near the base of the ear.

The following is a rough guide to the areas each branch innervates. Note that there is some “cross-talk,” or overlap of the circuitry, between branches.

Frontal (temporal): The muscles of the forehead

Zygomatic: The muscles involved in forceful eye closure

Buccal: The muscles involved in moving the nostril, upper lip, spontaneous eye blinking, and raising the corner of the mouth to smile.

Marginal Mandibular branch: The muscles involved in depressing the lower lip

Cervical: lower chin muscle (platysma), lowers the corner of the mouth.

SYMPTOMS OF FACIAL NERVE INJURY

Frontal: Paralysis of the forehead/inability to move the eyebrow. Usually, this means the eyebrow ‘hangs down’ in front of the eye and can impair vision.

Zygomatic: Difficulty with forceful eye closure.

Buccal: Difficulty with smiling and motion of the mouth. This leads to problems with speech, particularly sounds like “bee” and “papa,” where precise motion of the lips is required to articulate the sound. Food or liquid may fall out of the mouth unexpectedly due abnormal lip movement. In addition, there can be difficulty with nasal obstruction on the affected side as the muscles that help keep the nostril open may be paralysed, resulting in an obstructed nostril. Normal blinking may be slowed or absent.

Marginal mandibular: the muscles it innervates are involved with downward motion of the corner of the mouth. Injury here may result in an asymmetric smile and problems with eating and drinking.

Cervical: This is arguably the least important of the branches. Injury of this nerve results in paralysis of the platysma muscle, a thin sheet that lies just deep to the skin. This may cause lower lip asymmetry during smile in some patients.

HOW QUICKLY DO SYMPTOMS OCCUR?

The onset of your symptoms may be sudden (appearing overnight), or may appear over two or three days. Alternatively your symptoms may develop slowly over time (over weeks, or even months). In either situation you should visit your GP/specialist as soon as possible, as further investigations may be required.

WHAT CAUSES FACIAL PALSY?

Common causes of facial paralysis include:

Infection or inflammation of the facial nerve (e.g. viral illness)
Head trauma
Head or neck tumour (e.g. Parotid tumour)
Stroke

However there are more than 50 causes for facial nerve palsy, and you may need several investigations to try to identify the most likely cause for your condition. For more information about the causes of facial nerve palsy, please visit the following webpage found at Facial Palsy UK; https://www.facialpalsy.org.uk/causesanddiagnoses/

WHAT RECOVERY CAN I EXPECT?

In some cases of facial palsy, the facial nerve can recover, but this very much depends on the cause of the facial paralysis. Examples of causes where a full recovery is possible are Bell’s palsy and Guillain-Barré syndrome, although all cases are different and the degree to which the facial nerve will recover is difficult to predict. Unfortunately, complete recovery cannot be guaranteed.

Where patients have an intact facial nerve, there is often a “wait and see” approach to see if the palsy resolves naturally.

In other cases, the facial nerve may have been injured (for example, during surgery to remove a tumour or through trauma such as a road traffic accident). In these instances there may be no natural recovery and treatment from health care professionals will be required to help restore some facial function.

WHAT HAPPENS TO THE FACIAL NERVE WHEN RECOVERY IS EXPECTED?

Bell’s palsy and Ramsay Hunt syndrome

Spontaneous recovery will take place for the majority of people within one – three weeks after onset of their symptoms. Others will make a good recovery within the first three months but may continue to experience a few mild symptoms.
A minority of people will have persistent symptoms of weakness beyond three months.

Other causes

It is difficult to predict the rate of recovery as there is so much variation from person to person.

In general, as your face starts to recover, nerve signals will begin to reach the muscles and you may notice:

Some muscles begin to work before others: for example, your eye might start to close properly but your smile may still be weak.
Your face will begin to look more symmetrical when you are relaxed because the muscles will regain their tone and no longer look or feel so floppy.
People will start to tell you how much better you are looking but your movements may still be very weak.

As you progress you may notice other changes taking place in your face, for example:

The affected eye may seem smaller
The corner of the mouth may seem raised on the affected side.
The affected cheek may feel tight and stiff.

WHAT IS SYNKINESIS?

You may notice that some of the muscles move together instead of separately, for example, your eye may close when you smile. Your cheek may contract or tighten when you raise your eyebrows. This is called synkinesis.

In some patients, synkinesis can be troublesome enough to require the use of Botox, to selectively weaken muscles that are contracting inappropriately.

During the recovery process you may notice muscles recovering at different rates so the facial muscles are unbalanced. Your physiotherapist can assist you throughout recovery to regain your facial symmetry using exercises, massage and other techniques.

WHAT IF MY FACE DOESN'T FULLY RECOVER?

Seek help and advice to ensure that your eye is protected if your eye closure and blink has not fully recovered.

Do not attempt to carry out exercises without professional help as you may do more harm than good. Most people want to do something but trying too hard may lead to problems later on in your recovery.

Try and relax and allow nature to take its course.

Advice from the internet may not be appropriate for your individual case. Please seek professional help and guidance. If in doubt do nothing except simple massage and eye protection until you are assessed by a health care professional.

WHAT ARE THE TREATMENTS FOR FACIAL PALSY?

Much depends on the cause of a patient’s facial paralysis as to which medical treatments will be suitable for them, every case is unique.

Medical treatments used in the management of facial paralysis may include:

Botulinum toxin
Eye care
Hyoscine patches for drooling
Pain relief
Steroids, antivirals and antibiotics

Please note: treatments should only be used under the guidance of an experienced medical professional.

Various surgeries may be offered to people with facial palsy. These include procedures to help a person smile, improve the closure of an eye, and restore symmetry to the face at rest. In addition to the different surgeries, there are various treatments and therapies which can be helpful to people living with facial paralysis.

As with any surgical procedure, there are risks associated with facial surgery which should be explained fully by your health care provider, before you agree to a procedure.

There are limits to what any surgery can achieve so it is important to have realistic expectations. Currently there are no surgical treatments that can restore your face to the way it was before your facial palsy.

Surgery options may include:

Facial nerve decompression – occasionally performed early on to relieve pressure on the nerve to allow it to work better.
Oculoplastic surgeries – a set of procedures in the eye region designed to protect eye function, improve symptoms of dryness and tearing and also overall appearance.
Smile surgeries – operations designed to restore symmetry at rest or even to create a smile movement on the affected side.
Rejuvenating procedures – One of the consequences of having a facial paralysis is that the tissues of the face tend to droop more. Various procedures can help reverse that effect and improve symmetry. These include: brow-lift, face-lift, fat grafting and the use of dermal fillers.

SUPPORT FOR PATIENTS WITH FACIAL NERVE PALSY

For in depth, professional information please visit the Facial Palsy UK website at https://www.facialpalsy.org.uk

In addition to general information, the website provides self help videos to assist you in your recovery. These can be found at

https://www.facialpalsy.org.uk/support/self-help-videos/

Changing Faces is a charitable association that supports patients with facial differences

https://www.changingfaces.org.uk

Social and emotional support is very important following a diagnosis of facial nerve palsy. Please speak to our team if you would like a referral to a psychologist. Post traumatic counselling may also be beneficial.

Facebook support group; ‘Facial Paralysis Support Network Australia New Zealand World’