Understanding Bell's Palsy

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The condition known as Bell's palsy is a form of temporary facial paralysis that typically affects one half of the face.

Other types of facial muscle weakness are often mistakenly called Bell's palsy, but their causes and treatment approaches are not the same. For those who suddenly lose control of half of their mouth and can't close the eye on the same side of the face, an accurate diagnosis is essential for peace of mind and proper recovery.

Bell's Palsy"Suddenly developing facial paralysis is alarming and has a psycho-social impact," says Liliana Ein, M.D., facial plastic and reconstructive surgeon with the University of Miami Health System. "That's why I emphasize to patients that they won't remain the way they look at their worst. Without fail, Bell's palsy is going to improve, and this should make patients feel better. Every Bell's palsy case shows some level of spontaneous recovery within four to six months of onset.

"If the condition doesn't begin to recover on its own within four months, we go on high alert because something else is wrong." Other causes of facial paralysis include tumors, trauma, infections (such as Lyme Disease), and autoimmune diseases. When all other underlying conditions are ruled out, Bell's palsy is the diagnosis.

What causes Bell's palsy?

Experts think that this form of facial paralysis is due to the reactivation of the herpes simplex virus when the body is under some stress. "Most people have been exposed to HSV, usually from childhood, just like other common viruses," Dr. Ein says, though the virus can lay dormant and never cause blister outbreaks on the mouth or genitals. "The exact mechanism is unknown, but we don't think you're more likely to get Bell's palsy if you know you have or have not had a herpes outbreak."

When your immune system fights the viral reactivation, it causes swelling where the facial nerve cells live in the base of the skull. "The facial nerve is in a bony channel, so there's no room for the facial nerve to swell," Dr. Ein says. "This puts pressure on the nerve, causing muscle weakness and paralysis in less than 72 hours. When the nerves start to recover, the facial function returns."                                            

How is Bell's palsy treated?

Following diagnosis, the first line of treatment is a combination of high-dose oral steroids (to reduce inflammation) and antiviral medications that suppress the herpes simplex virus.

Bell's palsy typically doesn't involve severe pain. But analgesics like aspirin, acetaminophen, and ibuprofen, or moist heat, can be used to relieve discomfort behind the ear.

An essential part of managing Bell's palsy is eye care. Partial facial paralysis makes it difficult or impossible to blink and completely close the affected eye. Excessive dry and exposed eyes can lead to eye pain, infection, and exposure to keratitis (cornea damage or scarring).

Proper eye care includes using preservative-free artificial tears throughout the day, applying LACRI-LUBE® lubricant eye ointment before sleeping, and taping shut the affected eyelid or wearing a moisture chamber while sleeping.

Decompression surgery (which is intended to relieve pressure on the facial nerve) may be offered for certain patients with severe acute Bell's palsy. "This procedure requires the expertise of a neurosurgeon and neuro-otologist to drill the bony canal around the facial nerve to give it more room to swell. The surgery is done within 14 to 21 days following the onset of facial paralysis. This procedure requires specific testing to qualify, so it is not commonly performed."

Some Bell's palsy patients benefit from physical therapy administered by therapists who specialize in treating those with facial nerve disorders. Physical therapy can help with the loss of facial movement, lessen drooling, and help patients manage the changes in facial function experienced during recovery. Some types of physical therapy may include electromyographic biofeedback training, which is different from potentially painful electrical stimulation treatments (not recommended for those with Bell's palsy because it can delay recovery).

There's no evidence that acupuncture can help restore facial muscle function or improve the appearance of facial paralysis.

But, some patients find it calming. "If you like acupuncture, and you feel that this helps you relax or feel better emotionally, then go for it," Dr. Ein says.

"Bell's palsy has emotional repercussions. Losing your ability to express emotions on your face can be devastating. When you find it hard to keep food in your mouth, or you bite your upper lip as you chew or speak, it can cause a lot of stress. Relaxation techniques and therapies may help your mind and psyche cope."

What does Bell's palsy recovery look like?

Seventy percent of Bell's palsy patients will gradually and fully recover to their normal facial muscle function.

About 30% of patients experience improper recovery. This leaves permanent changes to their face that can affect function and appearance. "People in this scenario, with synkinesis or hypertonicity, could not have done anything to prevent this poor recovery. The body does what the body wants," Dr. Ein says. "But, if you have over-recovery in certain areas on the face and have some lingering issues, we can help achieve better facial balance and function."

"Once you reach the one-year mark after Bell's palsy onset, your body is finished recovering. You are likely at your new normal. At this stage, treatment can begin to address any signs of disorganized recovery," says Dr. Ein.

Reconstructive surgery may be an option for those with poorly recovered (or chronic) Bell's palsy. "At UHealth, we offer a stepwise approach to treating chronic Bell's palsy, starting with physical therapy and chemodenervation, or Botox. As we move up the reconstructive ladder, targeted myectomy or neurectomy surgery – to remove malfunctioning muscles or nerves – can improve facial symmetry and function, and achieve a more refined result. These surgeries are used frequently to help achieve a more balanced and meaningful smile. Additional surgeries include muscle transfers to further augment smile function," Dr. Ein says.

If you or a family member is experiencing facial paralysis or loss of facial muscle function, call UHealth's Facial Nerve Program at 305-243-3564 or schedule an appointment.


Dana Kantrowitz is a contributing writer for UMiami Health News.


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