For Physicians: Diagnosis, Treatment and Referral Information
UW Health's Facial Nerve Clinic at UW Hospital and Clinics in Madison, Wisconsin, provides a multidisciplinary approach to diagnosing and treating facial paralysis in children and adults.
The following information can guide providers in their treatment of patients with facial nerve disorders and inform them about the right time to contact the Facial Nerve Clinic for a referral.
Approximately 70 percent of facial nerve palsies are considered Bell's palsy. This statistic indicates that 30 percent of patients presenting with facial paresis/paralysis have other underlying causes.
The facial nerve is responsible for many functions in the head and neck including movement of facial muscles, stimulating secretions of tears and saliva and translation of sensory information. The following symptoms are general symptoms of paralysis:
- Paresis (weakness) or paralysis on one side of the face
- Difficulty with facial expression such as smiling
- Decrease in saliva production and/or drooling or a change in tear production
- Difficulty closing the eye
- Change in sense of taste on one side of the mouth
- Sensitivity to loud sounds
- Pain around the ear on the affected side
Additionally, patients with facial palsies may experience depression or low self-esteem related to this change in appearance.
Bell's palsy is a diagnosis of exclusion. Bell's palsy is characterized by rapid onset facial paralysis occurring in less than 72 hours. If the drooping occurs over weeks or months, this is not Bell's. The paralysis can appear as sagging, frozen expressions, frowns, drooping or other unusual expressions and will affect the entire half of the face.
- Bell's palsy may occur in men, women, and children but is more common in people 15 to 45 years old, people with diabetes, upper respiratory ailments, or compromised immune systems, or during pregnancy.
- The Bell's palsy diagnosis is reserved for describing sudden onset facial paralysis within 72 hours once all other causes have been excluded.
- Bell's palsy on both sides of the face is very rare.
- Other symptoms unique to the facial nerve may appear in Bell's. See signs and symptoms
Common differential diagnoses of facial paralysis include:
- Lyme disease | Learn about Lyme disease
- In endemic areas, Lyme disease can be the cause of facial paralysis in up to 25 percent of cases. In endemic areas like Wisconsin it is important to eliminate this possibility before diagnosing the patient with Bell's.
- The risk of Lyme disease is greatest in the following states:
- New Hampshire
- New Jersey
- New York
- Rhode Island
- Forehead sparing paralysis could indicate a "central" deficit cause by stroke or intracranial mass. A thorough head and neck exam is crucial.
- Tumor: Tumors can also cause facial paralysis, a complete history and physical exam screening for tumors of the ear or parotid (salivary) gland are important for a patient with a new paralysis.
- Parotid tumor: As the facial nerve divides into smaller divisions within the parotid (salivary) gland, a tumor may cause only a segment of the face to be affected with facial paralysis. A complete history and physical exam including palpation of the neck and parotid gland are important for a patient with a new paralysis affecting only segments of the affected side of the face.
- Acoustic neuroma/skull base tumor: Acoustic neuromas (vestibular schwanomas) can present with facial paralysis, although rare. A complete history screening for hearing loss and vertigo and a physical exam, including hearing evaluation or other cranial nerve changes, are important for a patient with new facial paralysis. We recommend any patient with recurrent facial nerve paralysis on the same side of the face should be to an otologist (ear specialist) for further evaluation.
- Ramsay Hunt/zoster: A zoster around or in the ear coupled with same-sided facial paralysis is indicative of Ramsay Hunt syndrome. Although this is not treated much differently initially (steroids and anti-virals), these patients are not appropriate candidates for surgery in the first two weeks. Facial nerve decompression is not performed due to skip lesions seen along the facial nerve on histology. Patient counseling is recommended. It is important that they understand difference in prognosis as compared to a typical Bell's patient.
- See the patient within 72 hours of symptoms. If patient cannot be seen in 72 hours, they should go to the Emergency Room.
- Complete head and neck exam and feel the parotid gland and neck.
- Assess for hearing loss or any other neurologic changes.
- Prescribe medications, if all other diagnoses are excluded. Go to PubMed to learn about the short-term and long-term effects of prednisolone and valaciclovir in relation to facial paralysis.
- Refer, if needed. We recommend immediate referral if (1) facial paralysis is recurrent on the same side of the face, (2) paralysis progresses to complete paralysis, (3) there is an atypical Bell's presentation (e.g., onset usually hours to days), (4) a parotid or neck mass is present, (5) there are any other neurologic changes. See referral chart (pdf)
The following recommendations are supported by the 2013 Bell's palsy clinical practice guidelines published by the American Academy of Otolaryngology.
- Imaging: Imaging is not routinely recommended for new isolated facial paralysis. However, it can be used if there is a suspicion of other diagnoses such as stroke, tumor, or head trauma with possible injury to the temporal bone or conditions. We recommend early referral when the history and physical does not fit a typical Bell’s palsy, such as recurrent same sided paralysis, paralysis of isolated branches, or other cranial nerve involvement. In these cases a neurologist or otolaryngologist/otologists may order certain imaging depending on the clinical scenario.
