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Facial Paralysis, Bell’s Palsy, or Eyelid Paralysis

What is Bell’s Palsy?

Bell’s Palsy is the paralysis or severe weakness of the nerve that controls the facial muscles on the side of the face, the facial nerve, or seventh cranial nerve. Patients typically find they suddenly cannot control their facial muscles, usually on one side. When Bell’s palsy occurs, the function of the facial nerve is disrupted, causing an interruption in the messages the brain sends to the facial muscles. This interruption results in facial weakness or paralysis. The facial nerve-also called the 7th cranial nerve travels through a narrow, bony canal (called the Fallopian canal) in the skull, beneath the ear, to the muscles on each side of the face. For most of its journey, the nerve is encased in this bony shell.

Each facial nerve directs the muscles on one side of the face, including those that control eye blinking and closing, and facial expressions such as smiling and frowning. Additionally, the facial nerve carries nerve impulses to the lacrimal or tear glands, the saliva glands, and the muscles of a small bone in the middle of the ear called the stapes. The facial nerve also transmits taste sensations from the tongue.

A person might have Bell’s Palsy first thing in the morning – they wake up and find that one side of the face does not move. If an eyelid is affected, blinking might be difficult.
Bell’s Palsy usually starts suddenly and must not be confused with cerebral palsy, which is a completely different condition. Associations have been found between migraine and facial and limb weakness and this led to a 2015 study which found that people with migraine may be at much higher risk of Bell’s palsy.

Most people who suddenly experience symptoms think they are having a stroke. However, if the weakness or paralysis only affects the face it is more likely to be Bell’s palsy.
Approximately 40,000 Americans develop Bell’s palsy each year. The National Health Service (NHS), UK, reports that about 25 to 35 people out of every 100,000 develop Bell’s palsy each year. It is classed as a relatively rare condition. It more commonly affects people over 15 and under 60 years of age, and affects men and women equally.

Bell’s palsy is named for Sir Charles Bell, a 19th century Scottish surgeon who described the facial nerve and its connection to the condition. The disorder, which is not related to stroke, is the most common cause of facial paralysis. Generally, Bell’s palsy affects only one of the paired facial nerves and one side of the face, however, in rare cases, it can affect both sides.

What are the Symptoms?

Because the facial nerve has so many functions and is so complex, damage to the nerve or a disruption in its function can lead to many problems. Symptoms of Bell’s palsy can vary from person to person and range in severity from mild weakness to total paralysis. These symptoms may include twitching, weakness, or paralysis on one or rarely both sides of the face. Other symptoms may include drooping of the eyelid and corner of the mouth, drooling, dryness of the eye or mouth, impairment of taste, and excessive tearing in one eye. Most often these symptoms, which usually begin suddenly and reach their peak within 48 hours, lead to significant facial distortion.

Our Austin Bell’s Palsy patients also report symptoms including pain or discomfort around the jaw and behind the ear, ringing in one or both ears, headache, loss of taste, hypersensitivity to sound on the affected side, impaired speech, dizziness, and difficulty eating or drinking.

The facial nerves control blinking, opening and closing of the eyes, smiling, salivation, lacrimation (production of tears), and frowning. They also supply the stapes muscles with nerves. The stapes is a bone in the ear which is involved in our ability to hear. When the facial muscle malfunctions, the following symptoms may emerge:

  • Sudden paralysis/weakness in one side of the face.
  • It may be difficult or impossible to close one of the eyelids.
  • Irritation in the eye because it does not blink and becomes too dry. Changes in the amount of tears the eye produces.
  • Parts of the face may droop, such as one side of the mouth.
  • Drooling from one side of the mouth. The amount of saliva produced changes.
  • Difficulty with facial expressions.
  • Sense of taste may become altered.
  • Sounds may seem louder.
  • An affected ear may lead to sensitivity to sound (hyperacusis).
  • Pain in front or behind the ear on the affected side.
  • Headache

What Causes Bell’s Palsy?

Bell’s palsy occurs when the nerve that controls the facial muscles is swollen, inflamed, or compressed, resulting in facial weakness or paralysis. Exactly what causes this damage, however, is unknown.

