Facial Nerve Paralysis – Treatment and Recovery
Facial nerve paralysis (also known as Bell’s palsy or facial paralysis) refers to the loss of function in part of the face due to the inability to move the muscles that control facial movements. Facial nerve function is crucial for various everyday actions: eating, smiling, blinking. Partial (paresis) or complete (paralysis) loss of facial function can be a significant source of not only functional but also psychological issues for the patient. The following provides an overview of the recovery process from facial nerve paralysis and the treatment, especially in cases of permanent paralysis.
What causes facial nerve paralysis?
Facial nerve paralysis can be classified as central or peripheral based on the location of nerve damage.
Central paralysis: This occurs due to damage above the facial nerve nucleus (supranuclear palsy), often resulting from a stroke. Central paralysis affects only the lower part of one side of the face, and the patient can still furrow the forehead, raise the eyebrows, and close the eyes tightly. Treatment for central paralysis falls under the domain of neurologists.
Peripheral paralysis: This occurs due to damage below the facial nerve nucleus, affecting both the upper and lower parts of the face: the patient cannot furrow the forehead. Diagnosis and treatment fall under the domain of otorhinolaryngologists.
Possible causes of peripheral facial nerve paralysis include:
- Viruses: At least 60–70% of cases are caused by viral infections, with the most common culprits being herpes simplex virus type I and herpes zoster oticus (Ramsay-Hunt syndrome). Other causes include coxsackievirus, Epstein-Barr virus, mumps, and influenza viruses, among others.
- Bacteria: During acute or chronic middle ear infections, Lyme disease (tick-borne), tuberculosis, botulism, etc.
- Injuries: To the temporal bone, skull base, face; barotrauma, surgery.
- Tumors: Of the brain, skull base, ear, facial nerve, salivary glands, skin.
- Systemic causes: Associated with diabetes, pregnancy, hypertension.
- Certain neurological, autoimmune diseases, and toxic damage: Rare syndromes such as Melkersson-Rosenthal syndrome, hereditary recurrent paralysis, etc.
- Unknown causes: Previously known as Bell’s palsy. Characteristics include: unilateral, sudden, peripheral, incomplete or complete. Bell’s palsy is diagnosed only after other possible causes have been excluded. Risk is increased in pregnant women, diabetics, and prevalence increases with age.
What are the symptoms of peripheral facial nerve paralysis?
Symptoms of Bell’s palsy gradually develop with a peak within a few days, often starting with pain behind the ear. Further manifestations include:
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- Asymmetry of the entire half of the face (the patient cannot furrow half of the forehead, cannot fully close the eye, has a drooping corner of the mouth, and the nasolabial fold is less pronounced)
- Dryness and burning in the eye, excessive tearing
- Difficulty chewing, especially with liquids leaking through the drooping corner of the mouth
- Altered taste sensation
- Decreased saliva secretion, dry mouth
- Hyperacusis (unpleasant loudness and noises in the ear)
What does the treatment of facial nerve paralysis involve?
Treatment for peripheral facial nerve paralysis is carried out based on recommendations from an otorhinolaryngologist.
The treatment depends on the cause identified through examination and diagnostic tests, indicating the severity and location of nerve damage. Since viral infections are the most common cause of paralysis, corticosteroids and antivirals are commonly used. Treatment should begin immediately, and in severe cases (herpes zoster), hospitalization and intravenous therapy are indicated.
Symptomatic therapy includes protecting the eye with artificial tears and ointments, as well as using protective glasses or patches. The use of botulinum toxin and acupuncture may be considered. Electrostimulation (“electrical treatment”) is unnecessary and even harmful, while physical therapy – kinesitherapy (facial muscle exercises) – is appropriate only once nerve recovery begins. Most facial nerve paralyses, about 85%, recover within 3 weeks, and most of the remaining cases recover within 3–6 months.
How does recovery from facial nerve paralysis look?
If paralysis does not show signs of improvement within 3 weeks or worsens, an otorhinolaryngologist will recommend a detailed diagnostic evaluation, including electromyography, brain MRI, blood tests, etc. Computed tomography of the pyramid (CT) is needed if there is suspicion of an issue within the intratemporal part of the nerve. Based on the complete evaluation, the otorhinolaryngologist will determine further treatment and decide if surgical intervention is needed. If there are no signs of recovery after 6 weeks, surgery may be recommended to relieve pressure on the nerve within the narrow bony canal of the ear, promoting recovery. Such surgery is performed by only a few surgeons trained in skull base procedures.
In cases of incomplete recovery and facial asymmetry at rest or during facial expressions, exercises for the facial muscles in front of a mirror and using EMG biofeedback are recommended. Therapy is complemented with facial massage. The goal is to prevent synkinesis – involuntary, combined, and non-functional movements resulting from disrupted nerve reinnervation, worsened by poorly conducted rehabilitation, especially electrostimulation. Synkinesis is most commonly observed when attempting to close the eye, causing the mouth corner to rise in a smile or when smiling causes the eye to close.
Treatment of permanent facial nerve paralysis
If no recovery has occurred 6 months after the onset of paralysis, electromyography (EMG) should be used to assess the chance of spontaneous recovery or to determine indications for surgical treatment. The type of treatment depends on the cause, duration, and location of the nerve injury.
Most congenital facial nerve paralyses recover spontaneously within the first year of life. Others require rehabilitation through various non-surgical and surgical methods. The earliest age to start surgical procedures for congenital facial nerve paralysis is preschool age, from 4 years old onwards.
In adults, when recovery does not occur after Bell’s palsy or tumor removal from the brain within 6 months, surgery is performed to connect the facial nerve with another cranial nerve (e.g., masseter/hypoglossal – facial nerve anastomosis) to facilitate reinnervation.
If paralysis lasts longer than 18–24 months, irreversible atrophy and fibrosis of facial muscles occur, making nerve function restoration methods ineffective. In these cases, the only option for re-establishing some degree of facial mobility includes:
- Free muscle flap transplantation: From the thigh or back with associated nerves and blood vessels (gracilis transfer).
- Temporal muscle transfer.
When nerve and muscle function cannot be restored, passive rehabilitation methods are used:
- Insertion of weights in the upper eyelid.
- Raising the mouth corner.
- Modified unilateral facelift.
- Reducing facial asymmetry: Through lipofilling, Botox.
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