Facial palsy

Disease Description (Causes and Symptoms)

• Definition: A condition in which the movement of the facial muscles is partially or completely reduced due to dysfunction of the facial nerve. It is classified into peripheral type (usually unilateral) and central type (caused by a brain lesion).
• Main causes: Idiopathic causes (Bell’s palsy), herpes zoster (Ramsay Hunt syndrome), head trauma (skull fracture), central nervous system diseases such as stroke and brain tumors, complications of otitis media, infections (e.g., Lyme disease), and others.
• Pathophysiology summary: Inflammation, compression, or transection of the facial nerve, or damage to the brain’s motor center, blocks nerve conduction, causing muscle atrophy, paralysis, and imbalance.
• Main symptoms:
  • Paralysis of the muscles of facial expression on one side of the face (usually unilateral): incomplete eye closure, loss of forehead wrinkles, asymmetry of the lips
  • Speech and articulation difficulties, drooling, and impaired whistling and drinking
  • Ocular symptoms: tearing, dry eyes, and irritation (risk of corneal dryness and damage)
  • Sensory changes: reduced taste in the front of the tongue (in some peripheral cases), hyperacusis (language), and ear pain (in Ramsay Hunt syndrome)
  • Pattern of onset: Bell’s palsy commonly develops acutely within several hours to several days; central lesions may be accompanied by other neurological symptoms

Treatment Methods and Precautions

• Diagnostic approach: First, rule out central causes (stroke, tumor, and trauma)—CT/MRI if necessary; serologic testing if Lyme disease is suspected; nerve conduction testing (EMG) to assess the severity of paralysis and prognosis.
• Medication treatment
  • Steroids (e.g., oral prednisone): Standard treatment for Bell’s palsy, intended to reduce vascular edema and inflammation. It is recommended to begin in the early stage of onset (immediately after onset if possible, and no later than 3–4 days after onset).
  • Antiviral medications (acyclovir, valacyclovir): Concomitant antiviral treatment is recommended when herpes zoster (Ramsay Hunt syndrome) is suspected; the addition of antivirals in Bell’s palsy is determined on a case-by-case basis.
  • Analgesics and symptomatic treatment: Relief of pain and neuralgia.
• Eye protection (important)
  • Mechanical protection such as artificial tears (during the day), eye ointment (at night), wearing an eye patch when necessary, or insertion of an eyelid weight (gold or platinum).
• Physical therapy and rehabilitation
  • Electrical stimulation of the facial muscles, muscle retraining (neuromuscular retraining), and speech therapy may aid recovery (effectiveness varies among individuals).
• Surgical treatment
  • Facial nerve decompression: Considered in some patients with severe acute cases (indications and timing vary depending on the literature and clinical practice; generally applied on a limited basis). The timing mentioned in the table indicates that the procedure may be possible within 2–4 days after onset in some cases.
  • Nerve repair and nerve grafting: May be performed early when there is nerve damage and before muscle atrophy develops.
  • Muscle transfer (microsurgery): When a long time has passed after the injury and muscle atrophy has progressed (e.g., 1–2 years), muscle transfer may be attempted to restore facial expression; the gracilis muscle, latissimus dorsi muscle, and others may be used as donor muscles.
• Complications and precautions
  • Risk of corneal ulceration and blindness (eye protection is essential)
  • Accompanying pain, residual paralysis, synkinesis, and facial asymmetry after paralysis
  • If the cause is central (such as stroke), emergency treatment is necessary—if weakness of the arms or legs, speech difficulties, or altered consciousness occur together with facial paralysis, visit the emergency department immediately
• Prognosis: The majority of patients with Bell’s palsy (approximately 70–90%) improve within several weeks to several months after conservative treatment, but some are left with residual symptoms (partial paralysis, synkinesis, and others).

Checklist Before an Outpatient Visit (Including Items to Prepare and Example Questions)

• Items to prepare (recommended to bring)
  • A list of all medications currently being taken (including prescription drugs, over-the-counter medications, and supplements)
  • Medical history (hypertension, diabetes, recent infections or history of herpes zoster, recent trauma or surgery)
  • The time of symptom onset and course (when and how abruptly it developed), with notes on factors that worsen or improve the symptoms
  • Record of accompanying symptoms: ear pain, rash (around the ear), fever, weakness of the limbs, speech difficulties, and visual disturbances
  • Recent travel or outdoor activities (possibility of tick exposure), and whether there is immunosuppression
  • Results of previous tests (copies of CT/MRI, blood tests, and EMG results, if available)
• Information useful to provide to the doctor during the outpatient visit
  • Whether there is a foreign-body sensation or dryness in the eye, and the degree of tearing or eye discomfort
  • Frequency of food spilling from the mouth and specific examples of changes in pronunciation
  • The time pattern of symptom improvement or worsening
• Simple self-assessment items before the visit
  • Which parts of the face cannot move (specifically indicate the forehead, eye, or mouth)
  • Whether it is bilateral or unilateral, and whether symptoms change during the day

General Example Questions to Ask the Doctor

• What do you think is the cause of this paralysis? (Is it Bell’s palsy, or is there another cause?)
• What treatment do you recommend (medication and rehabilitation), and when is the appropriate time to begin?
• What are the expected benefits and side effects of this medication (such as steroids)?
• What measures should I take to protect my eyes? Do I need artificial tears, an eye patch, or surgery?
• What is the prognosis, and how long is recovery expected to take?
• When should I undergo reevaluation (follow-up testing)? When do you recommend EMG or imaging tests?

Examples of Disease-Specific Questions

• How do you distinguish whether I have Bell’s palsy or Ramsay Hunt syndrome (herpes zoster), and do I need antiviral treatment?
• When is it best to undergo electrophysiological testing (nerve conduction testing and electromyography) to assess the degree of facial nerve damage, and would surgical treatment be considered based on the results?