Facial Paralysis: The Basics
What Happened & How to Treat It
Facial paralysis affects all facets of one's life. Social interactions may become sources of stress. Vision, eating, even breathing may be compromised. Dr. Markey previously served as the Director of the NYU Facial Paralysis and Reanimation Center to treat facial paralysis and minimize the debilitating symptoms that many experience. He continues this same philosophy to apply the most modern procedural and non-procedural treatments of facial paralysis and facial synkinesis following Bell’s Palsy, Ramsay Hunt Syndrome, traumatic facial nerve injuries, removal of cranial or parotid tumors, among other causes.
Facial paralysis is a distressing condition for patients that can result from a variety of causes.
It also presents in a variety of ways. Paralysis of the facial muscles can affect one or both sides. It may come on very suddenly in only a few hours to days or may develop slowly after weeks or months. It may result from Bell’s palsy, from autoimmune diseases, or following an injury. Regardless of the specific cause or presentation, the development of facial paralysis can be a significant traumatic event in a person’s life.
Facial paralysis stems from a facial nerve injury, the seventh cranial nerve, in which the signals from the brain are unable to travel down the nerve and its branches to their end target: the facial muscles. Facial paralysis results in both functional and aesthetic impairments.
First, our faces enable us to see, hear, speak, breathe, eat and drink – all essential functions of daily life. Patients with facial paralysis often have difficulty blinking on one side and suffer from dry eyes. Vision may be affected. Some patients suffer difficulty breathing through one side of their nose. Hearing may be affected with many being sensitive to loud sounds. Many patients have difficulty creating a proper seal with their mouth which may lead to the escape of food or liquid when eating and drinking, difficulty with articulating while talking, the inability to use a straw, and other problems.
Our face is also essential to the way in which we interact with the world. Our facial expressions are how we tell each other how we feel, what we want, and who we are. They’re the first thing one sees when meeting someone new, and the last thing they remember. When one or both sides of the face don’t respond as they should, the window through which we encounter the world is changed.
Many patients that recover from certain facial paralysis conditions, such as Bell’s Palsy or Ramsay Hunt syndrome, find that the signals traveling down the facial nerve follow an abnormal and uncoordinated circuit. Some patients note that when they try to smile or purse their lips their eye also partially closes. Or when they attempt to close their eye their cheek twitches. This condition is called facial synkinesis.
Facial paralysis, and subsequently facial synkinesis, can result from a variety of causes.
The most common cause is Bell’s Palsy. Bell’s Palsy is likely due to the reactivation of a latent viral infection by the same virus that causes cold sores around the mouth (Herpes simplex). This reactivation is more common during pregnancy, in patients with diabetes, and in patients with a compromised immune system. The viral reactivation causes swelling of the facial nerve in a narrow bony tunnel just deep to the ear. This swelling in a narrow space strangles the nerve temporarily, interrupting the normal signals that pass through the nerve. If the nerve is only bruised then normal facial function may return in days to weeks. However if the nerve is interrupted completely, the nerve endings may require months to find the muscle once again – resulting in an increased risk of miswiring and subsequent facial synkinesis.
Ramsay Hunt Syndrome causes facial paralysis through a similar method, although it stems from a different source – the virus that causes shingles and chicken pox (Herpes zoster). It is more likely to affect additional cranial nerves beyond just the facial nerve. It may also result in a more challenging recovery, but each patient and each recovery is different.
Facial paralysis can also occur whenever the nerve is interrupted for much less commonly encountered causes. These infrequent causes include rare tumors that form between the inner ear and the brain (Acoustic Neuromas, or Vestibular Schwannomas) as well as masses within a salivary gland called the parotid gland. Traumas such as skull fractures or sharp injuries to the face or side of the head can cause also facial paralysis if the nerve is involved.
Another infrequent cause follow diseases that can affect the facial nerve itself. Guillan Barre, multiple sclerosis (MS), and other demyelinating diseases can result in facial paralysis. Also, if the blood flow to the nerve is disrupted, as with a stroke, facial paralysis may ensue.
Why do so many vastly different causes all result in facial paralysis?
The answer is partly because of the complex anatomy of the facial nerve. The facial nerve is also called the seventh cranial nerve because it’s the seventh nerve that directly exits from the base of the brain when counting from the front. Other cranial nerves are responsible for smell (first), vision (second), chewing your food (fifth), sticking out your tongue (twelfth) and many other vital functions.
