Bells Palsy Information Site - Understanding Bell's Palsy, Ramsay Hunt Syndrome and facial paralysis.
Bells Palsy Information Site - Understanding Bell's Palsy, Ramsay Hunt Syndrome and facial paralysis.

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A Guide to Coping with Facial Paralysis

This article has been created to help you learn more about facial paralysis and its treatment options. It is a joint effort of medical practitioners, therapists and patients like you who also have facial paralysis. Your recovery is a personal journey. No two cases or stories are the same. You must evaluate all treatment options and discuss them actively with your care providers to determine the best treatment plan for your needs. For many patients, the onset of facial paralysis is sudden, and the resulting lack of facial movement is traumatic. The physical symptoms that accompany facial paralysis can be moderate to severe. The emotional aspects can be devastating. It is a life-altering event. So much of what we have been conditioned throughout culture to perceive as normal or acceptable is based on physical appearance. You may feel conflicting emotions including disbelief, anger, frustration and helplessness, but remember you are not alone.

The Facial Nerve

The facial nerve is one of the 12 cranial nerves originating from each side of the brainstem. It has approximately 13,000 individual neurons, of which roughly 7,000 serve as motor units to the face. The longest bony canal of any other nerve in the body protects it. The facial nerve is tiny. As it comes out of the internal auditory canal, it is less than one millimeter (.04 inch) in diameter. The good news is that there are thousands of nerve fibers in this tiny structure, much like a phone cable, and these fibers are resistant to damage. If the facial nerve is mildly damaged, the nerve will regenerate slowly (approximately one inch per month) all the way back through the five branches in the face. But even with mild damage, as a nerve regenerates there can be some misdirection of fibers. The regeneration can be somewhat chaotic and fibers can grow down the wrong nerve channel (with a result like crossed wires). This possibly "wrong" connection can cause inappropriate movement (synkinesis) such as the mouth in the affected side moving up when the eye closes, or tearing with chewing.

What is Facial Paralysis?

Facial paralysis is a lack of movement caused by damage to the facial nerve. It is usually unilateral and is the most frequently paralyzed peripheral nerve in the body, and it is also the most visible. Some of the early symptoms include unilateral facial numbness or weakness, feeling of "swelling" on the involved side, changes in taste, intolerance to noise, dry eyes and sometimes pain in, or around, the ear. Some of the causes of facial paralysis include:

• Trauma - accidental injury

• Tumors - both benign (ie. Acoustic Neuroma) and malignant

• Congenital - present at birth

• Infectious - Bell's Palsy and Ramsay Hunt

The target organs for the facial nerves are the nearly 80 facial muscles arranged in four layers that control facial movement. The most important aspect for considering facial movement as normal and adequate is spontaneity and secondarily, symmetry.

Diagnostic tests which can be used to aid in diagnosis and subsequent treatment, include nerve excitability tests, electroneuronography (ENOG), audiometry, CAT scans (with high resolution to denote the fallopian canal), MRIs with contrast, blood tests to determine if paralysis is caused by varicella zoster or HSV-2 and facial grading. In some cases, surgery to achieve facial nerve decompression and nerve grafting from other parts of the body has provided some benefit to patients. From a patient's perspective the primary issues of concern seem to concentrate on difficulties with eye closure and smiling. Secondary symptoms also reported include loss of taste and smell, vertigo, vesicles around the ear, pain, sinus infections, headache, tongue numbness, noise sensitivity, corneal scratches and eye dryness, "crocodile" tears, locking jaws, difficulty swallowing and chewing, and bacterial infections in the mouth. Bells phenomenon is also present, where the eyeball rolls upward upon the eye closure. Wallerian Degeneration (degeneration of the facial nerve) can begin within 24-72 hours after onset of paralysis, so prompt medical evaluation and treatment are very important

Treatment Protocol

Medication

For paralysis resulting from infectious and idiopathic causes, medication should include an antiviral drug (acyclovir, etc.). Recommended dosage if acyclovir is used is 2,000 mg/day for 10 days. Also oral prednisone, to reduce edema of the facial nerve in the fallopian canal within the temporal bone. Recommended dosage is 30 mg, twice a day or I mg. per kilogram of body eight for five days, withdrawn over the next five days. For Bells Palsy and Ramsay-Hunt Syndrome, administering both antiviral and steroids within 72 hours of onset in the recommended doses is expected to achieve the most favorable outcome. There has been some controversy over the administration of steroids for viral-linked paralysis; however, the potential benefits in reducing swelling of the nerve in the fallopian canal, which can cause permanent loss of facial movement, must be considered.

Education

When you start rehabilitation, you will learn more about the underlying physical structure of your face than you ever thought possible. Once you understand how movement is accomplished, you can increase the effectiveness of your treatment.

Rehabilitation

Facial retraining is a form of rehabilitative therapy that encompasses manual manipulation of facial muscles and can include electromyography biofeedback training. An assessment of three major features contribute to effective facial retraining:

• Deficient symmetry

• Functional loss due to inadequate muscle activity

• Impaired emotional expression (smiling, frowning)

Specific action exercises can be used (raise eyebrow, snarl, etc.) for targeted muscles. Electromyography biofeedback training uses a multi-channel computer to retrain and improve control of facial movement. In many cases, what was an automatic movement must be relearned. Relaxation of hyperactive muscles can be taught with a variety of exercises and manipulation technique to ease hyperactive muscle activity. As a result of the chaotic re-enervation synkinesis, mass movement and co-contraction are frequently seen after nerve healing. Specific exercises can help you reduce this problem that is usually perceived as facial rightness, involuntary pulling of the mouth or uncontrolled closure of the eye during smile.

