Facial paralysis

and Sabine Schrör, medical journalist

Hanna Rutkowski is a freelance writer for the medical team.

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Sabine Schrör is a freelance writer for the medical team. She studied business administration and public relations in Cologne. As a freelance editor, she has been at home in a wide variety of industries for more than 15 years.Health is one of her favorite subjects.

More about the experts All content is checked by medical journalists.

Facial paralysis often occurs suddenly and surprisingly. It can have serious effects: the eye can no longer be closed, the language becomes incomprehensible, the face appears disfigured. When faced with facial paralysis, many people think of a stroke first, but there are other reasons as well. Read more about the causes of facial paralysis here!

Facial paralysis: description

Facial paralysis is based on a disorder of the facial nerve (nervus facialis) and is therefore also called facial paralysis or facial paralysis.

The facial nerve (nervus facialis) controls the movement of most facial muscles and thus facial expressions. He is responsible for ensuring that people can laugh, wink, whistle or make faces. In addition, it regulates the function of the nasal mucous membrane, salivary and lacrimal glands and enables tasting in the front area of ​​the tongue. A disturbed function of the facial nerve can have serious consequences.

Facial nerve, the seventh cranial nerve

The facial nerve "Nervus facialis" is the seventh of a total of twelve cranial nerves. It runs on both sides of the head, both inside and outside the skull. The facial nerve has its origin in the brain stem. From there it runs through a bony nerve canal near the ear and through the parotid gland to the facial muscles, where it divides into further fine branches. These are responsible for the facial expressions and movement of the facial muscles. They control the movement of the forehead, cheek, eye and mouth muscles, but not the masticatory muscles.

In addition, the facial nerve also plays a role in the sensation of touch, the sense of taste, the production of saliva and tear fluid as well as hearing. One of its branches, the chorda tympani, is responsible for taste perception in the front part of the tongue, while the stapedius nerve is important for hearing.

If functions of the facial nerve are disturbed, the consequences can be correspondingly serious. Paralysis of the facial nerve often disfigures the entire face - an extremely stressful psychological situation for the patient.

Central and peripheral paralysis

In peripheral paralysis, the nerve itself is disturbed at some point in its course. In contrast to central paralysis, those affected can usually no longer move the entire half of their face, including forehead and eyes. For example, they can no longer frown.

With central paralysis, the area of ​​the brain that sends the impulses to the facial nerve is disturbed. These so-called "core areas" are located in the right and left hemispheres of the brain and are responsible for the function of the opposite side of the body. Only the function of the forehead and eye muscles is supplied by the nuclei on both sides. For example, people with central facial paralysis can still frown.

Facial paralysis: causes and possible diseases

Both peripheral and central facial nerve paralysis can have different causes.

Peripheral paralysis

In the most common form of hemiplegia, the cause is unknown. This phenomenon is also known as "Bell palsy". In the remaining cases, diseases are behind the peripheral paralysis.

Peripheral facial paralysis of unknown cause

With around 20 to 25 new cases per 100,000 inhabitants per year, Bell palsy - a peripheral facial paralysis with an unknown cause - is the most common form of facial paralysis. It affects younger adults more often, but can in principle occur at any age.

Doctors suspect that Bell palsy is an autoimmune inflammatory reaction of the facial nerve. This can be caused by factors such as drafts, stress, pregnancy, cycle fluctuations, and bacterial or viral infections. The inflammation causes the facial nerve to swell - it becomes trapped in the narrow bone canal and thus damages itself.

The facial paralysis usually develops on one side and the symptoms usually start very suddenly. Those affected often wake up in the morning with facial paralysis. Signs can be sensory disturbances in the cheek as well as pain in or behind the ear that set in a few days beforehand. Taste disorders and hypersensitivity to noises can also occur in advance. The facial paralysis is fully expressed within three days.

Peripheral facial paralysis with a known cause

Various diseases, as well as injuries to the facial nerve, can cause facial paralysis. The most common are:

Hereditary diseases:

• Melkersson-Rosenthal syndrome: This rare rheumatic disease usually occurs between the ages of 20 and 40. The cause of the triad of symptoms consisting of hemiplegic facial paralysis, swelling of the lips and tongue (lingua plicata) is inflammation. Just as spontaneously as it occurs, it usually disappears again after a few weeks.
• Möbius syndrome: The bilateral facial paralysis gives even babies a mask-like, rigid facial expression. Several cranial nerves can be underdeveloped and damaged here.

