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Facial Palsy Booklet

Posted Tuesday, 15 September 2020

Issue Date: September 2025

Review Date: September 2027

Ref: C-163/Physio/Neuro/LB/Facialpalsy v6

What does facial palsy mean?

Facial palsy is the medical term that refers to weakness of the facial muscles, mainly resulting from temporary or permanent damage to the facial nerve.

How does the facial nerve work?

When a facial nerve is non-functioning the muscles in the face do not receive the necessary signals to function properly. This results in paralysis of the affected part of the face, which can affect movement of the eye(s) and/or the mouth, as well as other areas.

There is a facial nerve on each side of the face, if it is damaged on the left side, it will affect the left side of the face and if damaged on the right it will affect the right side of the face. Each nerve leaves the brain through a tiny channel in the skull and enters the face in front of the ear. It then divides into 5 branches to supply different muscles for facial expression.

The facial nerve also has another 3 branches that are also responsible for production of tears, saliva, and taste for part of the tongue.

The diagram below shows the some of the nerve branches going to the muscles in the forehead, eye and cheek, lips, chin, and neck. These branches are responsible for facial movement.

What causes facial palsy?

The most common cause of facial palsy is Bell’s palsy however there are many other possible causes. Nearly all these causes result in swelling or pressure on or around the facial nerve which stops the nerve sending messages to the face. The nerve may stop working because of infection, virus, trauma, surgery, or anything that causes pressure on the nerve. Although a stroke can cause facial palsy it is slightly different as the problems are caused by injury to the brain rather than direct damage to the facial nerve. Sometimes people even have facial palsy from birth.

Are there different degrees of nerve injury?

Yes. Facial nerve injuries can be classified into 3 groups.

First degree, the nerve is “concussed or bruised” and recovers within 8 weeks.
Second degree injury, the nerve is more severely damaged, but the outer layer of the nerve is still intact. It recovers at the rate of 1mm per day, with the first signs of recovery usually at 4 months.
Third degree injury, the nerve is severely damaged and requires surgical repair. Recovery is very slow and always incomplete. If the nerve is severed and not repaired there will be no natural recovery and surgery (sometimes not suitable) would be required to help restore facial function.

What happens once your facial nerve is damaged?

When facial palsy initially occurs the affected side of your face will feel and look floppy as there are no nerve signals telling the muscles to contract. This early stage of facial palsy is called flaccid paralysis.

What else may be a problem when you have facial palsy?

Symptoms in this stage will vary between people but can commonly include:

Loss of movement and expressiveness on the affected side of the face
Difficulty communicating effectively
A dry eye which doesn’t close properly
Dryness of the mouth and altered taste
Difficulty with eating, drinking, and speaking
The affected nostril feeling blocked
Trouble with noise sounding too loud in the affected ear or no sound at all
It is also normal to feel self-conscious, and many people tend to avoid going out and about which can make them feel isolated and low in mood
Sometimes there can be pain in or around the ear or aching in the face.

*This is all perfectly normal throughout this stage.

*An important thing to know is that exercises when your face is floppy, are not recommended as they can do more harm than good.

Key functions the facial muscles perform:

Raising the eyebrows (frontalis)
Closing the eyes (orbicularis oculi)
Frowning (corrugator)
Open mouth smiling (zygomaticus)
Closed mouth smiling (risorius)
Pouting (orbicularis oris)
Lifting top lip (levator labii)
Pulling lower lip down (depressor labii)
Sticking bottom lip out (mentalis)
Pulling jaw and corners of mouth gently down (platysma)
Wrinkling nose (procerus/nasalis)

This YouTube clip is good at explaining the following information. Watch Understanding Facial Palsy

How do the facial muscles work?

It is very important to know all about the facial muscles and how they work in order to make the best possible recovery from facial palsy. It might be helpful to think about the facial muscles as being divided up into 5 zones. Normally, when the face moves in one zone all the other zones are relaxed. In the forehead zone the frontalis muscle raises the eyebrows, and the corrugator muscle makes us frown.

In the eye zone the orbicularis oculi muscle closes the eye and blinks the eye. This is important for protecting the eye and keeping it lubricated. In the cheek zone the levator muscles lift the top lip whilst the zygomatic and risorius muscles make us smile.

