What does facial palsy mean?

Facial Palsy is a general medical term which means weakness of the facial muscles, usually on one side of the face, as a result of damage to the facial nerve caused by swelling or pressure on
the nerve.

How does the facial nerve work?

There is a facial nerve on each side of the face. If you damage it on the left side it will affect the left side of your face and if damaged on the right it will affect the right side of your face. Each nerve leaves the brain through a tiny channel in the skull and enters the face in the front of the ear. It then divides into five branches to supply the different muscles for facial expression. The facial nerve is also responsible for production of tears, saliva and taste for part of the tongue.

The diagram shows the five branches coming out in front of the ear and going to the muscles in the forehead, eye and cheek, lips, chin and neck. These branches are responsible for facial movement.

What happens once you have damaged your facial nerve?

When facial palsy initially occurs the affected side(s) of your face will feel and look floppy as there are no nerve signals telling the muscles to contract.

Facial palsy can be caused by a number of different things some of which are listed here:

  • Viral Infection is a common cause of facial palsy known as bells palsy.
  • The Herpes Zoster virus can cause a more aggressive form of facial palsy known as Ramsey Hunt Syndrome. This is the same virus which causes Chicken Pox and Shingles (not cold sores).
  • Surgery to remove a facial nerve or acoustic nerve tumour can cause facial palsy. The acoustic nerve lies very close to the facial nerve so in the process of removing these tumours the facial nerve can become damaged.
  • Surgery to the parotid gland. The facial nerve runs through this salivary gland and so can be damaged during surgery.
  • Bacterial causes (eg. Lyme Disease of following a middle ear infection).
  • Neurological conditions (eg. Guillain-Barre syndrome or Neurofibromatosis).
  • Traumatic injury such as fractures to the brain, skull or face, as might be suffered in an accident.
  • Congenital condition, which means an abnormality of the facial nerve you are born with.

Stroke can cause facial palsy as a result of damage in the brain but this is slightly different to the causes above, which directly affect the nerve after it leaves the brain.

Yes: Facial nerve injuries can be classified into three groups:

First degree injury – the nerve is “concussed or bruised” and recovers within eight weeks.

Second degree injury – the nerve is more severely damaged but the nerve’s outer layer is still intact. It recovers at the rate of up to one millimeter per day, with first signs of recovery usually at four months.

Third degree injury – the nerve is severely damaged and requires surgical repair. Recovery from this is very slow and always incomplete. If the nerve is severed and not repaired in any way there will be no natural recovery and surgery will be required to help restore facial function.

The main movements that the facial muscles perform are as follows:

  • Raising the eyebrows (frontalis)
  • Wrinkling nose (procerus/nasalis)
  • Pouting (orbicularis oris)
  • Lifting top lip (levator labii)
  • Open and closed mouth smiling (zygomaticus and risorius)
  • Closing the eye (orbicularis oculi)
  • Frowning (corrugtor)
  • Pulling lower lip down (depressor labii)
  • Sticking bottom lip out (mentalis)
  • Pulling jaw and corners of mouth down gently down (platysma)

Once your face starts to recover you will notice that:

  • Muscles in some areas begin to work again earlier than other areas.
  • In some areas you may notice different things about your face:
    • The eye may seem smaller and the corner of the mouth may seem raised on the affected side.
    • The cheek may feel tight and stiff. Don’t panic you haven’t had a facial palsy on the other side.
  • The cheek branches of the nerve tend to recover first but aren’t balanced out by the forehead and chin branches of the nerve which take longer to get working again. So the face muscles are unbalanced.
  • As all the nerve branches recover you can help get balance back in the face with lots of slow, careful exercises in front of the mirror.
  • At first movements may be asymmetrical and difficult but slow repetitive practise will eventually wake up your brain’s memory of how the movement used to work. This is a slow process but worth preserving with as small improvements add up to a big overall change.
  • Exercises done at this stage must be done on a relaxed face and should concentrate on tiny, precise movements.

Synkinesis can occur in the later stages of recovery. Synkinesis is a medical term that means ‘unwanted movement’. Having Synkinesis means that different parts of the face move together outside your control.

The more severe your nerve injury is the more likely it is that you will develop Synkinesis. It happens because as the nerves being their recovery, if one branch of the nerve is activated all the others join to try and help, eg. you want to smile and the eye shuts.

The situation will improve as recovery continues as long as you get into the habit of stopping the unwanted movements from happening when you don’t want them to (your therapist will advise you how to achieve this).

Synkinesis also means some facial muscles act against each other in a “tug-of-war” which can stop parts of the face from moving even though the nerve has recovered. The affected muscles have to be gently re-taught when to move and when to stay relaxed and then this has to be practised over and over again. It is important not to practice incorrectly as this can make the situation worse.

If you put too much effort into a facial movement it can stimulate all the nerves and you will get unwanted activity in other areas. This is why facial exercises have to be slow, gentle and careful, stopping just before you get unwanted activity.

Techniques like looking in the mirror, touching your face and focused relaxation can all help your movement to become more refined.

The amount of muscle effort needed to do these exercises is very low, only approximately ten per cent, pushing your face to work harder will not make you get better more quickly. One exercise done perfectly is better than many done with poor

What else may be a problem when you have facial palsy?

  • A muscle in the ear (stapedius) can be affected causing sounds to appear louder on that side.
  • Eating and drinking can be harder due to weakness of the cheek and lip seal.
  • Food can collect in the affected cheek and difficult to remove.
  • Some people complain because they bite the inside of their cheek or lip.
  • Assessment.
  • Advice and education.
  • Monitoring of progress.
  • Reassurance and motivation.
  • Advice on eye care and taping the eye closed.
  • Advice on mouth care and dry mouth management.
  • Advice on eating, drinking and speech improvement.
  • Massage to keep the muscles mobile and healthy.
  • Stretches to lengthen muscles which become short or tight.
  • Exercises to help relearn and develop balanced facial movements.
  • Relaxation of your facial nerve and muscles.
  • Exercises to reduce involuntary, unwanted movements.
  • Teaching of home exercise programmes to enable you to be independent with your recovery.

British Bells Palsy Association (BPA)

The British Acoustic Neuroma Association (BANA)
Call: 01623 632 143

Bells Palsy Information Site
Call: 01623 632 143

The Therapy department is open Monday to Friday 8am to 5pm.

If you have any questions or require further information or advice during the above hours please contact:

Therapy department: 01935 384 358

The Patient Advice and Liaison Service (PALS)

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Ref: 16-17/122
Review: 02/19