Facial Paralysis

Facial Palsy is characterized by partial or complete loss of voluntary facial movements resulting from injury to the facial nerve. Bell’s palsy, of idiopathic etiology, is the most common cause(1). Facial palsy can also result from infectious, traumatic, iatrogenic, neoplastic, or autoimmune causes(2,3). Therefore, accurate evaluation and diagnosis are essential(4).

The treatment of facial palsy depends on the etiology, degree of impairment, and duration of symptoms. For Bell’s palsy, early administration of corticosteroids (ideally within the first 72 hours) is widely agreed upon and shows better rates of functional recovery(5,6). Combination therapy with antivirals may also be considered (especially in cases involving herpes virus), although the evidence for this is less consistent(5,7). Eye care and prevention of corneal injury are also crucial due to the presence of lagophthalmos (inability to completely close the affected eye)(5).

One of the challenges in managing patients with facial paralysis is the occurrence of synkinesis, which is the development of linked or unwanted movements (for example, involuntary eye closure while trying to smile). It is estimated that up to 30% of facial

paralysis cases develop some degree of synkinesis, particularly in those with incomplete neurological recovery or aberrant reinnervation(8,9).

Facial physiotherapy plays a central role in rehabilitation, promoting motor recovery, minimizing synkinesis, and preventing muscular contractures. Techniques such as neuromuscular facilitation, motor re-education, or facial massage are widely used and recommended(10,11).

In selected cases, especially with persistent synkinesis or contractures, botulinum toxin may be indicated, which has demonstrated efficacy in reducing involuntary movements(12,13).

If there is no functional recovery of the face after six months, the diagnosis should be reconsidered and other treatment strategies may be explored(5). In more severe cases of paralysis, facial reanimation surgeries may be considered. All approaches seek to reestablish the facial harmony that existed prior to the condition(3).

The management of facial palsy benefits from a multidisciplinary team approach. At Physiokinesis, we have physical therapists specialized in the rehabilitation of this condition across various etiologies and stages of facial palsy. Contact us for more information.

References:

1. Morris AM, Deeks SL, Hill MD, Midroni G, Goldstein WC, Mazzulli T, Davidson R, Squires SG, Marrie T, McGeer A, Low DE. Annualized incidence and spectrum of illness from an outbreak investigation of Bell's palsy. Neuroepidemiology. 2002 Sep-Oct;21(5):255-61. doi: 10.1159/000065645. 

2. O TM. Medical Management of Acute Facial Paralysis. Otolaryngol Clin North Am. 2018 Dec;51(6):1051-1075. doi: 10.1016/j.otc.2018.07.004. 

3. Kim SJ, Lee HY. Acute Peripheral Facial Palsy: Recent Guidelines and a Systematic Review of the Literature. J Korean Med Sci. 2020 Aug 3;35(30):e245. doi: 10.3346/jkms.2020.35.e245. 

4. Quesnel AM, Lindsay RW, Hadlock TA. When the bell tolls on Bell's palsy: finding occult malignancy in acute-onset facial paralysis. Am J Otolaryngol. 2010 Sep-Oct;31(5):339-42. doi: 10.1016/j.amjoto.2009.04.003. Epub 2009 Jun 24. PMID: 20015776. 

5. Van Haesendonck G, Jorissen C, Lammers M, et al. Guidelines for the initial management of acute facial nerve palsy. B-ENT 2022;18(1):67-72. 

6. Madhok VB, Gagyor I, Daly F, Somasundara D, Sullivan M, Gammie F, Sullivan F. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD001942. DOI: 10.1002/14651858.CD001942 

7.  Gagyor I, Madhok VB, Daly F, Sullivan F. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database of Systematic Reviews 2019, Issue 9. Art. No.: CD001869. DOI: 10.1002/14651858.CD001869 

8. Beurskens CH, Heymans PG. Mime therapy improves facial symmetry in people with long-term facial nerve paresis: a randomised controlled trial. Aust J Physiother. 2006;52(3):177-83. doi: 10.1016/s0004-9514(06)70026-5. PMID: 16942452. 

9. Boahene, Kofi D.O. (2022). Etiology, Epidemiology, and Pathophysiology of Post-Facial Paralysis Synkinesis. In B. Azizzadeh & C. Nduka (Eds.) Management of Post-Facial Paralysis Synkinesis (pp. 13-17). Elsevier. https://doi.org/10.1016/B978-0-323-67331-0.00002-6. 

10. Robinson MW, Baiungo J. Facial Rehabilitation: Evaluation and Treatment Strategies for the Patient with Facial Palsy. Otolaryngol Clin North Am. 2018 Dec;51(6):1151-1167. doi: 10.1016/j.otc.2018.07.011. Epub 2018 Sep 24. PMID: 30262166. 

11. Neville C, Beurskens C, Diels J, MacDowell S, Rankin S. Consensus Among International Facial Therapy Experts for the Management of Adults with Unilateral Facial Palsy: A Two-Stage Nominal Group and Delphi Study. Facial Plast Surg Aesthet Med. 2024 Jul-Aug;26(4):405-417. doi: 10.1089/fpsam.2023.0101. Epub 2023 Nov 3. PMID: 37922418. 

12. Filipo R, Spahiu I, Covelli E, Nicastri M, Bertoli GA. Botulinum toxin in the treatment of facial synkinesis and hyperkinesis. Laryngoscope. 2012 Feb;122(2):266-70. doi: 10.1002/lary.22404. Epub 2012 Jan 17. PMID: 22252570. 

13. de Jongh FW, Schaeffers AWMA, Kooreman ZE, Ingels KJAO, van Heerbeek N, Beurskens C, Monstrey SJ, Pouwels S. Botulinum toxin A treatment in facial palsy synkinesis: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol. 2023 Apr;280(4):1581-1592. doi: 10.1007/s00405-022-07796-8. Epub 2022 Dec 22. PMID: 36544062.