Surgery

Surgical treatment for facial paralysis is an option for some selected cases of facial nerve injury. Facial paralysis caused by trauma or by another surgical procedure (tumor removal) can sometimes be improved by surgical intervention. Those cases will need to be reviewed by a specialist and informed decisions can be made based on nerve testing (ENOG testing), clinical evaluation and review of previous surgical reports. On the other hand, surgical procedures for infectious or idiopathic facial paralysis (i.e. Bells Palsy) are rarely recommended. Some controversy still surrounds the discussion over the indications, or not, for nerve decompression after Bells Palsy or other infectious etiologies. One of the criticisms is that because the surgery needs to be performed in the first 14 days after onset, it would be difficult to determine whether the patient would have a good recovery without surgery. The opponents to the surgical approach believe that medication, with similar outcomes and less risks, is still the best treatment while the surgical proponents advocate that surgery would give a better outcome if done early. Another group suggests that patients with facial paralysis due to Ramsay Hunt (Herpes Zoster Oticus) should have the surgery due to the high incidence of poor recovery. We suggest that you discuss the matter at length with your physician and research the topic before making a decision. It is a very tough call. There is no way to tell how the recovery is going to be and how the face is going to look three months from now.

Eye core

If you are having difficulty with eye closure, several options are available. You should discuss the problem with your eye doctor to find out which is the best management for your eyes. As a rule, eyes should always be lubricated with eye drops or ointment and the affected eye should be taped shut at night. This should reduce risks of corneal ulceration or eye infections. Gold weights, patches, springs and other surgical procedures can be discussed with your doctor if difficulty closing the eye persists for an extended period of time.

Vitamin therapy

Vitamin B 12, B 6 and zinc have been suggested to aid in the nerve growth. There is very little scientific research to back up that belief, but many patients report significant improvement with a vitamin regimen. Also, B 12 injections can be prescribed and performed by your physician if indicated.

What you can expect

Normal regeneration is at the rate of one millimeter per day. Although regrowth of the nerve tissue is very slow, progress in regaining movement can be greatly assisted with proper training by specially trained rehabilitative specialists. This type of therapy requires daily dedication on the patient's part to follow through with exercises learned in clinical setting. You may need to spend one half hour per day on facial retraining on your own, once properly trained. Rehabilitation of facial nerve can be a long process. It is not unusual for facial retraining exercises to be used for extended periods of time - in some cases for three years or more to achieve maximum results. Setting aside a time period during the daily routine for relaxation immediately before your exercises can help you achieve optimum results. Progress can be slow or almost imperceptible in the beginning, but it is important that you maintain diligence in performing your exercises. Unlike some other types of rehabilitation, the goal is small controlled movement. Use pictures or a video camera to document your progress when possible.

What you can do.

Gross facial exercises are another common recommendation and form of treatment. Because of their nonspecificity, however, gross exercises typically given to patients reinforce abnormal movement patterns. Instruction such as "close your eyes as hard as you can," "smile broadly," or "pucker your lips" do not produce the desired facial symmetry and control required for normalized facial function. The use of maximum effort exercises recruits excessive motor units, producing patterns that differ from typical facial expressions, which are gentle and fluid. What you should do is practice slow and small movements, preferably in front of a mirror. Your goal is to re-establish a connection between the facial nerve and the muscle groups that are not responding. Even if no movement is seen it is important to keep practicing, and try to feel a small contraction indicating nerve/muscle response. Furthermore slow movements gradually allow the patient to observe and modify the angle, strength and speed of the movement as it occurs. As a result, new motor control strategies are systematically developed and learned. Movements performed rapidly will revert to the previous, abnormal motor pattern. Small movements preserve isolated responses of the facial muscle by limiting motor unit recruitment to those muscles targeted. Large movements recruit successively greater numbers of motor units as well as neighboring muscles (overflow), diminishing accuracy. Improved coordination develops as small movements are practiced accurately. Symmetry of movements is also key, and patients are instructed in symmetrical excursion of movements to reinforce the normal physiological response. Attempts to produce symmetrical movements initially include limiting excursion on the contra lateral side. If the contra lateral side is allowed to dominate, activity on the involved side could be diminished. Manual soft tissue manipulation (gentle massage with slow, deep pressure movements) is also recommended. That should help preserve the muscles soft and supple with less rigidity and contraction that shorten the muscle.

What you should not do?

One of the traditional therapy techniques, electrical stimulation, continues to be widely used in treatment of facial paralysis, although there is mounting evidence that it may be contraindicated. It has been suggested that electrical stimulation may interfere with neural regeneration following peripheral nerve injury, and studies proving its efficacy with facial muscles are lacking in the literature. A 1984 report by the National Center for Health Services Research concluded "Electrotherapy treatment for Bells Palsy... has no demonstrable beneficial effect in enhancing the function." Patients may demonstrate more synkinesis and mass action after using electrical stimulation. The main explanation is that it is difficult to produce an isolated contraction of the facial muscles using electrical stimulation because of their small size and proximity to each other. Additionally, patients who undergo acute electrical stimulation may demonstrate more synkinesis and mass action than those who do not. Finally, the contraction produced by electrical stimulation causes mass action, which reinforces abnormal motor, patterns and can be painful.

Peer support group

The Facial Paralysis Support Group meets bimonthly on the fourth Thursday of the month at 6 p.m. at the Florida Hospital Rehabilitation Center located at 5165 Adanson Street in Orlando, You are encouraged to attend these meetings to aid in your recovery. It is a time for fellowship and also a time to hear from specialists within the community including medical doctors, therapists, nutritionists, counselors and others who are willing to share their expertise. For more information, please call Celia Santini, Ph.D. at (407) 303-7600 or email celia_santini@mail.fhmis.net.