Saying Bell’s Palsy out loud when you suffer from idiopathic facial paralysis sounds like a mumble of sounds. Talking and whistling is out of the question. Eating in public can result in an embarrassing situation and people stare because of your Bell’s Palsy symptoms. Paralysis of your facial nerve results in a sagging down of the same half of your face, leading to an unflattering asymmetrical appearance. This idiopathic condition still has no definite known cause. It was named after the Scottish neurologist, Sir Charles Bell. Approximately 40 000 people are diagnosed with Bell’s Palsy each year. It remains a diagnosis of exclusion, meaning all other possible causes of facial paralysis need to be excluded before Bell’s Palsy is diagnosed. Physiotherapy treatment can accelerate your facial palsy recovery.
The Anatomy of your Facial Nerve
Your nervous system is like your electrical supply. It is a uniquely complex designed system that not only allows such precise movement of a surgeon saving a brain or a pianist playing Chopin but also receiving information from your environment, like a ballerina on point doing pirouettes. Your facial nerve is one of the team members of this complex system.
You have two facial nerves, one for each side. Your facial nerve is the seventh cranial nerve (CN VII) and communicates directly with your brain. It begins in your brain stem and runs through the facial canal in your temporal bone. The facial canal is 3 cm, the longest bony canal in your body, and Z-shaped. Your facial nerve and stylomastoid artery both exit through a tiny hole, the stylomastoid foramen. This foramen is about 0.7 mm wide.
After exiting through the stylomastoid foramen your facial nerve divides into the following branches:
- temporal
- zygomatic
- buccal
- mandibular
- cervical
What job does my Facial Nerve do?
Your facial nerve is a mixed nerve, meaning it sends and receives information. 70% of your facial nerve’s fibres are myelinated and supply your 30 facial muscles, while the other 30% have mixed sensory fibres. This sensory part of your facial nerve is responsible for the front 2/3 of taste sensation from your tongue, like when you lick ice cream, and the lubrication function of your lacrimal, submandibular and sublingual glands. These glands make tears to lubricate your eye and saliva to help digest the food you eat.
We take for granted how subtle changes in facial expression are part of communication. Remember when we were all wearing masks during the pandemic? When you cannot see someone’s face you can’t read the change of expression when they talk of a painful experience, hint at a sarcastic pun or busy taking you for a fool with a silly joke.
On a more practical note, you need your facial muscles to talk, chew, contain your sip of coffee to the inside of your mouth, whistle and close your eyes. This is very important to protect your eye from flying insects and keep your eye lubricated and cornea protected.
How did I get Bell’s Palsy?
Your nerves work pretty much like any electrical appliance. If electricity can’t be sent to your kettle, it cannot boil the water. In Bell’s Palsy, this is like having a cut in the kettle’s cord. Electricity or nerve impulses cannot be transported to your facial muscles and glands, so the muscles cannot move and the glands cannot secrete. The exact cause of Bell’s Palsy is still unknown, the following description is our best understanding of the pathology.
The length, circumference and Z-shape of the facial canal within the temporal bone, make the journey through it quite risky. The facial nerve and stylomastoid artery are susceptible to compression. This compression can be from inflammation caused by infection. Once the inflammation compresses both nerve and artery, the facial nerve also doesn’t receive fresh blood supply, delaying healing. The symptoms of facial paralysis are of sudden onset. It may be accompanied by a general feeling of tiredness or feeling flush.
Causes of Bell’s Palsy
- Viral infection
Infection of the following viruses can cause Bell’s Palsy: herpes simplex, epstein-barr or varicella-zoster virus. Ramsay Hunt Syndrome, caused by the herpes zoster virus, causes one-sided facial paralysis like Bell’s Palsy, but also hearing loss, balance problems and a painful rash.
- Bacterial infection
Borrelia burgdorferi infection, via tick bites, causes Lyme Disease that can cause facial paralysis.
- Tumours
Cholesteatoma, hemangioma, facial schwannoma or parotid gland tumours can cause Bell’s Palsy.
- Surgical complications
Surgical removal of acoustic neuroma, TMJ replacement, mastoidectomy and parotidectomy can cause facial paralysis.
- Trauma
Temporal and mastoid fractures can cause Bell’s Palsy.
Corticosteroid medication is most effective if started within 72 hours of onset of symptoms.
How severe is my facial palsy?
