Facial Nerve Paralysis - From Diagnosis to Rehabilitation

Added: 2026-05-27

[00:00:00]I'll be covering facial nerve paralysis and uh from evaluation to rehabilitation. I will thank uh organizers Dr. Jay Gaitri, Dr. Dakar for this opportunity.

[00:00:13]So um you know there are two types of facial nerve paly. One is upper motor neuron and the lower motor neuron paly.

[00:00:21]So it is a lower motor neuron fally which mostly affects the eyes and so I'll be dealing with the lower motor neuron fally.

[00:00:31]So low uh uh um facial nerve palcy not only causes the functional problems such as coral exposure, vision loss but it also causes brotosis, ectropion, pseudoptosis, a brain regeneration and these collectively they causes the very asymmetric face and this changes the looks of the patient. So patient uh doesn't want to interact publicly and uh it changes the personality overall personality of the patient and causes the uh this uh quality of the life poor quality of the life of the patient. So this is a patient of facial nerve paly who presented uh with the uh lag of inability to close the eye which is the most commonest type of the presentation and the other presentation can be redness tearing dry eye or foreign body sensations.

[00:01:24]So don't think that all the uh facial nerve paralysis is bell speli is a diagnosis of exclusion. So you need to rule out everything to establish that diagnosis. So ask for the onset and the duration of the symptoms and the signs.

[00:01:40]It can be congenital also the child can have while passing through the birth canal. There can be injury, it can be congenital. Take the history of the head injury or any regional injury and any surgery on the face or the ear surgery.

[00:01:56]Take the history of fever, rashes etc. and the rash around the ear at it may indicate the Ramsey hun syndrome. Take the history of tick exposure, weight loss, rule out the limes disease, tuberc losses etc. Uh ask for the history of the recent immunization for the polio and the influenza which can cause facial nerve paralysis. Other systemic conditions such as diabetes, malitis, hypertension, pregnancy, amoidosis, sarcoidosis. So a lot of the condition you have to rule out which can cause the facial nerve paralysis. Middle ear diseases such as otitis media, malignant, external otitis, choleasttoma all these you have to rule out.

[00:02:38]Then facial nerve paralysis is a like spot diagnosis. As soon as the patient enters into your clinic, you know that patient is having facial nerve paly. So this is a right-sided facial nerve paly.

[00:02:50]You see there are absent wrinkles. You see widened uh lid aperture vertical uh this fissure height is widened. The nasol labial fold it is not very prominent and your mouth is deviated to the other side.

[00:03:09]Also determine whether it is paralysis or it is parasis. In most of the case of bell's pel when it is incomplete it usually recovers.

[00:03:17]Examine the skin of the pina oracle for the rashes. palpitate the paroted gland for any infiltrative tumor head and neck nodes to rule out any infection and also the lacrimmal gland which may be enlarged in the sarcoidosis and may be associated with the facial nerve paralysis.

[00:03:37]So first of all you have to take the baseline vision for all the patient and then check the position of the eyebrows.

[00:03:43]When the patient comes uh uh uh the recent presentation patient may not have the brotosis but the patient presenting very late after 10 15 years you may significant brotosis like this. So this here you are seeing the both side brotosis. So this is the combination of the age related and facial nerve paling.

[00:04:01]So this side he's having age related.

[00:04:03]They said it's combination of both age related and facial nerve paralysis.

[00:04:10]Now this is a levator muscle which this levator muscle which is a retractor of the upper lid. Here this is a capsular paltebral fasia which is a retractor of the lower lid. So when these two contract they will open the eyelid and the orbicularis is going to close the eyelid. So in case of facial nerve paly orvicularis is paralyzed. Now what what will happen to the lid? It will retract upper lid, lower lid will retract and there will be increase in the vertical fissure height. Both MRD and MRD1 and MRD2 will increase and there may be ectropion also. And so you this is a uh medial and this is medial canthal ligament and lateral canthal ligament which holds the lid firmly against the globe. orvicularis by its attachment to these ligaments. They firmly close the lids uh uh they hold the lids against the globe and the tone of the orbicularis helps in lifting the lower lid about 2 to 3 mm when we are trying to close the eyelid. So normal position of the uh lower lid is at the limbbus and which is important for the complete eyelid closure. So when the orvolar is par is paralyzed this lower lid will fall part from the globe and lead to the ectropion with this there may be the punctal ectropion also. So you need to see the position of punctum also and patient because of the um punctal tropion and because of the loss of the normal tone of the orbicularis which will which will affect the leinal pump.

