Advanced Expertise in the Diagnosis and Treatment of Facial Paralysis
The University Hospitals Facial Paralysis Treatment Center has a team of experts with advanced training and expertise in the diagnosis and treatment of facial paralysis or dysfunction.
The facial nerve controls the muscles involved in facial expression, taste sensations and tear production. If the nerve is damaged due to injury, disease or trauma, it can result in facial paralysis, affecting the ability to speak, blink, swallow or smile. Regardless of the cause, extent or location of the nerve damage, the experts at our Center can help.
Your health is important. Get expert care.
If you experience any symptoms of facial paralysis, you should immediately seek medical help. To schedule an in-person consultation with a UH facial paralysis expert, call 216-844-3223.
Virtual appointments are also available.
About Our Team
Dr. Cyrus Rabbani, Director, UH Facial Paralysis Treatment Center leads a team of ophthalmologists, oculoplastic surgeons, physical therapists and speech therapists to provide multidisciplinary, personalized treatment for each patient who comes to us for care.Meet Our Team
Dr. Cyrus Rabbani, Director, UH Facial Paralysis Treatment Center, explains the different types of facial paralysis and how they are treated.
What Is the Facial Nerve?
Every person has twelve cranial nerves that connect the brain to different parts of the body. The facial nerve is known as the seventh cranial nerve.
The facial nerve originates in the brain stem (base of the brain) and exits the skull through an opening located near the base of the ear and travels through the parotid gland – a salivary gland that sits just in front the ears on each side of the head. Within the parotid gland, the nerve splits into five distinct branches. Each branch exits the parotid gland and controls different areas of the face. The five branches of the facial nerve are as follows:
- Temporal or frontal: Controls the muscles of the forehead and eyebrows. When not functioning correctly, the eyebrow can droop and potentially obscure vision.
- Zygomatic: Controls the muscles around the eyelids that allow the eye to close completely. When not functioning correctly, it can cause dry eye and potentially damage the cornea if untreated.
- Buccal: Controls the muscles used to move the nostrils and upper lip. When not functioning correctly, there can be difficulties with smiling, speech, eating/drinking and spontaneous eye blinking.
- Marginal mandibular: Controls the muscles of the lower lip. When damaged, it can cause an asymmetrical smile and problems with eating and drinking.
- Cervical: Controls the lower chin muscle. Damage to this facial nerve branch may result in an asymmetrical smile.
What Causes Facial Paralysis or Dysfunction?
Facial paralysis is almost always caused by some type of damage to or deformity of the facial nerve. The damage can be present at birth (congenital) or can be caused by:
- Infections, including middle ear infections (otitis media), herpes simplex, herpes zoster (shingles) and Lyme disease.
- Traumatic injury including temporal bone fracture, birth trauma or any head injury that damages the facial nerve.
- Stroke – a stroke in the brainstem may cause long-term, debilitating facial paralysis.
- Brain tumors.
- Tumors of the inner ear (acoustic neuroma).
- Parotid gland tumors and malignancies (cancer) can invade the facial nerve.
- Surgery to remove head and neck tumors can sometimes lead to facial nerve damage.
- Ramsay Hunt Syndrome, a complication of shingles that can damage the facial nerve.
In some cases, the cause is unknown (idiopathic). The most common cause of idiopathic facial muscle weakness or paralysis is Bell’s palsy. This disorder typically has a sudden onset with symptoms worsening over the next 48 hours, and often resembling those of a stroke. This type of facial palsy usually occurs on only one side of the face, but in rare cases can affect both sides. Bell’s palsy is usually a temporary condition that resolves within three months.
Advanced Treatments for Facial Paralysis
It is very important to consult with a member of the Facial Paralysis Treatment Center as soon as you experience symptoms of facial paralysis to ensure the appropriate treatment is started promptly. Some conditions, such as Bell’s palsy, may resolve on their own, while others may be successfully treated with medication, physical therapy or other conservative measures. Treatments may include:
One or more of the following medications may be prescribed to help treat facial nerve inflammation and swelling:
- Antivirals. When facial nerve paralysis is caused by a virus, the symptoms are usually due to inflammation and swelling which can restrict blood flow to the facial nerve. Oral antiviral medications stop the virus from multiplying and spreading, relieve the inflammation and restore normal blood flow - allowing the nerve to heal and return to normal function.