Upon exiting the brain, the facial nerve enters a narrow tunnel and heads toward the inner ear. It then makes two ninety-degree turns sending off nerves along the way that are responsible for eye tearing, nasal mucous production, the sense of taste, and minimizing excessive noise exposure. It passes through the middle ear and down and out of the base of the skull immediately in front of a bony protuberance behind your ear called your mastoid prominence. The nerve then sweeps forward and enters the parotid gland. Here it divides into five main branches, each with important responsibilities. These include raising your eyebrows, closing your eyes, wrinkling your nose, puffing out your cheeks, pursing your lips, smiling, frowning, and tensing your neck.
During Bell’s Palsy, the facial nerve is injured within the perilabryinthine segment of the nerve in the narrow bony tunnel. With an Acoustic Neuroma, the nerve is injured before it exits the inside of the skull. With a lesion in the parotid gland, the nerve may be injured after it branches near the angle of the jaw. Regardless of location, if the nerve is injured it is unable to send signals to the facial muscles downstream. This results in facial weakness.
If the injury is upstream, as with Bell’s Palsy and Ramsay Hunt Syndome, when the nerve, and all the specific branches within it, begins to heal itself it needs to carefully find its way back from high in the skull to the facial muscles. This regeneration is sometimes less than accurate – which can result in facial synkinesis. The nerve regrows at about 1mm per day, and can thus take a long time for the regeneration process to occur. Within the nerve are branches that each operated a specific facial muscle and resulted in a specific facial movement. After this regeneration process takes place the nerve branch that previously operated the mouth, for instance, may mistakenly travel towards the muscle around the eye. When this occurs the patient’s eye narrows when pursing the lips or smiling. If the nerve that previously operated the muscle around the eye travels to a smile muscle the patient may suffer twitching of the cheek whenever he or she blinks. Facial synkinesis can have a distressing effect for some patients.
If the onset of facial paralysis is sudden, most patients visit the emergency department, urgent care, or their primary care doctors. The doctor’s first priority during this initial visit is to identify the cause of facial paralysis. The tests that each doctor orders depends on the set of circumstances specific to each patient. If the doctor is concerned about a stroke, he or she will order a set of lab tests and likely a CT scan of the brain. If the doctor is concerned about Lyme Disease, a tic-borne illness endemic to the Northeast and Great lakes regions, he or she will order lab tests to ensure the patient doesn’t require antibiotics. If the doctor is concerned about a mass putting pressure on the facial nerve he or she will likely order an MRI. Bell’s Palsy, the most common cause of facial paralysis, and Ramsay Hunt Syndrome normally are usually diagnosed based on the symptoms alone rather than with lab tests or imaging studies.
With the most frequent causes of facial paralysis, the immediate goal is to quell the inflammation of the nerve in the narrow bony canal. The doctor in the emergency department, urgent care, or primary care will often prescribe both an oral steroid medication (e.g. prednisone, solumedrol) as well as an anti-viral medication (e.g. acyclovir). These medications help to decrease the inflammation as well as fight the virus directly and are important for minimizing the duration and severity of the facial paralysis.
For Bell’s Palsy, when treated properly there is a good chance of a full recovery.
Approximately 7 out of 10 patients will return to their normal facial function. About half of the patients with Ramsay Hunt Syndrome will be return to normal movement. Those that have long-term symptoms following these two conditions normally experience some degree of facial synkinesis. However, one must allow ample time for recovery. It may take a year before the final result is known, sometimes longer. For other injuries, such as autoimmune diseases, intracranial or parotid masses, a fracture or facial injury, and other causes, the chances of recovery vary on a case-by-case basis. The severity of the facial paralysis or synkinesis for all of these injuries should be monitored closely by a facial nerve specialist.
Finally, there are many long-term treatment options. These vary for each patient, and each patient should talk with a specialist to learn about what options are available to him or her. The NYU Facial Paralysis & Reanimation Center consists of plastic surgeons, facial plastic surgeons, oculoplastic surgeons, neuro-otologists physical therapists, and neurologists that all provide a different viewpoint when discussing treatments. Each patient should discuss his or her individual concerns early after the onset of paralysis. This is important to find out what can be done to avoid any complications – as well as what may be helpful after the allowing more time for recovery.
For those dealing with facial synkinesis, a group treatment effort is essential. Physical rehabilitation helps to loosen any cramping or tightness in the face. It’s also helpful to pinpoint the problem areas and work to practice symmetric facial movements. Normally, these can be taught over a few sessions. Additional sessions can be helpful to better practice the exercises.
