Facial Nerve Palsy

What is a facial nerve palsy?

The nerve that makes the muscles of the face (lips, eyelids, and forehead) move is called the facial nerve. A facial nerve palsy means the nerve to the face does not work properly. The muscles in your face may not move properly or not at all. It can make everyday things like smiling, blinking, eating or saying words correctly difficult.

Most facial palsy only affect one half of the face (figure 1).

Does it mean I had a stroke?

People who have a stroke may have facial weakness as one of their symptoms. A facial nerve palsy is not caused by a stroke even though it can look similar.

If you have unexplained facial weakness, you must seek medical attention immediately.

A stroke that affects the part of the brain that controls facial muscles can result in a weak face. This will only affect the lower part of the face. The forehead creases are still present.

A facial nerve palsy will affect all muscles of the face equally. Doctors may do a CT or MRI scan to differentiate between a stroke and a facial nerve palsy.

What causes a facial nerve palsy?

There are many possible causes of a facial nerve palsy. Your doctor will do a thorough assessment to find the most likely cause.

Bell’s Palsy:

Over 70 out of 100 of all facial nerve palsies. Other causes of a facial nerve palsy need to be ruled out (usually by history and examination) before a diagnosis of Bell’s palsy is made. Nobody knows the exact cause. It is often linked to inflammation of the facial nerve due to viral infections. Most people recover on their own. This may take weeks to months.

Trauma:

Injury to the face or head, such as a fracture in the skull, can damage the facial nerve. This is because the nerve runs in a bony canal inside the skull and within the parotid saliva gland. This causes 10 to 20 out of 100 of all facial nerve palsies.

Infections:

Viral infections like shingles (reactivation of the chickenpox virus) can affect the facial nerve and cause a facial nerve palsy. Rarely infections of the middle ear (acute otitis media) or mastoid bone (mastoiditis) can cause inflammation or damage to the facial nerve. Bacterial infections like Lyme disease (from tick bites) are a rare cause of facial nerve palsy. Infections cause between 4 to 7 out of 100 cases of facial nerve palsies.

Lyme disease is transmitted by tick bites. It infects 1.9 people per 100,000 in the UK per year. Between 3 to 10 out 100 patients with Lyme disease go on to develop facial nerve palsy. It is more common in the Scottish Highlands or south of England.

Tumours:

Growths or cancers that press on the facial nerve can cause facial palsy. This is particularly true of tumours within the parotid salivary gland. Tumours are the cause of approximately 2 to 5 out of 100 cases of facial nerve palsies.

What symptoms can I have with a facial palsy?

You may notice various symptoms depending on the cause and severity:

• Difficulty closing the eye: You may find it hard to blink or close your eye completely. The surface of the eye or cornea may become dry, sore and sometimes you may have ulcers on the surface because of reduced blinking.
• Drooling or trouble eating: You might notice drooling or difficulty eating and drinking due to muscle weakness of the lips and cheeks.
• Loss of taste: You may experience changes in taste, particularly on one side of your tongue.
• Dry eye or mouth: Since the facial nerve also affects tear and saliva production, you may have a dry eye or mouth.
• Ear pain or sores around the ear: Some people feel pain around the ear before the facial nerve palsy develops.

How is a facial nerve palsy diagnosed?

Diagnosis of facial palsy is primarily from the history of your symptoms and an examination. Occasionally your doctor might order additional tests like blood tests or a CT or MRI scan to find the cause.

How is a facial nerve palsy treated?

Treatment varies depending on the underlying cause of the facial palsy. Most cases improve with time and treatment.

If you have Bell’s palsy, you may be given a short course of steroids tablets for example prednisolone to reduce inflammation and improve recovery. This may be given with a tablet to protect your stomach if you are at risk of developing stomach ulcers. There is currently no evidence that an antiviral tablet helps with recovery. However, some evidence suggests they may reduce the longterm symptom of a facial palsy.

Since it may be hard to blink, keeping your eyes moist with artificial tears and lubricating ointment is important. Using an eye patch during the day and taping your eyelids shut at night will also help to prevent problems. It is important to see an ophthalmologist (eye specialist) if you develop eye pain or vision problems.

Facial exercises and physiotherapy may be offered to maintain muscle bulk if your facial weakness is not improving. There is no good evidence that it will help.

If your facial palsy is caused by an infection, antibiotics will occasionally be used. Most cases of facial palsy do not require antibiotics.

Rarely, surgery may be needed if there is pressure on the facial nerve, such as after trauma or to remove tumours. Sometimes if the facial nerve does not recover, facial surgery or Botox injections to the other side of the face are offered to improve the symptoms and facial symmetry.

Will the facial palsy get better?

Most people with a facial palsy will recover some function over time. However, recovery can be variable depending on the underlying cause.

Over 70 out of 100 people with Bell’s palsy recover fully, usually within 3 to 6 months. Four out of 100 people may have symptoms that last longer, but severe or permanent damage is rare. Approximately 7 out of 100 people with Bell’s palsy will have a further episode, on average after approximately 6 years.

Many people with prolonged facial palsy can develop a symptom called synkinesis. This means unwanted or involuntary movements that occur on the affected side of the face. A common example of synkinesis is a patient’s eye closing when they smile. People can also experience tightness or straining of the neck and face. Facial physiotherapy is the primary treatment for synkinesis.

Support

Facial palsy can be a scary and a life altering condition. Support is available for people who are suffering from this diagnosis. Facial Palsy UK (www.facialpalsy.org.uk)  is a charity set up to support those affected by facial palsy, and to act as a comprehensive source of information for health professionals involved in the care of those with facial palsy.

Further information

Disclaimer: This publication is designed for the information of patients. Whilst every effort has been made to ensure accuracy, the information contained may not be comprehensive and patients should not act upon it without seeking professional advice.