What is Facial Palsy

What is Facial Palsy?

 

Facial palsy is weakness or paralysis of the muscles of the face caused by temporary or permanent damage to the facial nerve (cranial nerve VII). Most people experience facial weakness on one side of the face (unilateral facial palsy), although in rare cases both sides can be affected (bilateral facial palsy).

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The facial nerve controls facial expression, eye closure, speech, eating and drinking, and contributes to tear and saliva production. Damage to this nerve can therefore have a significant impact on everyday life.

Causes of Facial Palsy

 

Facial palsy occurs when the signal between the facial nerve and the facial muscles is disrupted. There are many possible causes, and identifying the underlying cause helps determine the most appropriate treatment.

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Bell's Palsy

Bell's palsy is the most common cause of facial palsy. Although the exact cause remains unknown, it is thought to result from inflammation of the facial nerve, often triggered by a viral infection. The swelling of the nerve within the narrow facial canal temporarily disrupts the nerve signals to the facial muscles.

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Ramsay Hunt Syndrome

Ramsay Hunt Syndrome is caused by reactivation of the varicella zoster virus (the virus responsible for chickenpox and shingles).

Symptoms may include:

• Facial weakness or paralysis

• Painful blisters or a rash around the ear, scalp, mouth or nose

• Hearing loss

• Tinnitus (ringing in the ear)

• Dizziness or vertigo

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Not everyone experiences all of these symptoms, so diagnosis is based on the overall clinical picture.

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Bacterial Infections

Certain bacterial infections can affect the facial nerve, including:

• Lyme disease

• Middle ear infections (otitis media)

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Traumatic Injury

Facial palsy may occur following injuries such as:

• Skull fractures (particularly the temporal bone)

• Facial fractures

• Traumatic brain injuries

These injuries are commonly associated with road traffic collisions, falls, sporting accidents or assaults.

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Neurological Conditions

Some neurological disorders can affect the facial nerve, including:

• Neurofibromatosis Type 2

• Guillain-Barré Syndrome

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Birth Trauma

Facial palsy can occur during childbirth if pressure or forceps cause temporary injury to the facial nerve. Most babies recover well over time.

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Congenital Facial Palsy

Some babies are born with facial palsy due to abnormal development of the facial nerve or facial muscles during pregnancy.

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Stroke

Although a stroke can cause facial weakness, it is not a facial nerve injury. The cause and treatment are very different, making urgent medical assessment essential.

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Classifying Facial Palsy

 

Facial nerve injuries are classified according to the degree of damage.

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First Degree (Neuropraxia)

The nerve is bruised but remains intact.

• Excellent prognosis

• Full recovery is common

• Recovery typically occurs within 6–8 weeks

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Second Degree (Axonotmesis)

The nerve fibres are damaged, but the outer covering of the nerve remains intact.

• The nerve must regenerate

• Recovery usually takes several months

• Physiotherapy can help optimise recovery during this period

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Third Degree (Neurotmesis)

The facial nerve has been severely damaged or completely divided.

• Surgical repair is often required

• Recovery depends on the extent of the injury and timing of treatment

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How We Assess Facial Palsy

At Midlands Jaw Physiotherapy, we use the Sunnybrook Facial Grading System to assess facial function.

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This internationally recognised assessment measures:

• Resting facial symmetry

• Voluntary facial movement

• Synkinesis (unwanted facial movements)

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A score is calculated between:

• 0 = Complete facial paralysis

• 100 = Normal facial function

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Your score is reassessed at each appointment to monitor progress and guide your treatment programme.

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What Do the Facial Muscles Do?

The facial muscles are unique because they attach directly to the skin rather than to bones. They allow us to communicate emotion, protect our eyes, eat, drink and speak.

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Examples include:

• Frontalis – raises the eyebrows

• Orbicularis oculi – closes the eyes

• Corrugator and procerus – produce a frown

• Zygomaticus and risorius – create a smile

• Levator labii superioris – lifts the upper lip

• Orbicularis oris – puckers the lips

• Depressor labii inferioris and depressor anguli oris – pull the mouth downwards

• Nasalis – wrinkles the nose

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Every person's facial movement pattern is slightly different, which is why rehabilitation should always be tailored to the individual.

Working with a physiotherapist who has specialist knowledge of facial anatomy and movement can significantly improve the quality of your recovery.

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What Should You Do if You Develop Facial Palsy?

 

If you develop a sudden facial droop, seek urgent medical attention by calling 999, attending A&E, or contacting your GP immediately.

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The priority is to determine whether the symptoms are due to a stroke or a facial palsy.

A useful clinical difference is:

• Unable to raise the eyebrow on the affected side → more suggestive of a facial palsy.

• Able to raise both eyebrows normally despite lower facial weakness → may suggest a stroke and requires urgent emergency assessment.

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Only a healthcare professional can make this distinction, so never attempt to diagnose yourself.

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Once a stroke has been excluded, treatment for Bell's palsy usually includes:

• A 10-day course of corticosteroids (prednisolone), ideally started within 72 hours of symptom onset.

• Antiviral medication if Ramsay Hunt Syndrome is suspected.

• Eye protection, including lubricating drops during the day, ointment at night and advice on taping the eye closed if it cannot fully close.

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Most people begin to notice some return of movement within a few weeks, although recovery varies depending on the severity of the nerve injury.

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If your recovery is slow or incomplete, specialist facial rehabilitation can help optimise your outcome.

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If, at any stage, your affected eye becomes red, painful or increasingly irritated, seek urgent assessment from an eye specialist or your local eye emergency department.

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How Can Physiotherapy Help?

 

Physiotherapy cannot speed up the healing of the facial nerve itself. However, specialist rehabilitation plays an important role in ensuring the recovering nerve and muscles work together as effectively as possible.

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Treatment may include:

• Detailed facial assessment

• Education about recovery

• Individualised facial exercises

• Neuromuscular retraining

• Massage and soft tissue techniques

• Stretching for tight muscles

• Advice on eye care

• Management of muscle tightness and unwanted facial movements

• Progress monitoring using the Sunnybrook Facial Grading System

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Our aim is to help you regain natural, symmetrical facial movement while reducing the risk of long-term complications.

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Hyperkinesis

 

Hyperkinesis refers to excessive or involuntary muscle activity that can develop as the facial nerve heals. Muscles may feel tight or overactive, making facial movements appear exaggerated or strained.

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Hyperkinesis may occur on either the affected or unaffected side of the face.

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Synkinesis

 

Synkinesis is the involuntary movement of one facial muscle when attempting to move another.

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For example:

• Your eye closes when you smile.

• Your cheek tightens when you blink.

• Your neck muscle contracts when you pucker your lips.

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This occurs because regenerating nerve fibres reconnect to the wrong muscles during healing.

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Unlike hyperkinesis, synkinesis only occurs on the affected side of the face.

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Specialist facial physiotherapy focuses on retraining these abnormal movement patterns to improve facial control and function.

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