[00:05:41]So patient may have constant watering also and which may cause the changes in the skin of the cheek. So look for that also and these patient usually have the blink rate is reduced in these patient and it may not be complete. So you need to document the blink rate in these patients too.

[00:05:58]Now if the patient is having ectropion then you assess the horizontal lid laxity little canthal laxity medial canthal laxity and if this ectropion is for a long period then this may cause the zerosis of the conjunctiva here and this is going to cause the punctal stenosis also. So if you are planning for any lower lid procedure first dilate the punctum and do syringing.

[00:06:24]Now assess all the other cranial nerves.

[00:06:26]See the extracular movements to look for the third, fourth and sixth nerve. See the direct and indirect pupilary reflexes. Look for the corial sensation uh and upper and the lower lid sensation for fifth nerve. And also check the eighth nerve to rule out any uh cause of the ear which is contributing to the facial nerve paralysis.

[00:06:51]Now you have to grade the lack of thness. So for this first you ask the patient to close the eye gently and this then see the distance between upper lid margin and the lower lid margin which is lag of if it is not closing appropriately it is lag of thness and again then ask your patient to tight close the eye tightly with a maximum force and again try to see the uh document the or measure the lag of thness. So a grade one lag of thness will be noticeable on a very close inspection. Grade two lag of thillness patient will be able to close the eye completely with just minimum effort.

[00:07:27]Grade three lag of patient will be able to close the eye completely but with lot of effort and such patient has the risk of nocturnal lag of because the patient when sleeps in uh the eyelids will be relaxed and patient may have nochal lag of them. Grade four lag of there will be incomplete closure even with the maximum effort but patient may not have the coral exposure. Grade five incomplete enclosure with maximum effort but there will be coral exposure and grade six will be absent closure. So there will be exposure and such patient needs the immediate surgical intervention.

[00:08:07]Now with this you have to assess the bell's phenomena. If the bell's phenomena is very poor and even the grade one and grade two lag of thness is going to cause uh the coral exposure. So there will be the risk of conal exposure and we need again surgical intervention.

[00:08:23]In this case you have to check the tears do a shermas test and the low shermus test reading again uh is present along with the some amount of lag of the then there is a risk of keratopaththing. So these cases needs to be seen properly.

[00:08:43]Now these cases also have a very uh tearfilm uh status will not be very good. So you have to because the blinking is also not complete and blinking is also reduced. So in this patient you have to do a tier assessment also like tier film breakup time you need to check you need to check the tier film height do fluorescent staining and in grade four and grade five cases uh you may have the punctate staining like this on the cornea and if you don't treat it can go into the corial ulcer and the loss of the vision.

[00:09:17]Now can you tell me which side uh facial palacy this lady is having? Anyone loudly please?

[00:09:27]So I am hearing the right side but this now I will show you the next picture.

[00:09:32]Now can you tell?

[00:09:36]Okay this is a leftsided facial paly isn't it? So we have asked the patient to raise the eyebrows. Patient is not able to raise the eyebrows on this side.

[00:09:45]But what else you are seeing here the nasol labial fold is very prominent and the mouth is deviated to the same side which is just opposite of the usual facial paly. So this is actually the due to aberant facial nerve regeneration.

[00:10:01]So in case of old facial paly the other nerves may grow into the pathways of the facial nerve and they will start uh supplying the orbicularis.