Nerve injury classification was described in 1943 by Seddon. The severity of nerve injuries is classified into the following three groups:
I. Neuropraxia
The physical nerve remains intact, both the power cable and surrounding insolation, but the nerve’s ability to transport impulses is temporarily damaged. Where infection, inflammation and compression caused your Bell’s Palsy, you can expect to recover within a few months.
II. Axonotmesis
The connective tissue surrounding the nerve (insolation) remains intact, but the axon (power cable) is damaged. This type of nerve damage is uncommon in Bell’s Palsy, but trauma, tumours and fractures may cause axonal damage to your facial nerve. You can expect a longer recovery of 5 – 6 months, with your eyes and mouth regaining movement first and your chin and cheeks later.
III. Neurotmesis
Both surrounding connective tissue and axon are damaged or severed. This can happen as a result of trauma or surgical complications. Lengthy and partial recovery is expected. Nerves can regenerate about 1 mm a day under ideal circumstances.
Sudden onset facial paralysis of the lower half of the face, that doesn’t involve the eye, indicated upper motor neuron injury like stroke or tumor.
SEEK IMMEDIATE MEDICAL CARE!
Diagnosing Bell’s Palsy
Bell’s palsy is a diagnosis of exclusion and care must be taken to rule out sinister pathology if you meet certain risk factors for vascular problems. Your doctor will consider your history when deciding what tests or imaging to send you for. Your unique situation and comorbidities will determine the workup you receive.
Physiotherapy diagnosis of facial paralysis
Bell’s palsy causes sudden onset of one-sided facial paralysis. When facial muscle tone is affected so suddenly with one half of your face hanging down, most people are worried that they have suffered a stroke and rush to the ER. This is a normal and needed reaction to rule out a CVA. You will also receive the correct medication to start immediately and prevent pressure on the facial nerve for an extended period.
We can then determine the extent of your facial palsy and give you an approximate time line for your recovery, while starting your Bell’s Palsy rehabilitation. Our physiotherapist can evaluate range of motion, muscle strength, endurance, and sensation to customise your treatment program and home exercises.
Blood tests
Blood tests that include complete blood count, erythrocyte sedimentation rate, thyroid hormones, liver enzymes and viral/bacterial load can be done to exclude other causes of your facial palsy. This will be done routinely in the ER by your doctor.
MRI/CT
A brain MRI/CT scan can view all of the structures of your head, including vasculature and nerves. This will be done to exclude a cerebrovascular attack (CVA) if you went to the ER with your facial palsy and have certain risk factors for a stroke.
Why does my face still look asymmetrical?
Complete recovery from Bell’s Palsy without intervention is uncommon. Young, healthy individuals, without bad habits like smoking, who can rely on fantastic circulation have a greater chance of making a speedy recovery without physiotherapy intervention. Older individuals with co-morbidities need extra assistance to hasten recovery.
The faster we can introduce impulses and guide muscle contraction the less likely you will develop connective tissue restrictions and synkineses. Synkinesis is the involuntary, simultaneous movement that can develop up to 6 months into your recovery. This will cause your eye to close when you smile or your mouth corner to twitch when you close your eyes. This can be prevented with physiotherapy treatment where the aim during the later phases of your rehabilitation is focussed on movement specificity.
There is no vanity when it comes to Facial Palsy rehab, we aim to get you feeling confident on photos again.
Problems we see when patients come to us with facial palsy
Waiting too long
Time is of the essence! The longer you wait, the greater the chance of delayed recovery, because the nerve is losing out on crucial circulation while you weigh the odds of a spontaneous recovery. Go to the ER, rule out any dangerous pathology and get your cortisone and antiviral prescription. Make an appointment to start your Bell’s Palsy treatment as soon as possible. We can get started while you are on oral medication.
Dry eye
It is crucial to assist eye closure regularly throughout your waking day. During the night you can tape your eye shut or make use of an eye patch. Your GP/pharmacist can recommend eye drops to use. If your eye isn’t lubricated you can develop a corneal ulcer that causes loss of vision.
Too much too soon
Initially getting some movement will take all of your effort, this is fine in the first few weeks of your recovery. From here the emphasis falls on precision in order to avoid synkinesis. Do not over do and try to get a set amount of reps when the muscles are fatigued. Rather rest a few hours and complete your reps once rested.
