A local high school teacher came to my office with weakness and numbness on one side of her face. This well-groomed, attractive middle-aged woman was unable to smile, frown, pout, speak, or eat with facial symmetry. She suffered from a cold, on and off, for about two months. It was not a bad cold, but it would not go away. One day in early summer, while engaged in bird watching, one of her favorite pastimes, she noticed that she could not look through her binoculars. She noticed that her eye would not open and close at will. The next day she woke with ear pain, flaccid muscles on one side of her face, and an inability to close her eye. She had difficulty speaking with clarity due to weak mouth muscles and feared she had a stroke.
She immediately saw her family physician who determined that she had shingles in her ear and developed Bell’s palsy. She was prescribed a steroid anti-inflammatory (Prednisone), antiviral medicine (Acyclovir), and a topical cream (Zovirax). Once she got over the initial fear and shock, she was grateful that her problem of facial weakness was not due to a more serious problem, such as a stroke or brain tumor. She began physical therapy and improved slowly. Her story, along with many other patients, reminded me of the need to raise awareness about cause, diagnosis, symptoms, complications and treatment of Bell’s palsy.
Bell’s palsy, a facial nerve paralysis, occurs when the nerve that is responsible for the movement and sensation of the muscle and skin of the face becomes damaged. The end result of this damage is paralysis of the muscles and numbness of the skin on one side of the face. Typically, the first sign of this disorder is the inability to close one eye or smile on one side of the face. While this problem can occur in any age group, it is rarely seen in people less than 15 or more than 60 years of age. The good news is that most people show signs of improvement within 3-4 weeks and have complete recovery in 4-6 months. The bad news is that reoccurrence can occur on the other side of the face in approximately 10 percent of those affected.
Bell’s palsy is caused by a viral infection. The most common virus is the herpes simplex virus, the same virus that causes cold sores and genital herpes. Other viruses that can cause Bell’s palsy are herpes zoster virus that causes chicken pox and shingles and Epstein-Barr virus, which causes mononucleosis, and cytomegalovirus. When one of these viruses causes inflammation to the facial nerve, it becomes swollen and irritated in the narrow tunnel of bone by the ear. As pressure on the facial nerve increases, damage progresses to the point that the muscles and skin of the face are unable to receive messages from the nerve, leading to paralysis, numbness and other symptoms.
The hallmark symptom of Bell’s palsy is sudden onset of facial muscle weakness and numbness on one side of the face. As a result, it is difficult to close the eye and smile on the weak side. Other symptoms on the affected side can include: the inability to make facial expressions, speak clearly (especially vowel sounds), diminished sense of taste, pain in the area of the jaw or ear, sensitivity of sound, headaches, and changes in production of tears and saliva.
While Bell’s palsy can occur in anyone, it is more common among those who are: pregnant, (especially during the third trimester or first week after birth), diabetic, or suffering from a cold or flu. Also, some research suggests that there may be a genetic predisposition to this problem.
In mild cases of Bell’s palsy, symptoms are completely resolved within 4-6 weeks. As mentioned before, most cases resolve in 4-6 months. However, recovery for those with complete paralysis may vary. For example, permanent facial weakness, facial muscle twitching, and visual problems due to the inability to close the eye, can occur.
Contact you primary care physician immediately, because these symptoms may be associated with a more serious medical condition such as a stroke. Remember, most people with Bell’s palsy make a complete recovery, but early intervention can expedite the process. In severe cases, a neurologist may be consulted. Two commonly used medications are corticosteroids and antiviral drugs. Corticosteroids such as prednisone are strong anti-inflammatory drugs used to reduce the swelling and inflammation on the facial nerve. Antiviral drugs such as acyclovir are used to stop the viral infection that may have caused the inflammation. Studies show that these drugs, when used in combination, are most effective when administered in the first 3 days of the appearance of symptoms.
Physical therapy can also assist in the restoration of facial muscle recovery. Ultrasound with anti-inflammatory drugs, electric stimulation, massage and exercise are commonly performed. While the use of electric stimulation has limited support in the literature, a home exercise program that concentrates on facial muscles, is an essential part of the therapy program. Some simple exercises performed in front of a mirror are: raise eyebrows, bring eyebrows together, open/close eye, fill cheeks with air, suck in cheeks, smile, frown, whistle, say vowels.
Surgery, to relieve pressure on the nerve by removing bone, is rarely performed. Plastic surgery, to improve the appearance of the face, may be an option in cases with permanent paralysis.
Sources: Mayo Clinic; WebMD
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Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is an Associate Professor of Clinical Medicine at GCSOM.
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