Facial Paralysis, is one of the most frequently observed nerve paralyses, involving the facial nerve (facial nerve), which has the longest bony canal among the nerves that control the muscles of the body. Approximately 90% of these paralyses occur due to diseases within the temporal bone, where the nerve passes through its canal.

While Bell’s palsy is the most common cause of facial paralysis and is generally a self-limiting disease, it is important to remember that pathologies such as inflammations that damage the bone or tumors originating from the middle ear can also cause paralysis. Since the treatment of these regional diseases falls under the field of otorhinolaryngology, patients diagnosed with facial paralysis must undergo an ENT evaluation.

After exiting the brain, the facial nerve travels alongside the auditory and balance nerves into the temporal bone. In the inner ear canal, pathologies in this area can accompany facial paralysis with hearing and balance complaints.

As the facial nerve progresses through the canal in the temporal bone, it gives off branches that stimulate the lacrimal gland, the muscles of the malleus in the middle ear, taste sensation in the front two-thirds of the tongue, and the submandibular salivary glands. After exiting the temporal bone, the nerve extends forward, passing through the parotid gland, and splits into branches that stimulate the mimic muscles of the face.

The presence or absence of tear secretion, taste sensation in the tongue, and function of the malleus are helpful findings in determining the location where the disease has occurred.

Causes of Facial Paralysis

The causes of facial paralysis are varied, but the most common can be grouped into two categories: acute rapidly developing and chronic slowly progressing.

Acute Rapidly Developing Paralyses:

  • Nerve inflammations
  • Bell’s palsy
  • Herpes Zoster
  • Guillain-Barré syndrome
  • Autoimmune facial paralyses such as Lyme disease
  • AIDS
  • Kawasaki disease
  • Trauma
  • Temporal bone fractures
  • Pressure trauma
  • Birth trauma
  • Middle ear inflammations
  • Acute bacterial
  • Chronic bacterial
  • Formation of tissue that erodes the bone in chronic middle ear infections (Cholesteatoma)
  • Sarcoidosis
  • Neurological nervous system diseases

Chronic Slowly Progressing Paralyses:

  • Benign tumors
  • Parotid gland tumors
  • Metastatic tumors from other locations
  • Benign tumors (glomus tumor, schwannoma)
  • Chronic middle ear inflammations (Cholesteatoma)

Treatment of Facial Paralysis

The treatment of facial paralysis varies depending on the underlying cause. The goals of treatment are to restore normal facial appearance, ensure symmetry during voluntary movements, and maintain the function of emotional movements and muscles around the mouth, nose, and eyes.

Bell’s Palsy:

Acute facial paralyses where no obvious cause such as trauma, tumor, or infection is identified are named Bell’s palsy. Although the exact cause is not known, it is accepted that it occurs due to viral inflammation and an immune mechanism. Bell’s palsy is a self-limiting pathology and does not progress, generally resolving spontaneously.

In 80-90% of patients, the paralysis completely resolves, and in those without complete nerve fiber loss detected in early tests, this rate increases to 95-100%. However, in patients with complete paralysis and over 90% nerve fiber loss detected in early tests, the full recovery rate drops to 50%.

In the treatment of Bell’s palsy, corticosteroids are administered intravenously within the first four days after paralysis onset to patients without any impediments. This is followed by oral corticosteroid therapy, gradually tapering the dose every 2-3 days for approximately 15 days.

To prevent gastrointestinal side effects of corticosteroids, gastroprotective treatment should be administered. Due to the possible viral etiology, antiviral medications are added orally. During the period when facial nerve function is absent, warm compresses, massages, and facial exercises are applied to prevent muscle atrophy. Protection is applied to prevent complications such as keratitis caused by dry eyes.

In situations where corticosteroid use is contraindicated (uncontrolled diabetes, pregnancy, etc.), treatments aimed at increasing capillary blood circulation may be administered. If there is improvement after three weeks of follow-up, supportive treatment continues. In patients without clinical improvement, electromyography (EMG) is performed. Patients showing improvement in EMG continue with monitoring, while those with total nerve fiber loss and no improvement undergo MRI. If pathology location is determined in this test, appropriate surgical techniques are applied to free the nerve within the canal.

The longer the paralysis duration, the lower the quality of recovery. Early surgical intervention is considered the most important factor in restoring facial functions ideally. Therefore, early diagnosis and appropriate treatment in patients with facial paralysis have significant effects on recovery.

Trauma:

Trauma is the second most common cause of facial paralysis. It can be due to temporal bone fractures, surgical trauma (inevitable during surgery), or inadvertent surgical trauma.

Temporal Bone Fractures:

In cases of facial paralysis immediately following trauma, it is assumed that there is a nerve cut or injury. In such cases, surgery should be performed as soon as possible, and appropriate surgical techniques should be applied to repair the nerve based on the pathology’s condition.

Paralyses that begin some time after trauma may be due to swelling or bleeding within the nerve canal. In such cases, treatment is similar to that of Bell’s palsy. Surgical decompression is considered if there is no response to treatment.

Acute and Chronic Middle Ear Inflammations:

In cases of facial paralysis observed during acute middle ear inflammation, antibiotics should be started intravenously, and a perforation should be made in the tympanic membrane to allow the discharge of accumulated inflammation from the middle ear. Additionally, corticosteroid therapy may be applied.

In cases of paralysis associated with chronic middle ear inflammations, there is a higher chance of finding a cholesteatoma, which is an inflammatory mass that erodes the bone. In these cases, urgent surgical intervention is necessary as paralysis occurs due to pressure on the nerve or regional inflammation caused by the cholesteatoma.

Herpes Zoster Oticus:

(Ramsey Hunt Syndrome) It is caused by the Varicella Zoster virus. It typically presents with vesicular lesions in the auricular pavilion, scalp, face, or lips. Unlike Bell’s palsy, the findings are more severe and usually result in complete nerve disruption.

It is more frequently observed in individuals with cellular-type immunodeficiency. The full recovery rate is low, ranging between 10-22%. Antiviral medications specific to this virus should be used in treatment. The treatment protocol is similar to that of Bell’s palsy.

Temporal Bone External Pathologies: These are usually due to trauma or tumors originating from the parotid gland. Depending on the cause, different surgical methods are used in treatment.