- Laboratory Testing: Routine laboratory testing in patients with new-onset Bell’s palsy is not recommended. Exceptions include atypical Bell’s palsy, such as bilateral facial nerve paresis or paralysis, or serology for the specific diagnosis of Lyme disease. Certainly other underlying suspected diagnoses may require special testing.
- Electrodiagnostic testing: In cases of new, incomplete facial weakness (paresis), routine electrodiagnostic testing for Bell’s palsy is not recommended. However, patients with new complete facial paralysis should be referred urgently, where electroneuronography testing (ENOG) may be obtained at the time of the evaluation in the UW Otolaryngology clinic. For facial nerve paralysis persisting beyond three months, our clinicians may obtain electromyography testing (EMG) in cases where the history and exam is unclear if facial muscles are recovering or not.
Prophylactic eye care should be used in in all patients with facial nerve paresis or paralysis with incomplete eye closure. Bell’s palsy causes weakness of the orbicularis occuli muscle that closes the eye. Muscle weakness of the lower eyelid results in less pumping of the tear film, worsening the drying effects of incomplete eye closure. An unprotected eye may lead to a corneal abrasion, foreign body or exposure keratitis.
The American Academy of Otolarygology recommends the following possible interventions:
- Use of ophthalmic ointments when sleeping
- Incomplete closure of the upper eye lid at night will result in severe drying of the exposed portion of the ocular surface. This will lead to surface of the eye epithelial breakdown and potential thinning of cornea (outer clear window of the eye), leading to scar formation or perforation
- Appropriate immediate therapy for incomplete upper eyelid closure is the copious use of an over-the-counter, bland lubrication ointment applied to the involved eye four to six times, day and at night. This will blur the vision during the day but will provide significant reduction in the drying effect of incomplete blinking and nighttime exposure. Alternatives would be a thicker ophthalmic lubricating ointment.
- Eye patching or taping when sleeping. These may be difficult to apply correctly, resulting in corneal exposure to the material, so we recommend careful patient instruction and a consultation with an ophthalmologist or optometrist.
- Following initiation of the lubrication, the patient needs to be seen by an ophthalmologist within seven to 10 days.
- Use of sunglasses.
- Any combination of the above treatments.
Any patient with ocular symptoms including burning, itching, eye irritation, changes in vision, or pain should be should have a detailed ophthalmologic evaluation by an optometrist or an ophthalmologist. The providers in the Facial Nerve Clinic can perform a procedure to place a metal weight in the upper eyelid or inject botulinum toxin to aid in lid closure when conservative measures fail.
For facial paresis or paralysis lasting more than two weeks but fewer than three months:
- Two weeks after the onset of facial weakness of unknown cause (Bell’s), further treatment is unlikely to alter the prognosis or improve the rate of recovery.
- Patients should be monitored during the recovery period for any new neurologic symptoms or worsening paralysis, as this may be a sign of an undiagnosed underlying cause.
- Vigilant eye care must be employed when there is incomplete eye closure. Your patient may be a candidate for an upper eyelid weight placement to aid in eye closure. Since the weight can be removed at a later time, it can be placed in cases with good chance of recovery but profound difficulty in eye closure. Weight placement can be done under local or light sedation. If your patient is having difficulty with eye closure, you may want to refer earlier than the usual three months.
- Alternately, non-surgical methods of eye care are routinely utilized, reserving weight placement only for persistent difficulty with eye closure at three months.
For facial paresis or paralysis lasting more than three months:
- For ongoing facial paresis or paralysis lasting more than three months, the team at the Facial Nerve Clinic can evaluate your patient.
- If you are provider within the UW Health system, you may place an electronic consult order to the Facial Nerve Clinic through Health Link.
- All outside providers: How to Refer a Patient
Please note that referrals and questions are channeled through the UW Health Otolaryngology Clinic and directed to the Facial Nerve Clinic. Please send any information that may be helpful. When referring, please include relevant MRIs or CT scans. If the patient has post-surgery paralysis, please include surgical notes.
- Surgery for Facial Paralysis Caused By Trauma or Tumors (Parotid or Acoustic Neuroma/Skull Base)
- Surgery for Chronic Facial Paralysis: Nerve Transfers
- Surgery for Chronic Facial Paralysis: Static Procedures
- Surgery for Chronic Facial Paralysis: Dynamic Procedures
Examples of Facial Paralysis
Flaccid Facial Paralysis
Facial paralysis causes weakness to many muscles of the face. In flaccid paralysis, all muscle tone is lost and no movement exists, resulting in eyebrow and lower eyelid droop, inability to close eye, midface sagging, nasal twisting and obstruction, lower face droop with sagging at the corner of the mouth, difficulty eating, and inability to smile.
Synkesis After Facial Paralysis
Although many patients with flaccid facial paralysis will see improvement, sometimes the facial muscles can "over-correct" causing the face to become tight, stiff or "heavy". The eye may appear small. The crease between the side of the nose and corner of mouth (nasolabial fold) may seem deeper than the unaffected side. In some cases, the facial nerve can heal improperly causing muscles to contract out of sequence at the same time. For example, the eye may close during a smile or pucker, or the cheek may pull up when the eye closes. This improper movement, called synkinesis, can result in uncoordinated or distorted facial expression.