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Facial Palsy Booklet

Posted Tuesday, 15 September 2020

Issue Date: March 2018

Review Date: March 2020

Ref: C-163/Physio/Neuro/LB/Facialpalsy v5

What does facial palsy mean?

Facial palsy is a medical term which means weakness of the facial muscles, usually on one side of the face, as a result of direct damage to the facial nerve.

How does the facial nerve work?

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 is also responsible for production of tears, saliva and taste for part of the tongue.

The diagram shows the 5 branches coming out of the ear and 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?

Facial palsy can be caused by a number of different things some of which are listed below;

Surgery to the facial nerve or acoustic nerve tumour .The acoustic nerve lies very close to the facial nerve so in the process of removing these tumours the facial nerve can be damaged.
Surgery to the parotid gland. The facial nerve runs through this salivary gland and so can also be damaged during surgery.
Viral infection causing a palsy known as ?Bells Palsy?.
Neurological conditions (e.g. Guillian-Barre Syndrome or Neurofibromatosis)
Traumatic injury such as fractures to the skull or face, as might be suffered in an accident.
Stroke can cause facial palsy as a result of damage in the brain but this is slightly different to the causes above, as it directly affects the nerve after it leaves the brain.

Are there different degrees of 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 in any way 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.

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 slow, careful exercises in front of a mirror.
At first movements may be asymmetrical and difficult, but slow repetitive practice will eventually wake up your brain?s memory of how the muscles used to work. 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.

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

A muscle in the ear (stapedius) can be affected causing sounds to appear louder on that side. You may also not be able to hear at all.
Eating and drinking can be harder due to weakness of the cheek, lip seal and sensory changes.
Food can collect in the affected cheek and be difficult to remove
Some people complain because they bite the inside of their cheek or lip.
Taste can be reduced.

Eye Care - Why is this important?

Inability to blink, 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 effect 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.

IF ANY OF THESE PROBLEMS DO OCCUR YOU MUST SEEK URGENT MEDICAL ADVICE

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.

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.
Cut the tape slightly longer than the width of your eye.
If using night time ointments these should be inserted into the eye.

See the next page for instructions on how to do this

Look down
Assist the 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 doctor. If you 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.

Artificial tears and Ointments

Extra moisture for the eye will be required both during the day and at night.
You will have been prescribed what drops to use and how often they should be used.
We use Lacrilube or VitA-POS over night; it is thicker then artificial tears and therefore protects your eye for a longer period of time. As it is thicker it may make vision ?blurry? which is why we use it at bedtime.
Artificial tears (Viscotears) can be used frequently during the day if you feel it getting dry.

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 actively blink you should aim to carry out a manual blink every 10 minutes and definitely do it if your eye feels dry at all.

Technique

Look down, this will relax and lower the upper lid.
Using the back of your finger bring the upper lid down to a fully closed position.Keep looking down as hard as you can.

Eyelid stretches

To help maintain the length and suppleness of the eyelid, you may be advised to stretch the upper eyelid

Assist eyelid closure with the back of your finger
Using the other hand, gently lift the skin under the eyebrow upwards. Hold for 3 seconds then release.
Repeat this action along the eyebrow

General Advice

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 the 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.

Taping of the face

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

Apply tape to the face in the direction indicated.
You can apply a second piece of tape, partially over lapping the other piece if required.
Only wear the tape for a maximum of 3 hours at a time, twice a day.
Any signs of soreness or irritation/redness please remove immediately

Why do it?

Facial massage helps:

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

General principles for massage

If you have fragile skin or bruise easily please consult with your therapist as firm massage may not be appropriate for you.
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 finger tips or wearing disposable gloves
Massage in a circular movement for 1-2 minutes each muscle group. Do not rush or tense up. Start at the forehead and work downwards.

Brow and Temple Massage

Place the pads of your fingers above the eyebrows. Massage in a slow circular, upward movement. Do this for 1-2 minutes.
Then place your fingers on the temples and gently do the same for 1-2 minutes.

Eye and Cheek massage

Using your ring fingers, slide them from the outer corner of your eyes, towards the nose, then up between the eyebrows. Ensure all the movements are gentle as the skin around the eyes is thin and fragile. Only light touch is required.
Using your fingers make slow circular upwards movements over your cheeks.

Work from the jaw bone to the cheek bone. Use enough pressure to move the muscles underneath the skin.

Chin and neck massage

Use the pads of your thumbs and apply firm pressure and massage in a slow, circular direction for 1-2 minutes
Neck- 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.

Additional Advice

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

Dry mouth?

A dry mouth can be associated with a number of medical conditions including facial palsy, if you feel you are experiencing this please speak to your physiotherapist

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