It had been 27 years since the woman had smiled normally.
Explore This IssueNovember 2020
Her face had drooped more than two decades ago, and although many cases of facial palsy resolve spontaneously, hers didn’t. Her face twisted, limiting her expression, affecting nearly every aspect of her life. Previous treatment attempts hadn’t helped.
She had a little hope left, though, and scheduled an appointment with Kofi Boahene, MD, professor of otolaryngology–head and neck surgery at Johns Hopkins Medicine in Baltimore, after reading an article about his success with smile restoration and facial reanimation. Minutes into her appointment, Dr. Boahene told her, “I think we can help you.” Tears of relief and joy flowed.
“There’s a solution for almost everyone,” Dr. Boahene said.
But that wasn’t the case just a decade ago. Those who developed Bell’s palsy, the most common form of facial palsy, and didn’t recover completely were often left with lingering paralysis and, in many cases, synkinesis, or unwanted contraction of facial muscles during attempted movement. Other causes of facial palsy (acoustic neuroma, trauma, neoplasms of the parotid gland) also often result in long-term physical and psychological complications and have had few effective treatment options. Today, however, physicians can help most patients regain their smiles and facial movement.
“The field of facial reanimation may have changed more in the past decade than any other sub-specialty within otolaryngology–head and neck surgery, certainly within facial plastic surgery,” said Patrick Byrne, MD, MBA, chair of the Cleveland Clinic Head and Neck Institute in Cleveland, Ohio. “Now, virtually everybody with either incomplete or complete facial paralysis has treatment options that can help them improve.”
Making an Accurate Diagnosis
When patients first notice their faces drooping or failing to respond as usual, they often assume they’re having a stroke and call 911 or head to a local emergency department. When testing rules out a stroke, patients may be instructed to follow up with their primary care physician.
If the paralysis is restricted to one side of the face, the patient may have idiopathic facial palsy, or Bell’s palsy. According to the National Institute of Neurological Disorders and Stroke, more than 40,000 Americans are diagnosed with Bell’s palsy each year, and most—three out of four—improve without treatment.
The field of facial reanimation may have changed more in the past decade than any other sub-specialty within otolaryngology–head and neck surgery, certainly within facial plastic surgery. —Patrick Byrne, MD, MBA
Not all cases of facial paralysis are Bell’s palsy, however, and careful diagnosis allows patients to access effective treatment in a timely manner. A detailed history is crucial for accurate diagnosis, as symptom timing and progression are important differentiators between Bell’s palsy and other causes of facial paralysis. Bell’s palsy occurs suddenly and unilaterally and involves every zone of the affected side of the face. Symptoms should “be as bad as they’re going to get” within 72 hours of onset, said Caroline Banks, MD, a facial plastic and reconstructive surgeon specializing in facial nerve surgery at Massachusetts Eye and Ear Infirmary in Boston. If the patient reports continued evolution in symptoms over a period of weeks or months, they do not have Bell’s palsy. Additionally, patients who present with systemic symptoms, such as fever, body rash, severe fatigue, headache, vertigo, and hearing loss, probably don’t have Bell’s palsy.
If you practice in an area where Lyme disease is endemic, as Dr. Banks does, it makes sense to order a blood draw and test for Lyme disease. Otherwise, blood work is unnecessary. Palpation may help uncover other possible causes of facial paralysis, including tumors in the parotid gland; medical imaging may be a good idea if it’s unlikely that the patient has Bell’s palsy and you cannot palpate a tumor, as CTs and MRIs can uncover small tumors. You may also want to ask the patient if they’ve ever had a skin cancer, pre-cancer, or growth removed from their face, Dr. Boahene said. If so, it’s possible the cancerous cells have invaded nerves supplying the face, and exploratory surgery may be warranted.
Some centers will offer electrodiagnostic testing for patients who present within two weeks of the onset of symptoms. Patients who do poorly on both electroneuronography and electromyography may be candidates for facial nerve decompression; however, this surgery is controversial among facial nerve surgeons, and many patients aren’t good candidates, either because they don’t fit the electrodiagnostic criteria, they don’t seek specialist care within that two-week window, or they aren’t interested in facial nerve decompression, Dr. Banks said.
“In general, electrophysiologic testing isn’t necessary unless you want to act on the result of the test,” Dr. Boahene added. “Also, if somebody’s weakness isn’t complete—there’s still a little bit of movement—there’s no need to do these tests.”