What Is Bell's Palsy?

Interviewer: Bell's Palsy is a relatively uncommon condition that is typically characterized by a loss of motor function in one side of a person's face. And while it only lasts a relatively short time for most people and isn't as life-threatening as say a stroke, diagnosis and treatment are time-sensitive.

And losing control of half of your face can be a serious detriment to your quality of life. Trust me, I've experienced it personally. To help us better understand Bell's Palsy, we are joined by Dr. Sarah Akkina. She is an assistant professor of Facial Plastic and Reconstructive Surgery at the Department of Otolaryngology-Head and Neck Surgery and the director of the Facial Nerve Center at University of Utah.

Symptoms and Causes of Bell's Palsy

Interviewer:Now, Dr. Akkina, let's start with the basics. When someone first experiences Bell's Palsy, I guess the first thing they notice is facial droop. Half of their face is paralyzed? It stops working. Is that like the main sign?

Dr. Akkina: That's the main sign. That's the one that. A lot of people clue into, and of course there's recent celebrities such as Justin Bieber, who had photos out in the world of him having that facial droop on one side or just really not being able to move one side of the face.

Now, Bell's palsy can very rarely occur to both sides of the face. But that is more unusual.

Interviewer: So what exactly is going on here? It's not brain damage or a clot or something like what is it that causes this facial paralysis?

Dr. Akkina: Overall, we suspect that Bell's Palsy is related to swelling around the facial nerve, probably related to an unnamed or unknown virus. The nerve that travels from the brain to the face to control face movements is in a very small bony canal at the base of the skull. So swelling in that area can lead to compression and that can cause the dysfunction that we see.

Interviewer: So if I understand this right, the nerves that connect half of that face to the brain are kind of pinched off. So what all do these nerves control in the face?

Dr. Akkina: The facial nerve controls muscles in the face, but it also controls tear glands, saliva glands, a muscle in the ear and tastes to the front of the tongue, as well as sensation to the eardrum and parts of the ear canal. So outside of the obvious facial weakness, patients with Bell's palsy can also have dryness in their eyes and mouth. A change in taste, sensitivity to loud sounds, and a change in the sensation of the ear.

Interviewer: Wow. So it's not just like not being able to smile. I mean, these nerves do a lot of other things like what are some of the other symptoms that can come from this condition?

Dr. Akkina: So while patients recover, they can have debilitating functional losses in the short term, and that includes the inability to close their eye. Trouble keeping food and liquid in their mouth, nasal obstruction and overall difficulty expressing emotions so they can't smile on that side of the face, which obviously impacts everyone's day-to-day lives.

Always Treat Facial Paralysis as an Emergency

Interviewer: Typically in healing from Bells Palsy you in two to three weeks, a month or two, you should start to get your face movement back.

Dr. Akkina: That is totally correct. So for most patients who come in with facial paralysis, we say about 70% of those patients. So a big majority have Bell's Palsy, though that does mean that 30% of people who come in with a face droop may have something else going on, and that's why it is so critical if you or a loved one starts to have a strange movement in their face. They need to see a healthcare provider immediately, ideally within 72 hours.

Interviewer: Go to the ER?

Dr. Akkina: Yes. Either an emergency department, urgent care. If you can get into your family care, primary care provider's office, all of those things are great options as long as you can see a healthcare provider within 72 hours.

Part of that is because one of the main treatments of early Bell's Palsy is being able to start oral steroids. And Mitch, I know you had an experience of this, I'm curious. Were you able to see someone right away and did you start steroids?

Interviewer: Well, there's a long funny story and you can hear about it on one of our other shows.

But yes, I very quickly got to the hospital as quickly as I could. I thought I was having a stroke, et cetera. The doctors thought I was having a stroke. They went through the whole like "brain attack protocol" and then at the. Found out it was "just Bell's Palsy."

But they were expressing, it's really important that you came in. Because if it had been a stroke, there's a lot of other things we could do to help you. And then on top of that, with the Bell's Palsy, they gave me some antivirals and some some pretty intense steroids to try to get as much pressure off of that nerve as possible. As early as possible.

Dr. Akkina: And that is so critical. There are really good research studies that people have done in the past where they actually randomize people to either getting steroids, plus or minus antivirals or getting a placebo, and they really found that upwards of 10 to 20% more patients were able to get early recovery when they started the steroids. Interestingly, the antivirals did not show a very clear benefit. So in our recommendations we say you can certainly consider antiviral medicines, especially if you know there are no other contraindications for you, but we don't have great data that the antiviral medicine helps as much as we know the steroids really help.

Potential Risk Factors for Bell's Palsy

Interviewer: Are there particular risk factors for someone to develop Bell's Palsy over, say one of these other conditions?

Dr. Akkina: There are and overall, Bell's Palsy affects 35,000 to a hundred thousand patients in the United States each year. So there are a decent number of patients, although overall rare. Patients who have diabetes, obesity, hypertension, or high blood pressure, other upper respiratory ailments and compromised immune systems are all at higher risk.

Importantly, patients who are pregnant are actually also at higher risk. Partly related to that compromised immune system. But yes, interestingly we do see a higher number of Bell's palsy in pregnant patients. They can also have a little bit more of a struggle with their recovery sometimes.