In the mouth zone the orbicularis oris muscle allows us to pucker the lips, whistle and pout. It also helps to make a seal around the lips when we eat and drink and allows us to clearly speak our words during speech. In the chin and neck zone the depressor muscles pull the lower lip down helped by the platysma muscle and the mentalis muscle sticks the bottom lip out. Another important muscle is the buccinator muscle which is inside the cheek and sucks the cheek in towards the teeth. This page of information has been taken from https://www.qvh.nhs.uk/wp-content/uploads/2022/02/What-is-facial-palsy-0644-web- version.pdf

How long will it take me to recover?

For some people the nerve has only been mildly swollen or compressed and usually they recover in the first 3-6 weeks. If you don’t notice improvement within this time, it is likely that the pressure on the nerve was more severe. You are still likely to improve (if the nerve is not severed) however it will take longer and facial movement on that side of your face may not be as easy to control as it was before.

Recovery tends to be split into 3 stages. The first stage is called flaccid paralysis when the face is floppy with no movement, this has already been described. The 2nd stage is called paresis which is when symmetry improves, and tiny movements may begin. The final stage is called synkinesis.

More severe swelling and pressure on the facial nerve means the nerve must regrow from where it has been compressed. Nerves regrow at a rate of 1mm per day, so the first signs of facial recovery are often not seen until 4 months has passed. As the nerve branches are different lengths the first recovery will usually be seen in the cheek and eye as the nerve branches here are shorter meaning the re-growing nerve gets here first. The nerve branches to the forehead and chin are longer so regrowth of the nerve to these areas can take longer.

Eye Care

Our eyes need to be kept moist to stay healthy. This requires enough tears to be produced and the ability to blink to spread the tears across the eyeball like windscreen wipers.

The facial nerve tells the eyes to blink and close. It is also responsible for tear production (via the lacrimal gland). People with facial palsy can experience issues with dry, irritable eyes if the affected eye no longer blinks or closes properly and / or insufficient tears are made. Sometimes both eyes are affected. Weakness of the muscle that closes the eye can also lead to the lower eyelid drooping, making it harder to keep tears or eye drops on the eyeball and harder for the eyelids to meet.

Eye care is the most important consideration in the flaccid stage when you may not be able to close your eye fully when asleep or resting and/or not fully close your eye when blinking. Patients are often not aware when their eye is partially open and/or when their blink is either absent or slowed. Some people’s eyeballs roll up when they attempt to close the eye and that gives them the impression the eyes are both closed as it ‘goes dark, but the eye has not in fact closed. Your therapist will look at this with you.

Why is Eye Care important?

Inability to blink effectively, produce tears and close the eye means that the surface of the eye (the cornea) has very little protection.
It can become dry and easily damaged, which can seriously affect your vision.
Sometimes the sensation on the surface of the eye may be lost i.e. loss of ability to feel pain. This means that without any sense of discomfort, dust or grit could enter the eye and cause damage.

Is this serious?

Drying or damage to the eye will affect vision. The eye may become red, sore and sensitive to light.

An ulcer can form on the surface of the eye which may cause permanent damage if not treated. This is a serious condition and if not treated promptly will cause permanent scarring and loss of vision.

How can these problems be prevented?

Follow the eye care advice, which will normally include protective eye drops, ointment, taping the eye shut at night and using the manual blink.

If you are unable to blink the upper part of the eyelid may become tight. As your nerve recovers, this can make it difficult for the muscles to close the eye fully.

A manual blink helps to spread the tears over the surface of the eye and therefore helps to keep the eye moist. It also maintains the mobility of the eyelid so that it doesn’t stiffen which would make it harder to regain normal eyelid movement in the future.

An average adult blinks 10 times per minute with the average blink lasting 400 milliseconds, therefore if you are unable to blink fully you should aim to carry out a manual blink every 10 minutes and do a manual blink if your eye feels dry at all.

Technique

Look down, this will relax and lower the upper lid.
Gently using the side of your index finger bring the upper lid down to a fully closed position. Then release. Use your finger to push your lower lid up to your lower lid

Eyelid stretches

To help maintain the length and suppleness of the eyelid as it can get tight from lack of full closure.

This is particularly useful to do before taping your eyelid at night before taping.

1. Look down

2. Help to close your eyelid further using a finger across your lid (be careful not to touch the eyeball)

3. Using the other hand, gently lift the skin under the eyebrow upwards. Hold for 3 seconds then release.

Taping of the eye shut at night

If your eyelid does not close fully when asleep you may be advised that your eye should be taped shut at night. You will be shown how to do this. It is important that the first time you tape your eye you are watched to see that it is done correctly.