It’s also helpful for patients with facial synkinesis to visit with a facial plastic surgeon, like Dr. Markey. After working with a physical rehab specialist, Dr. Markey commonly injects botulinum toxin (Botox®, Dysport®, Xeomin®) to weaken carefully selected facial muscles and improve facial symmetry and function. During the initial visit each patient is examined and facial movement is photographed and videotaped. Dr. Markey and the patient identify the problem areas together. One common area that responds well to Botox® is around the eye. Many patients notice that the eye on the problematic side is narrower than the other. Others find that their eye partially closes when smiling or pursing their lips. Dr. Markey is able to inject Botox® into the muscle around the eye, the orbicularis oculi, to encourage symmetry and improve facial function. Other areas include the neck, the lower lip muscles, and others.
In contrast to facial synkinesis, with facial paralysis the muscles of the face remain weak and ineffective. The goal of treatment in this situation is to both restore movement as well as bring the structures on one side of the face into alignment with the other side. There are multiple surgical treatment options for each problem area.
For example, if the eyebrow is too low on the paralyzed side, Dr. Markey will often perform a brow lift to raise the eyebrow to a more suitable position. If the upper eyelid is unable to close properly a gold or platinum weight can be placed within the eyelid to gently bring it down when blinking. If the lower lid is too lax to collect tears, causing a “dry eye” sensation, then it can be surgically tightened with a minimally invasive incision in the corner of the eye. If the lower lid is too short, a cartilage graft (“spacer” graft) can be inserted in the eyelid to increase its height.
The inability to smile on the paralyzed side is also a common concern. There are multiple surgical options to both correct the positioning of the corner of the mouth and restore the motion of a smile. These are categorized as static and dynamic corrections. Static repairs help to provide a symmetric appearance at rest, but do not restore movement. Dynamic repairs both provide a more symmetric appearance as well as restore some movement. Which treatment option is best for which patient depends on a host of factors. Dr. Markey partners with each patient to discuss the benefits and risks of each procedure to decide the appropriate course of action.
To raise the corner of the mouth, a static surgery called fascia lata resuspension is performed. Dense tissue called fascia lata is taken through a minimally invasive incision in the side of the leg. Another incision hidden around the ear is used to carefully use this tissue to suspend the corner of the mouth and cheek to a position symmetric with the opposite side.
Two dynamic surgical options are available to restore a patient’s smile. One is called the temporalis tendon transfer. With this surgery a small incision hidden in the cheek crease is performed to identify the attachment of a muscle used for clenching the jaw called the temporalis. The temporalis muscle attaches to a part of the jawbone. During a temporalis tendon transfer the attachment of the muscle is redirected to the corner of the mouth so that when one clenches his or her jaw a smile forms on the paralyzed side. With practice, this leads to more symmetric facial movement.
The second surgical option is called the gracilis free tissue transfer. With this surgery a narrow band of muscle is taken from the inner thigh from the gracilis muscle. The nerve and blood supply associated with this muscle is also taken. Through a similar incision mentioned previously the narrow muscle strip is carefully stretched from in front of the ear to the corner of the mouth. Nerves already present in the area, either the nerve that operates the masseter (jaw) muscle or the healthy facial nerve from the opposite side, are then used to operate the gracilis muscle. The blood supply is also preserved by connecting to the blood vessels in the area. After allowing ample time for healing the muscle contracts when smiling or clenching the jaw leading to a more symmetric smile.
Finally, Dr. Markey and his team will often use the healthy nerves in the area to provide muscle tone and movement to the paralyzed facial muscles. The commonly used nerves include the previously mentioned masseteric nerve (the fifth cranial nerve), the healthy facial nerve from the opposite side (the seventh cranial nerve), the nerve to the tongue (the twelfth cranial nerve), among others. After making the same incision mentioned previously Dr. Markey is able to connect the injured facial nerve branches to these nerves to restore muscle tone and movement with microscopic suturing techniques. This results in improved facial symmetry.
The treatment option that is best depends on the specific goals of each patient. Dr. Markey and his team describe each technique that may be appropriate given the desired outcome for each patient. After an open discussion of the risks, benefits, and alternative treatment options the best plan forward is carefully laid out.
Regardless of the technique chosen, the ultimate goal of treating both facial paralysis and facial synkinesis is the same: to provide a healthy, functional, and symmetric result. Dealing with facial paralysis and facial synkinesis can be a challenging and difficult process. It requires patients to look to the future rather than focus on the past. For the best possible outcome, patients must strive to make improvements to their facial function and appearance - day-by-day, week-by-week, and month-by-month. Along the way, the treatment options detailed here can be vital to help make these improvements. The best plan is different for each patient. It’s essential to partner with a facial nerve specialist to find the right treatment for the best outcome.
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