Recovering from Bell's Palsy

Interviewer: Talk me through recovery. So the person experiences facial group, ideally they go in, they get some pretty intense anti-inflammatories as fast as possible. What, a week or so?

Dr. Akkina: About 10 days. Seven to 10 days.

Interviewer: And then what's'the next thing? Like what happens after that?

Dr. Akkina: Yes. So overall, most patients show some sort of recovery within two to three weeks after their weakness starts. With a majority having complete recovery in three to four months. So it does take some time in patients who continue to have some movement at the time of their face droop, about 94% of those will completely recover in six months.

And that's one of the key things that we establish when we first see someone with facial paralysis is, "Do they have a complete paralysis or do they have partial weakness?" Because the recovery can be different for each of those patients. And again, for those with a little bit of weakness, but having some movement, the recovery is better and overall prognosis is better.

For patients who have complete paralysis and weakness. About 70% of those will recover completely in six months. So alternatively, 30% of those patients who start with complete weakness will continue to have some weakness in the long term or other disabilities.

Interviewer: Wow. And so during those times, during the recovery, what are some of the things that a patient can do to minimize some of the potential side effects that can come from having facial paralysis?I know that, myself included, I could not blink on that side of my face, could not keep food in the side of my mouth, et cetera. What are some of the things that can be done to minimize that?

Dr. Akkina: The number one thing we always wanna make sure for all of our patients who have facial nerve weakness is we're taking care of the eye.

And you even said that first, right? It's so important for us to make sure that the eye is protected, that it's getting enough lubrication and moisture. Otherwise, people can have permanent issues with either scratches of the eye or other disorders. So, number one, we always wanna make sure that patients with face weakness are taking care of the eye.

Number two is actually something that a lot of research is being done on because we don't have great evidence to say that some alternative therapies actually help in recovery. Overall, as we reviewed, most patients do recover, but things that have been tried, including physical therapy, acupuncture, and even electrical stimulation. We're still learning about. Currently we don't have enough evidence to recommend things like immediate physical therapy or acupuncture. But you know, we're still conducting studies on those aspects. So hopefully in the next five to 10 years we'll have more information on that. But at this time, I can't recommend those other aspects because of that.

Interviewer: So for a patient that recovers in six months or however long it takes. Is there a likelihood of recurrence?

Dr. Akkina: So there is a possibility of recurrence, and this is where it's really critical for us to make sure we know that a patient either does have Bell's Palsy or if they have any other factors that they come in with. We've identified that.

Because having a recurrent paralysis makes me more concerned that there might be another reason that that patient has facial paralysis. In other words, that maybe they were diagnosed with Bell's palsy for their initial paralysis, but it turns out they might actually have something like a skull-based tumor or a vascular reason to have other issues causing facial weakness.

So it is possible for patients to have recurrent Bells Palsy, but it does make us want to really carefully examine that patient on a physical exam and get a great history so that we can make sure we're not missing these other factors.

What to Do if Bell's Palsy Lasts Longer than 6 Months

Interviewer: So say a patient who has been diagnosed with Bell's Palsy has experienced that facial droop, that facial paralysis it is now seven months. Eight months. We are past that six month ideal window of recovery. What kind of treatment options are available to them?

Dr. Akkina: And that's a great question because even as early as three months, if a patient is not fully recovered from what's been diagnosed as Bell's Palsy, they need to see a facial nerve specialist. Because there are, again, other reasons that might be causing that. Bell's Palsy as an overall phenomenon, part of the definition is that you recover. So if you don't recover, we need to evaluate other reasons why that might be.

So things that you should definitely be referred to a facial nerve specialist for if you have Bells Palsy are: one, if you have incomplete recovery three months after. Two, if you have any new or worsening neurologic findings at any point.

And three, if you have ocular symptoms.

Interviewer: So if someone is out there listening or reading along with the transcript for this piece, there's a good chance that either they or a loved one are suffering from some of the side effects of Bell's Palsy. Maybe they're dealing with facial drooping. Maybe they're dealing with facial paralysis.What is something that you can tell them to give them a bit of hope? To give them a bit of understanding about their condition.

Dr. Akkina: I would focus on the prognosis and that's the most important part about Bell's Palsy. Most patients will recover, so hopefully there's always some comfort in knowing that for any patient who comes in with Bell's Palsy, the majority will get better.

It just takes some time and that timeframe is on the order of weeks to months. In the meantime, it's so important to take care of their eye and make sure they're getting enough, both moisture to the eye and protection of the eye, especially when they're sleeping. Wearing things like an eye patch or taping the eye is incredibly important for that.

Other things to know are that should you be in that small category of patients that have ongoing issues, we have a specialized facial nerve center that is built to take care of you and your loved one. We would love to see you at any stage at your disease to talk about prognosis, ensure that you've gotten the right diagnosis and that there's nothing else we need to look into. And be with you as you recover from this process.

We also, again, would love to eventually identify ways that we can help patients recover faster. So being plugged into our facial nerve center is our first step in us being able to track outcomes for people and make things better overall.