Message From the Center Director
P. Daniel Ward, MD, MS
The University of Utah Facial Nerve Center is a multidisciplinary center that offers a full range of treatments for patients with facial nerve disorders. This includes treatment of facial paralysis, facial synkinesis (abnormal facial movement after paralysis), trauma, and tumors. The team includes experts in facial plastic surgery, neurotology, otolaryngology (head and neck surgery), oncology, ophthalmology and oculoplastic surgery, facial nerve rehabilitation, neurology, and audiology. This approach allows the center to treat each patient individually and address the entire patient rather than an isolated issue or problem. P. Daniel Ward, MD, is the Facial Nerve Center director.
We treat facial paralysis due to each of the following conditions:
- Facial paralysis
Facial paralysis can be a devastating condition that may broadly affect a person’s life. It affects how a person eats, drinks and interacts with other people. For patients with relatively new onset paralysis, the problems are typically those related to how facial nerve functions, such as the inability to fully close the eye, sagging of the lower eyelid, sagging of the brow, inability to smile, sagging of the face, nasal obstruction and asymmetry of the lower lip. For patients with more long-standing facial paralysis, they can have all the problems of short term paralysis, but may also have the problems of synkinesis. The following is a list of conditions we treat:
Synkinesis is the abnormal movement of one part of the face with intentional movement of another part of the face. For example, when attempting to smile, the eye may close or when attempting to close the eyes, the neck may tighten. Synkinesis may present after any type of facial paralysis and usually starts after three to six months, but may develop up to two to three years after the paralysis. It may lead to eye problems, difficulty eating and speaking, social isolation and facial pain.
Medical treatment is typically undertaken only after at least a three month trial of facial therapy to improve the synkinesis. The treatment is with botulinum myomodulator (Botox, Dysport or Xeomin) with targeted treatment to the affected facial musculature. This treatment, when combined with physical therapy, leads to improvement in the symptoms of most patients with this disorder. The procedure is almost always covered by insurance plans, including Medicare.
Facial physical therapy is probably the single most important aspect of the treatment of facial synkinesis. Through this treatment, patients are able to retrain the brain to help decrease the effects of synkinesis. In addition, techniques are taught to help decrease the asymmetry, facial deformity and facial pain that may be present.
Surgery is reserved for those patients who have tired of receiving botulinum myomodulator therapy and have been determined to benefit from resection of the offending muscle or nerve branch. Procedures that are specifically targeted at treating synkinesis include the following listed below:
- Platysmectomy: The platysma is a large flat muscle in the neck that extends towards the lower portion of the jaw. This muscle is controlled by the facial nerve and is a frequent site of synkinesis. Synkinesis of this muscle may lead to decreased ability to lift up the corner of the mouth when attempting to smile, because the platysma pulls down on the corner of the mouth opposing the action of the smile muscles. It may also be associated with a prominent band in the neck and neck pain from chronic contraction of the muscle. The procedure involves resection of a portion of the muscle through one of the deeper neck creases in the neck. The procedure is typically performed in the clinic under local anesthesia.
- Resection of the lower lip depressors: There are several muscles that cause the lower lip to depress. These muscles may be responsible for asymmetry when smiling or speaking. In most cases of facial paralysis where lower lip asymmetry is a concern, the lip depressor muscles no longer pull down the corner of the lip, whereas the non-paralyzed side continues to pull down as it did before the paralysis. This leads to lower lip asymmetry. The treatment is to resect the still active depressor muscle on the opposite side to lead to a more symmetric lower lip. This procedure is typically performed under local anesthesia in the clinic.
- Resection of the nerves that lead to overactive eye closure: Eye closure resulting from synkinesis is usually treated with botulinum myomodulator; however, if a patient tires of this treatment, the nerve that controls eye closure can be resected leading to improvement in eye opening.
Rehabilitation, Interventions & Treatment Options
We provide treatment, intervention and rehabilitation options divided in the following ways:
- Eye and brow problems
- Nasal obstructions
- Lower lip asymmetry
- Inability to smile
Eye and Brow Problems
The problem that is most often noted by patients with facial paralysis is the inability to smile. However, the most important concern initially is the inability to fully close the eye, which may lead to eye dryness, corneal abrasion and even blindness. Eye protection measures should be undertaken as soon as the paralysis begins and typically includes eye drops used multiple times per day, eye ointment, a moisture chamber (a clear patch-like guard that covers and protects the eye) and proper taping of the eye.