Bacterial infections

• Borreliosis (Lyme disease): This bacterial infection is usually transmitted by tick bites and runs in stages: It begins with the typical wandering redness and unspecific symptoms such as fever, headache and body aches. In stage 2, paralysis along the puncture site or facial palsy with swelling of the lymph nodes can occur.
• Middle ear infection (otitis media): The bacterial otitis media is not only very painful, but can also have a dreaded complication: Due to the anatomical proximity of the facial nerve to the ear, the inflammation can spread into the bone canal and nerve and lead to temporary facial paralysis .
• Other bacterial causes of facial paralysis: scarlet fever, inflammation of the parotid gland, meningitis (meningitis)

Viral infections

• Zoster oticus: If the herpes zoster virus (which causes shingles) only affects the ear and the auditory canal, the anatomical proximity to the facial nerve can lead to facial paralysis. Small red vesicles in the ear canal are noticeable. Other symptoms include severe pain in the ear, hearing loss, and impaired balance.
• Other viral causes of facial paralysis: Chickenpox (varicella), mumps, flu (influenza), polio (poliomyelitis or polio for short)

Autoimmune diseases

• Sarcoid / Boeck's disease: This is where small tissue nodules form in the lungs. The disease can also affect the face (Heerfordt syndrome): typical signs include fever, inflammation of the parotid gland and lacrimal gland, and facial paralysis.
• Guillian-Barré Syndrome: Bacterial and viral infections appear to trigger this nerve disorder - various peripheral nerves become inflamed or die. The bilateral paralysis begins with weakness and numbness in the legs and then spreads over the arms and upper body to the face. The disease progresses within two to four weeks, whereby the entire body can be paralyzed; later it slowly regenerates.

Tumors

Tumors of the nerve or adjacent areas can also lead to facial paralysis:

• Acoustic neuroma: The most common tumor of the brain stem initially manifests itself as tinnitus and hearing impairment.
• Tumors of the facial nerve
• Parotid tumors: Malignant growths often cause facial paralysis
• Neurofibromatosis Recklinghausen: inherited multi-organ disease that mainly affects the skin and the nervous system
• Metastases from other tumors

Injuries

Various injuries to the facial nerve can also cause facial paralysis:

• Birth trauma: forceps delivery
• Traumatic brain injury with fracture of the petrous bone
• Facial injuries to the parotid gland
• Barotrauma in the middle ear from flying or diving

Central facial palsy

The cause of central facial paresis are all diseases of the brain that cause disorders in the core area of ​​the facial nerve. These include:

• Cerebral infarction (stroke caused by bleeding or vascular occlusion)
• Tumors
• Injuries
• Polio (poliomyelitis)
• multiple sclerosis
• Möbius syndrome

Facial paralysis alone is rare in central facial paralysis. Often an arm or half of the body is also affected. Urination disorders (e.g. incontinence) are also typical side effects.

Facial paralysis: when do you need to see a doctor?

If someone can suddenly no longer move certain muscles or parts of the body, this is always an alarm signal and usually a medical emergency. Facial paralysis in particular can be a sign of a stroke that requires immediate action. Quick help is life-saving here!

The signs of a stroke are:

• Sudden weakness or paralysis, usually one half of the body (face, arms and legs)
• Sudden visual disturbances: double vision, poor eyesight, reduced field of vision
• Sudden language disorders: slurred, difficult to understand language, word finding disorders, comprehension disorders, meaningless word salad
• Drowsiness, dizziness, headache
• sudden change in consciousness: e.g. aggression or disorientation

Call an emergency doctor immediately in the event of such signs of a stroke!

But even if you have temporary numbness or paralysis of the face, you should consult a doctor for clarification. If you have mild complaints, you can also see your general practitioner first. They can arrange for further examinations or refer you to a specialist (neurologist).

Facial Paralysis: What Does the Doctor Do?

Diagnosis of facial paralysis

The doctor can often recognize unilateral facial paralysis at first glance: the corner of the mouth on the affected side hangs down, the eyelid cannot be closed completely or not at all (lagophthalmus), and speech is slurred and difficult to understand due to the paralyzed facial muscles. Often saliva also flows from the corner of the mouth.

At the beginning, however, there is an interview with the patient to collect the medical history (anamnesis). The following questions are important for the doctor:

• When did the first signs of paralysis appear?
• How do they express themselves exactly?
• Do you have any other complaints (e.g. headache)?
• Do you suffer from high blood pressure?

The heart, lungs, and large cervical vessels are inspected in the internal or physical exam. An otoscopy is also important: If the doctor discovers small vesicles in the ear canal, this could indicate shingles (zoster oticus).

Blood tests and a smear will help detect the pathogen. The detection of Borrelia, herpes viruses or other pathogens can give the first clues as to the cause of the facial paralysis.