Not completing your rehabilitation
Your Bell’s Palsy treatment is complete when your facial expressions look and feel symmetrical. Stopping before the end can cause synkinesis and an asymmetrical apprearance.
Physiotherapy treatment for Bell’s Palsy
Our physiotherapists are experts in rehabilitation and understand physiology. We have studied how a viral infection causes a cascade of inflammation, how nerves react to pressure and what effects that will have on your everyday life. Physiotherapy enhances function while promoting healing. Neural plasticity excites us, muscles are our friends, in that we understand how movement translates to facial expressions. Flexibility, control, endurance and strength are the commodities we deal with daily. There are no shortcuts to healing. It’s important to do the right exercise at the right time as your facial palsy treatment progresses. We will guide you every step of the way.
Phases of Bell’s Palsy Rehabilitation
1st Phase of Bell’s Palsy treatment: Facilitate a flicker (weeks 0 – 3)
Our first aim is to get the proper diagnosis, establish when you started oral medication and make sure you know how to take care of your eye. Now we use electrical muscle stimulation (EMS) to get a muscle flicker while facilitating some facial expressions. Laser can be used for pain and inflammation. Your physiotherapist will teach you self soft tissue mobilisation and taping techniques for home use.
2nd Phase of Bell’s Palsy treatment: Strength through range (weeks 4 – 6)
Once you have regained some movement of your facial muscles we aim to strengthen that movement through the entire range. You can expect some hands on assists while you are doing your facial expressions with the EMS. Full, wide smiles, snarls, pouts and eye closure are our priority.
3rd Phase of Bell’s Palsy treatment: Endurance & Eccentric Control (weeks 7 – 8)
The EMS has been your friend until now. From this stage, you can expect to work against the machine, similar to Body 20 and Bodytec training. You should be more comfortable eating in public as you regain mouth closure.
4th Phase of Bell’s Palsy treatment: Isolated Specificity (weeks 9 – 12)
Now we work on the subtle nuances as you gain isolated control of your facial expressions. No more forcing your eyes shut, please wink. Whistling and blowing bubblegum bubbles and watching laugh out load sitcoms is part of your rehabilitation now.
5th Phase of Bell’s Palsy treatment: Synkinesis watch (months 3 – 6)
Your pre- and post-rehabilitation selfies should be difficult to distinguish now. Even though we won’t be seeing each other often, keep an eye on those involuntary movements to ensure you don’t develop synkinesis.
Healing time for Bell’s Palsy
Facial palsy when diagnosed correctly and treatment protocol of corticosteroid and antiviral medication started immediately takes approximately 8 weeks to recover fully. The duration of nerve compression and loss of sensation and motor function greatly influences your overall recovery period. Your general health and any comorbidities, like diabetes and vascular problems, will also influence the duration of your recovery.
Unfortunately, 30% of people diagnosed with Bell’s Palsy may suffer long term side effects of nerve injury. This may include weakness that leads to asymmetrical appearance, sensory loss, and involuntary movements of synkinesis.
Other medical treatment options for Bell’s Palsy
- Your doctor (GP) will probably prescribe corticosteroids and antiviral medication.
- Eye care is very important while you recover from Bell’s Palsy. You need to protect your eye from drying out with drops, salve and and/or an eye patch while sleeping. Ask your doctor/pharmacist about different options to protect your eye.
- Supplementation of vitamins and minerals can be considered during your recovery.
Is surgery an option for Bell’s Palsy?
No, there is no surgical intervention that can restore nerve function. Facial reanimation surgery can be considered for aesthetic purposes that make your face look more symmetrical if you suffer from permanent paralysis.
What else could it be?
- Cerebrovascular Accident (CVA/stroke)
Hemorrhagic or ischeamic incidents can also cause facial palsy, but will be accompanied by sudden, sever headache, inability to talk, confusion, loss of balance and weakness in one or more limbs.
Cervicogenic headaches can cause facial and scalp pain.
Whiplash or other injury to your high cervical spine can cause referred pain to your face and jaw.
Vertigo and balance dysfunction, caused by a viral infection of the vestibulocochlear nerve (CN VIII), may also cause facial pain.
- Ramsay Hunt Syndrome
Shingles infection (Herpes Zoster Virus) of your facial nerve leads to similar facial palsy, with a painful rash and hearing loss.
Bell’s Palsy is also known as:
- Facial nerve paralysis
- Idiopathic facial palsy
- Facial nerve palsy
- Antoni’s palsy