We use Transpore plastic tape. You will be given a roll to use at home. It is clear.

Preparation:

Cut the tape slightly longer than the width of your eye.

If using nighttime ointments these should be inserted into the eye prior to taping.

(See the next page for instructions on how to tape your eye).

Eye taping technique

Look down.
Assist your eye closure with the back of your finger.
Apply tape from the inner corner to outer corner of the eye in a horizontal direction so that it extends beyond the width of the eyebrow. Ensure that the eyelid is fully closed; the tape is on the upper lid and covers the area underneath the eye.

Please note, if not done correctly the eyelid can easily pop open exposing the eye to worse damage.

These are guidelines. You must adhere to the eye care procedure that has been recommended to you by your therapist/doctor. If your eye becomes sore or red you must seek medical advice.

You may be advised to wear an eye shield instead of taping. Please speak to your therapist about this.

Artificial tears and ointments

Extra moisture for the eye will be required both during the day and at night. We use thicker gel for overnight as it is thicker than artificial tears it therefore protects your eye for a longer period of time. It may make vision blurry which is why we use it at bedtime.

A thin solution (Artificial tears) can be used frequently during the day if you feel it getting dry. You will be prescribed the eye drops and lubricant.

Technique for inserting drops and ointments into the eye

What are the symptoms of dry eye?

Gritty, burning, or scratchy feeling in the eye

Redness of the eye

Excessive watering of the eye*

Crusting along the lash lines

Eye infection, evidence of pus

*A watery eye does not mean the eye is OK, this is a common misconception, the eye can be watering because it is dry, and the irritation has led to it watering. This watering dilutes the healthy tear film, putting the eye at risk of drying out further.

Eye care: General information

Watch out for situations where you will automatically blink less often such as reading, watching TV, and looking at a computer screen. Try to blink more often when doing these activities, take frequent rests and use the manual blink exercise.
Avoid places where there are fumes, smoke, or dust, which can irritate your eyes.
Protect your eyes from the wind with wrap - around sunglasses.
Cover and protect your eye when washing hair or taking a shower.
If you are sensitive to light wear sunglasses.
Avoid sitting in front of or next to fans, open car windows and blow heaters.
Avoid air conditioning, which will dry out your eye.

If you are unable to tape your eye at night this is an alternative.

Moisture chamber goggles can be helpful for some people with facial palsy and dry eye. One example is the soft silicone EyeSeal. It comes in clear and smoked versions and is comfortable enough to sleep in. The smoked version blocks out daylight for sleeping. It cannot be used as sunglasses.

Eyeseals Moisture chamber goggles

Taping to support your cheek

Applying tape to your cheek for short periods of time can be very useful. It can give support to the cheek when eating and drinking and make your speech clearer.

It is advisable to keep the tape on all day, as constantly as removing the tape may make the skin sore.

Any signs of soreness or irritation/redness please remove immediately.

Option 1: Technique

1. Prepare 4 pieces of thin tape.

2. Place 1st piece as shown in first picture. When placing the tape always anchor it at the bottom and gently pull up towards your ear to secure.

3. Place 2nd piece vertically (2nd pic) to act as an anchor.

4. Place 3rd strip from corner of lip to anchor (pic 3).

5. Place 4th strip between mouth and nose and secure on the anchor.

Option 2

Secure at the corner of your lip and gently pull up to secure on cheekbone.

This is not always work as well if you have a very floppy cheek.

Taping to support the lower eyelid

A floppy lower eyelid can contribute to a dry eye. If your lower eye looks like in this diagram, it may be useful. Using tape to lift the lower eyelid can be a useful temporary measure to make your eye more comfortable.

Technique:

1. Tear off a short section of tape.

2. Rip it down the centre to make 2 narrow strips

3. Place the first strip under the lower lid, be careful not to touch your eye/lashes

4. Secure the second strip under the eye and gently pull up and secure.

Facial Massage

Facial massage helps:

Improve circulation to the muscles.
Identify parts of the face that feel too tight or too loose.
Keeps you in touch with your facial muscles.
Preserve the idea of movement in your face.
Keep the face supple.

General principles for massage

1. If you have fragile skin or bruise easily, please consult with your therapist as firm massage may not be appropriate for you.

2. Use the pads of your fingers and apply enough pressure to move the muscles underneath the skin, they should remain still whilst moving the muscle in a circular motion. If you find it hard to get a grip, try using a tissue under your fingertips or wearing disposable gloves.