The treatment of the inability to fully close the eye is typically through placement of a platinum weight in the upper eyelid, which allows gravity to help pull the eyelid down and close the eye. This procedure is typically performed in the clinic under local anesthesia. The eye may also require treatment of a sagging lower eyelid. Tightening of the lower eyelid is a also a procedure that can be performed in the clinic under local anesthesia. The eyebrow and eyelid may also droop and become problematic, because they can obstruct vision and be associated with severe facial deformity and asymmetry.
Nasal obstruction is very common in patients with facial paralysis. One rough way to determine if a patient has nasal obstruction is to pull the cheek on the affected side outward (to the side of the face) to open up the nose. If this leads to improvement in breathing, then procedures to open the nose may be helpful.
Treatment of nasal obstruction typically begins with a complete examination of the nose to look for any existing issues that may have been worsened by facial paralysis, such as a deviated septum, turbinate hypertrophy or internal nasal valve collapse. If nasal obstruction is present, the patient is often started on nasal saline irrigations and/or a nasal steroid spray to help decrease any swelling or build up of crusts in the nose. If these are not helpful or if the anatomic deformity is not thought to have the potential to be helped through these measures, then surgical intervention to help better improve the nasal breathing may be performed.
Lower Lip Asymmetry
Lower lip asymmetry is common in facial paralysis. There are several muscles that cause the lower lip to depress. These muscles may be responsible for asymmetry when smiling or speaking. In most cases of facial paralysis where lower lip asymmetry is a concern, the lip depressor muscles no longer pull down the corner of the lip, whereas the non-paralyzed side continues to pull down as it did before the paralysis. This leads to lower lip asymmetry. The treatment resects the still active depressor muscle on the opposite side to lead to a more symmetric lower lip. This procedure is typically performed under local anesthesia in the clinic.
Inability to Smile
The inability to smile is the most distressing element of facial paralysis. The treatment of this problem may include measures ranging from physical therapy and botulinum myomodulator therapy to surgical procedures.
Surgical procedures to restore smile
- Free tissue transfer: This procedure involves transplantation of a muscle with its associated artery, vein and nerve from the leg to the face to replace the facial musculature that is no longer working. It is typically done as a one or two stage procedure that also involves transfer of a nerve graft from the leg across the face to connect the muscle to the opposite, functioning facial nerve in an attempt to restore spontaneous and symmetric smile. This procedure is done in the operating room under general anesthesia and requires a five to seven day stay in the hospital after the procedure.
- Nerve grafting: This procedure involves transferring a nerve from the leg, arm or neck from the uninvolved facial nerve to the paralyzed nerve. This may lead symmetric spontaneous smile in many patients.
- Nerve transfer techniques: If the portion of the facial nerve that goes to the facial musculature is still functional, a nerve that controls a different facial muscles or a nerve that controls tongue movement may be transferred or grafted to the facial nerve and lead to good results in restoring smile.
- Muscle transfer techniques: In cases where the facial musculature is non-functional and a free tissue transfer cannot be performed, one of the muscles associated with chewing (that is not innervated by the facial nerve) can be transferred to help restore facial function. Static procedures: These procedures do not lead to active smile, but lead to improvement of the symmetry of the face. They may include facelift, brow lift, suspension of sagging facial tissue with fascia or sutures.
Dr. Richard Gurgel graduated magna cum laude from the University of Utah with an Honors B.A. in Biology. He then continued his training by attending medical school at the University of Utah. There he was elected to the Alpha Omega Alpha honor society as a junior. Dr. Gurgel did his residency in Otolaryngology – Head and Neck Surgery at Universi... Read More
Dr. Hunt completed his sub-specialty training Head and Neck Oncology at Vanderbilt University after otolaryngology training at Louisiana State University -New Orleans. He has been at the University of Utah since 2006 and primarily sees patients at the Huntsman Cancer Institute where he serves as the clinical director of head and neck surgical oncol... Read More
Bhupendra C. K. Patel is an expert in the management of disorders involving eyelids, periorbital tissues, lacrimal system and facial bones including fractures. His clinical research interests include thyroid disease, optic nerve disorders, orbital and eyelid tumors, blepharospasm, lacrimal surgery and facial cosmetic surgery.... Read More
Dr. Shelton has been associated with the University of Utah since 1994. Prior to that time, he was a partner at the House Ear Clinic in Los Angeles. He has lectured throughout the world on Neurotology disorders. He has published over 100 articles and edited books on Neurotology. He is an active member of both national and international professi... Read More
|Intermountain Hearing and Balance Center||(801) 595-1700|
Otolaryngology/ENT, Clinic 9
Lisa Dahlstrom is a native of Salt Lake City and an audiologist with the Divison of Otolaryngology at the University of Utah, where she has worked since 1989. She has a special interest in cochlear implants. Her hobbies include playing the piano and classical guitar, and enjoying time with her family.... Read More
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