- Corticosteroids. Steroid medications may be prescribed to reduce inflammation and swelling around the facial nerve. Usually they are taken orally for 10 to 14 days although in some cases a more aggressive approach to treatment may be required. For example, if your doctor suspects that your symptoms are causes by the herpes zoster virus (shingles), a stronger dose delivered intravenously may be the first step, followed by a course of oral medication for 7 – 10 days.
- Analgesics. If there is pain associated with your facial nerve inflammation, your doctor will recommend the appropriate pain medication(s) as part of your total treatment plan.
- Eye Drops. When facial nerve dysfunction affects the ability to blink and/or fully close the eyelid, keeping the eye lubricated is an essential part of treatment. In addition to using eye drops frequently throughout the day, your doctor may recommend the use of a lubricating gel at night, with the eye taped shut.
Injectables and Fillers
Injectables and facial fillers are often used as part of the total treatment plan for patients with facial nerve/muscle dysfunction.
They may be used separately or together to enhance facial movement, function and cosmetic appearance.
- Botulinum toxin or Botox® has been used for many years to relieve facial tightness and improve facial symmetry by weakening or paralyzing certain muscles in the face. It is most commonly used to treat tightness around the eyebrow, mouth, cheek and neck or to improve facial symmetry by weakening the muscles of the non-paralyzed side of the face. The effect is temporary, lasting approximately 3 – 6 months but can be repeated every 4 – 6 months if the results are beneficial to the patient.
- Facial fillers are used to add volume and restore symmetry to areas of the face affected by muscle atrophy. They can also be used to treat certain functional problems – for example, injecting filler around the lip can help resolve recurrent lip biting or drooling and improve certain speech problems. Facial filler treatments are typically done in the doctor’s office with local anesthesia and may last up to 18 months or more.
Many patients with facial paralysis, nerve damage or temporary facial palsy will benefit from specialized rehabilitative therapy as part of their treatment and recovery plan.
At University Hospitals, our team of physical, occupational and speech therapists carefully evaluates each patient and develops a personalized plan of care based on their diagnosis, prognosis and the severity of their condition. The goals of therapy are to:
- Stimulate, strengthen and retrain the facial nerve and supporting muscles to improve facial coordination
- Improve facial symmetry
- Regain or refine facial movements for specific functions such as speaking, eating and closing the eye
- Restore the ability to smile, frown and other facial expressions
- Correct abnormal patterns of facial movement
These goals are achieved through a series of special exercises designed to retrain the brain to coordinate the facial muscles more effectively. Our therapists take the time to teach each patient how to do the exercises properly and how often to do them for the best possible outcome.
To supplement other treatments, there are certain plastic surgery procedures that may be recommended as part of the total treatment plan.
Surgery May Be a Treatment Option for Some Patients
If conservative treatments like medications and physical therapy fail to restore function and/or symmetry in patients with facial paralysis, surgery may be a treatment option.
Facial reanimation procedures are extremely intricate surgeries given the proximity of the facial nerve to other important structures, including the eighth cranial nerve which is responsible for hearing and balance. The ENT facial plastic surgeons at University Hospitals have the advanced training, skills and experience to perform these delicate procedures and provide their patients with the best possible cosmetic and functional outcomes.
A Comprehensive Evaluation Is the First Step
Our surgeons will first perform an in-depth consultation to assess the patient’s facial nerve and muscle function, facial symmetry and any related speech, breathing or eating problems. They will also take a medical history and make note of which treatments and therapies have already been tried. They will then offer recommendations for surgical procedures that may relieve the patient’s symptoms, restore function and/or improve appearance. All procedures are performed through incisions that are aesthetically hidden for an optimal cosmetic outcome.
Surgical options for the treatment of facial paralysis will be determined by how long the patient has been experiencing symptoms, the severity of the paralysis and the specific facial organs affected. Based on the results of the comprehensive evaluation, your surgeon may recommend one or more surgical procedures.
Surgical Treatment Options
Facial paralysis that prevents the eye(s) from fully closing can put the eye at risk for excessive dryness and loss of sensation, which can ultimately lead to eye ulceration and infection. If nonsurgical treatments such as eye lubrication and external eyelid weights are not sufficient, we offer a surgical procedure to correct eyelid closure. During the surgery, we place a thin platinum weight under the upper eyelid skin to help achieve better descent of the eyelid and full eyelid closure. The weight can be removed at any point if it is determined it is no longer required.
Facial Nerve Decompression
When the facial nerve is compressed by surrounding bone or muscle due to injury or disease, the associated facial muscles can become numb or paralyzed. Decompression surgery removes whatever is pressing on the nerve to relieve the pressure, improve blood circulation and restore feeling and function. Nerve decompression surgery is most effective for acute episodes of facial paralysis in which symptoms have been present for less than three weeks.