3. Massage in a circular movement for 1-2 minutes each area. Do not rush or tense up. Start at the forehead and work downwards.

4. You should complete this routine daily, if possible, if you are doing the massage yourself, complete it looking in a mirror.

5. The nerve will recover in its own time and no amount of massage or exercise will speed the recovery process. Massage is for maintenance of muscle health and mobility. Separate exercises will be required to retrain the normal facial movement once the nerve has recover.

Brow, temple and eyebrow massage

Place the pads of your fingers on your hairline then. Massage in a slow circular movement down towards the temple and back up the centre of the forehead, with slightly more emphasis on the up section.
Place your fingers on the temples and gently circle.

Eye/Cheekbone

Using your 1st and 2nd fingers, gently slide them from the outer corner of your eyes, towards the nose, up the side of the nose, then up between the eyebrows and across the eyebrows toward the temples and repeat. Ensure all the movements are gentle as the skin around the eyes is thin and fragile. Only light touch is required.

Cheek massage

Using your fingers make slow circular upwards movements over your cheeks. Work from the jawbone to the cheek bone. Use enough pressure to move the muscles underneath the skin.

Chin massage

Use your 1st and 2nd fingers and apply firm pressure and massage in a slow, circular direction.

Neck massage

Using your hands to massage your neck using an upward movement. Work from the left ear lobe round under the chin and across to the right ear lobe for 1-2 minutes.

Back of the head

Place your fingers on the back of your skull and gently massage in small circles.

Other tips

In flaccid paralysis it is important to find alternative strategies for eating and drinking: to compensate for loss of muscle strength and tone

Taping cheek up on the affected side.
Drinking from a straw on the unaffected side.
Avoid drinking from water bottles.
Avoid dry crumbly or chewy foods.
If able to drink from a cup choose thin lipped, wide brim cup.
Take small mouthfuls that are easier to control.
Chew on unaffected side to minimise pouching and food loss.
If eating out find a table where the affected side is turned away from the rest of the room, so the person feels less self-conscious.
Brush teeth after meals to remove pouched food and debris.

Helping your speech in early flaccid paralysis it is about compensatory techniques

Slowing rate of speech.
Maintaining eye contact.
Cheek and lower lip taping to give support to floppy muscles.
Using hand to support the affected cheek.
Use non-verbal communication- hand gestures nodding etc.

Stretches *for unaffected side of your face

These stretches can be used if you feel your unaffected side is getting tight and improve symmetry.

Stretch unaffected cheek: ‘clock stretches’

Place opposite thumb inside cheek with fingers on outside and grip firmly but without causing pain
Start next to the nose slowly pull the hand right down to the lips x 5
Work on each area of cheek (following arrows) imagining working around a clock from 12-3. Do 5 releases on each spot
Hold any trigger points found for 60sec ‘melts

Once your face starts to recover you will notice that:

Muscles in some areas begin to work again earlier than other areas.
In some areas you may notice different things about your face:
Your eye may seem smaller, and the corner of the mouth may seem raised on the affected side.
Your cheek may feel tight and stiff. Don’t panic, you haven’t had a facial palsy on the other side.
The cheek branches of the nerve tend to recover first but aren’t balanced by the forehead and chin muscles which take longer to get working again. So, the face muscles are unbalanced.
As all the nerve branches recover you can help get the balance back in the face with small, slow, repetitive exercises shown to you by your therapist.
At first movements may be very difficult, but slow repetitive practice will enable the nerve to redevelop in a healthy way. This is a slow process but worth persevering with, as small improvements add up to big overall change.
Exercises done at this stage must be done with a relaxed face and should concentrate on tiny, precise movements. Using about 10% effort.

All the information in the booklet has been taken from Facial Therapy Specialists-UK guidance (Members) and affiliate websites

Other information/Useful sites:

Facial Palsy UK is a national charity dedicated to helping those affected by facial palsy, regardless of the cause of the palsy. Their mission is to promote access to the best information, treatment and support available. Enquiries: 0300 030 9333, Email: info@facialpalsy.org.uk
Visit British Acoustic Neuroma Association
Visit changing faces a visible difference and disfigurement charity

Contact Numbers

If you have been a patient under Neurosurgery at Derriford Hospital then you can contact your therapist on this extension:

01752 202082 Ext 37168 or

Facial Specialists at The Therapy Unit, Local Care Centre, Mount Gould Hospital on Tel: 01752 434810