Most scientists believe that a viral infection such as viral meningitis or the common cold sore virus (herpes simplex) causes the disorder. They believe that the facial nerve swells and becomes inflamed in reaction to the infection, causing pressure within the fallopian canal and leading to ischemia (the restriction of blood and oxygen to the nerve cells). In some mild cases (where recovery is rapid), there is damage only to the myelin sheath of the nerve. The myelin sheath is the fatty covering which acts as an insulator on nerve fibers in the brain.

The disorder has also been associated with influenza or a flu-like illness, headaches, chronic middle ear infection, high blood pressure, diabetes, sarcoidosis, tumors, Lyme disease, and trauma such as skull fracture or facial injury.

Who Gets it?

Bell’s palsy afflicts approximately 40,000 Americans each year. It affects men and women equally and can occur at any age, but it is less common before age 15 or after age 60. It disproportionately attacks people who have diabetes or upper respiratory ailments such as the flu or a cold.

How is it Diagnosed?

There is no specific laboratory test to confirm diagnosis of the disorder. However, a diagnosis of Bell’s palsy can be made based on clinical presentation, for example, a distorted facial appearance and the inability to move muscles on the affected side of the face and ruling out other possible causes of facial paralysis. At Austin Oculofacial Plastics, Dr. Paul will carefully examine the patient for upper and lower facial weakness. In most cases this weakness is limited to one side of the face or occasionally isolated to the forehead, eyelid, or mouth.

With this thorough evaluation, Dr. Paul will also look for evidence of other conditions which may be causing the facial paralysis, such as a tumor, Lyme disease, or stroke. This will involve checking the patient’s head, neck and ears. He will also check the facial muscles carefully and determine whether any other nerves are affected apart from the facial nerve. If there is a change in facial structure, it could be evidence of a tumor. A characteristic rash may be evidence of tick bites in Lyme disease.

If all other causes can be excluded, Dr. Paul may diagnose Bell’s palsy. If he is still unsure, the patient may be referred to an ENT (ear, nose and throat) specialist, an otolaryngologist. The referred specialist will then examine the patient and may also order the following tests:

  • Electromyography (EMG) – electrodes are placed on the patient’s face. A machine measures the electrical activity of the nerves and the electrical activity of a muscles in response to stimulation. This test can determine the extent of nerve damage, as well as its location.
  • MRI, CT scans or X-rays – these are good at determining whether other underlying conditions are causing the symptoms, such as a bacterial infection, skull fracture, or a tumor.

How is it Treated?

Bell’s palsy affects each individual differently. Some cases are mild and do not require treatment as the symptoms usually subside on their own within 2 weeks. For others, treatment may include medications and other therapeutic options. If an obvious source is found to cause Bell’s palsy (e.g., infection), directed treatment can be beneficial.

Recent studies have shown that steroids such as the steroid prednisone, used to reduce inflammation and swelling are effective in treating Bell’s palsy. Other drugs such as acyclovir, used to fight viral herpes infections, may also have some benefit in shortening the course of the disease. Analgesics such as aspirin, acetaminophen, or ibuprofen may relieve pain. Because of possible drug interactions, individuals taking prescription medicines should always talk to their doctors before taking any over-the-counter drugs.

Another important factor in treatment is eye protection. Bell’s palsy can interrupt the eyelid’s natural blinking ability, leaving the eye exposed to irritation and drying. Therefore, keeping the eye moist and protecting the eye from debris and injury, especially at night, is important. Lubricating eye drops, such as artificial tears or eye ointments or gels, and eye patches are also effective. Other therapies such as physical therapy, facial massage or acupuncture may provide a potential small improvement in facial nerve function and pain.

In general, decompression surgery for Bell’s palsy to relieve pressure on the nerve is controversial and is seldom recommended. On rare occasions, cosmetic or reconstructive surgery may be needed to reduce deformities and correct some damage such as an eyelid that will not fully close or a crooked smile.

What is the Prognosis?

The prognosis for individuals with Bell’s palsy is generally very good. The extent of nerve damage determines the extent of recovery. Improvement is gradual and recovery times vary. With or without treatment, most individuals begin to get better within 2 weeks after the initial onset of symptoms and most recover completely, returning to normal function within 3 to 6 months. For some, however, the symptoms may last longer. In a few cases, the symptoms may never completely disappear. In rare cases, the disorder may recur, either on the same or the opposite side of the face.

If you feel that this information applies to you or someone you love, we are here to help. Give us a call at 512-642-5050 to schedule an informative consultation with Dr. Paul at Austin Oculofacial Plastics.