Facial Nerve Repair and Grafting
If the facial nerve itself is diseased or damaged, a direct nerve repair may be a good surgical option. In this procedure, the affected segment of the nerve is removed and the two nerve ends reconnected. If there is not a sufficient length of nerve to reconnect the ends, a piece of nerve taken from elsewhere in the body may be used to “bridge” the gap created once the injured portion is removed. This is called a nerve graft.
Facial Nerve Transfer and Reinnervation
If the original source of input into the facial nerve and muscles is limited or completely unavailable and we know the facial nerve will not regenerate, a nerve transfer procedure may be recommended. In these procedures, a nearby, healthy nerve or nerve branch is cut and its end is sutured to the non-functioning nerve. Over time, the healthy nerve will grow into the damaged one and restore movement to the associated muscle(s). There are three main nerve transfer procedures that may be performed alone or in combination with one another. These include:
Cross Face Nerve Graft
This procedure involves taking a sensory nerve from the neck, arm or leg and attaching it to a facial nerve branch on the non-paralyzed side of the face, tunneling it across the face and connecting it to nerves on the paralyzed side to restore function.
Masseter Nerve Transfer
This procedure involves dividing the masseteric nerve (which runs through the muscle we use for chewing) and connecting one end to a branch of the facial nerve. This procedure is a reliable way to restore movement of the lip and cheek on the paralyzed side.
Hypoglossal Nerve Transfer
This procedure involves dividing the hypoglossal nerve (which controls tongue movement) and attaching one end to the facial nerve to improve facial tone and symmetry. There is some risk of tongue weakness following this procedure but this can often be resolved with appropriate therapies.
Long-term facial paralysis (more than two years) often leads to atrophy of the facial muscles which have lost function. In these cases, the muscles usually cannot be reanimated even if the facial nerve is the body, “transplanting” them in the face and reanimating them by connecting them to the facial nerve. Muscle transfers may require more than one procedure and several brief hospital stays. Procedures may include:
Temporalis Tendon Transfer
The temporalis muscle lays over the side of the skull and attaches to the jaw to help close the mouth and clench your teeth together. We can provide movement to the corner of the mouth by detaching this muscle from the jaw and re-attaching it to the lip. The beauty of this procedure is it can be hidden either through an incision in a crease on the cheek or in the mouth. Once it has healed, the lips will be in better position and the corner of the mouth will move up with clenching (similar to a sile). We usually overcorrect the smile at first because over time this muscle relaxes to provide great symmetry. As one can imagine, clenching your teeth is how you would control the muscle and that means the patient needs retraining and rehabilitation to get the best outcome from surgery.
The gracilis free flap takes a muscle from the leg and transfers it to the face. We reattach both blood and nerve supplies to achieve healthy and desirable movement. This procedure often involves two stages of surgery separated by 6 – 8 months. We perform these surgeries through incisions hidden along the hairline and around the ear similar to a facelift surgery. The first stage of surgery takes a nerve from the side of the leg to attach to a facial nerve on non-paralyzed side of the face. We tunnel this nerve across the face to be primed for the next stage of surgery that is the muscle transfer. For the second surgery, we attach the gracilis muscle to the previously tunneled nerve, as well as a second nerve we use to chew (the masseteric nerve). This provides the mouth muscle with coordinated and strong movement, leading to more facial symmetry. The muscle takes up to 6 months to begin moving and continues to improve with retraining and rehabilitation over the next few years.
Muscle myectomy is a surgery involving removal of a muscle that is moving unfavorably, commonly seen in patients who experience a limited recovery after facial paralysis. The most common reason for this procedure is to treat muscles around the mouth or neck that are pulling the corner of the lip down, leading to discomfort or an abnormal smile. A myectomy can remedy this by removing a portion of the dysfunctional muscle. Often, we would first inject Botox® into these muscles to temporarily weaken them and investigate if a myectomy would be effective as a long-term option.
Abnormal, uncoordinated muscle movements of the face (synkinesis) is often due to abnormal nerve activity in patients who experience a limited recovery after facial palsy. Neurectomy is a procedure during which we excise the specific nerves that are no longer communicating properly with the facial muscles The malfunctioning nerves are identified and either cut out or rerouted to improve facial movement. Similar to myectomy, we will often try Botox® injections first to ensure a neurectomy is necessary for an optimal outcome.