Particular attention is paid to the functionality of the nerves. In a neurological examination, among other things, the condition of the cranial nerves and the central and peripheral nervous system is checked. With peripheral paralysis, it is important to localize the location of the damage more precisely. Based on additional symptoms, the doctor can roughly estimate the level of damage to the facial nerve.

Paralysis of some or all of the facial muscles suggests a nerve lesion outside the skull. If the nerve is damaged in a section further inward, other symptoms can arise in addition to the hemiplegic facial paralysis, for example:

• Taste disturbance in the front two thirds of the tongue
• decreased salivation
• Sensory disturbances in the area of ​​the ears
• increased sensitivity to noise (hyperacusis)
• reduced tearing and dry nasal mucous membranes
• Hearing loss or deafness

The twelve cranial nerves mainly supply the face and neck area. By testing eye movements, eyesight, facial expressions, but also the sense of taste and touch, the failure of certain cranial nerves can be detected. It is also important to clarify the function of the salivary and lacrimal glands, as this can provide an indication of the location of the damage. If the facial nerve is affected, this is noticeable in a disturbed facial expression. But the eyes, mucous membranes and taste buds can also be affected.

Important neurological examination methods are electromyography (EMG) and electroneurography (ENG): Here, the electrical muscle activity (EMG) or the functional state of nerves (ENG) is checked. This helps back up the diagnosis of facial paralysis.

The distinction between central and peripheral facial paralysis is also important. If the patient can no longer frown, this indicates peripheral facial paralysis.

If, on the other hand, the examinations suspect central facial paralysis, further imaging procedures are often necessary. These include x-rays, magnetic resonance imaging (magnetic resonance imaging, MRI) and computed tomography (CT) if a cerebral haemorrhage or traumatic brain injury is suspected.

Severity of facial paralysis

The severity of facial paralysis is determined using a six-point scale. Level I means that there is no facial nerve disorder. Grade VI, on the other hand, is complete paralysis. Levels II and III are tricky: the facial nerve is slightly damaged here. However, the lesion does not yet visibly distort the face and is therefore sometimes only recognized late.

Therapy of facial paralysis

Therapy for facial paralysis depends on the underlying cause. Usually drugs or surgical procedures are used.

With Bell palsy, the chances of recovery are good: Even without treatment, facial paralysis heals without consequences in around 85 percent of those affected. It even disappears in up to 90 percent of patients with cortisone therapy. The healing time is between three and six weeks, but can also be up to six months in a more pronounced form.

If the eyelid can no longer be closed completely, you can prevent the cornea from drying out with an eye patch or suitable ointment. Long-term effects such as residual paralysis or so-called "crocodile tears" are possible. A faulty connection between two branches of the facial nerve causes tears to flow when you eat.

If facial paralysis is due to a stroke, it is a medical emergency! Affected patients must be treated immediately in a clinic - preferably in a specialized facility (stroke unit). If the stroke is caused by the blockage of an artery in the brain (cerebral infarction), doctors try to reopen the vessel. If there is a stroke as a result of a cerebral haemorrhage, the doctor must stop it as soon as possible and reduce the increased pressure inside the skull.

Facial Paralysis: What You Can Do By Yourself

Most people panic when they suddenly experience facial paralysis. The relatives also often feel helpless. Most people think of a stroke first.

Stroke test: FAST

Whether symptoms such as sudden paralysis on one side of the face or sudden speech disorders actually indicate a stroke above, laypeople can use the FAST test to assess:

• Face: Make the person concerned smile! The one-sided paralysis pulls the face into an asymmetrical shape.
• Arms: Have the victim raise both arms with the palms facing up. If one half of the body is paralyzed, this does not work.
• Speech: The person concerned has to repeat a simple sentence in an understandable way and without mistakes. Failure to do this can be the sign of a stroke.
• Time: If at least one of these tests is positive, you should call an ambulance immediately and provide first aid.

How to act if the FAST test is positive

• Call the emergency services: Dial 112 and answer the questions calmly.
• Stay with the person affected, talk to them and calm them down - they are often confused and very frightened.
• Avoid dangers: remove dentures, loosen clothes, give nothing to drink or eat (paralysis-related swallowing disorders can cause the patient to choke).
• If the person concerned is conscious, you should position them with the upper body raised - the angle between the floor and back should be around 30 degrees.
• In the event of unconsciousness or vomiting, place the patient on their side in a stable position. You can find out how to do this here.
• Check your breathing and pulse! If neither can be determined in an unconscious person, you must immediately begin resuscitation.

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