[00:10:10]So in that case if you ask the patient to blow the mouth or uh blow the mouth in this case there will be tossis. So this this syndrome is also known as a marin ab syndrome. When you ask the patient to blow the mouth then the palpable aperture becomes narrow. This is just opposite of the marcus gunings phenomena. Okay. So this is due to aberant facial nerve regeneration.

[00:10:36]Another problem which the patient with a facial nerve paly can have is tearing during the eating. So which is also known as crocodile tear syndrome. So crocodile they usually tear when they eat. This happens because this is not due to some emotional reasons but this happens because of the aggressive jaw movement and the forceful breathing which forces the air into their sinuses and it stimulates the lacriminal gland to cause the tear.

[00:11:03]So similar uh type of symptoms a patient with old facial nerve paly can also have which is due to aberarent facial nerve regeneration again.

[00:11:14]So facial nerve paly the clinical diagnosis is very clear like it is a spot diagnosis. So you don't usually need a investigations but to if you want to go into the ethology which is causing facial nerve paly you can go for investigations like imaging may be required when you are thinking about tumors or some electrodiagnostic testing will be required to know which uh to know the level of the facial nerve insult. Cerology may be required to rule out the infectious causes and the hearing testing when uh you are suspecting the ear as a cause for facial nerve paly.

[00:11:53]Now this finishes with the evaluation of the facial nerve paly. Now we come to the management. So what are the aims for the management is to give the comfort to the eye and then protect the cornea so we can preserve the vision of the patient. correct the lid deformities in a aesthetically acceptable manner and if there is an infection we need to control the infection.

[00:12:15]So if the lack of them is less than grade three that means patient is able to close the eye completely with minimum effort and recovery is expected when the bell's phenomena is good you need only the lubricating drops and preferably you should give a nonpreserved lubricating drop in all these cases the bell's phenomena is poor then you need to give the lubricating drop plus you can ask him to tape the lids whenever he's going for sleep now if the lag of the is more than grade three that is patient is uh if lag of this is grade three that is patient is able to close the eye but with maximum effort and recovery is expected. So we will give the lubricating drops and again tapping during the night times.

[00:13:01]So uh eyelid taping this is the simplest form of the care which we can give to the patient of the facial nerve pel but it has to be done in a right way. So this is a wrong way of taping the eyelid. Okay. So you need to secure both the eyelids that is upper lid and lower lid. Lower lids especially we need to secure when there is a tropion or there is a lower lid retraction because your eyelid is not going to close completely.

[00:13:25]So this is a small clip which I have downloaded from YouTube to show the correct method of um closing uh doing the taping. So here you take the micro pore around uh length more than the length of the eyelid and then you cut it into a thin strip. You stick to the medial side of the lower lid and then lift the lower lid slightly and then stick to the outer angle of the eye. And then you put the ointment inside the eye and then you again take the same length of the um micro pour.

[00:14:00]You close the eye with the finger and then you stick this tape to the medial end and then pull it and stick to the outer side of the eye.

[00:14:11]And when you are trying to remove this tape, you should peel the skin from the tape not the other way around.

[00:14:25]Okay.

[00:14:28]Now if the lag of the is more than grade three that is patient is not able to close the eye even with the maximum effort and the recovery is expected. So we are worried about the exposure and hence we can do some temporary procedure while we are waiting for the recovery.

[00:14:45]So along with this medical management we can do one of this procedure. Eyelid uh simplest way is to ask the patient to do eyelid taping. If eyelid taping is not working then we can do a temporary tarsory which can be either cheotars or it can be suture tarsory or we can give the temporary eyelid weights or we can do fillers also.

[00:15:08]Now the tarsor FE um we uh usually this the lateral or medial tarsor FE that is enough uh which leaves a small space in the center to put the drops uh to check uh for the vision and to do a corial assessment. So we are going to this video.

[00:15:30]So first we'll pass through bolster then through the skin then through eyelid margin. Again we'll pass it through the eyelid margin then through skin then through the bolster again through bolster and then skin and eyelid margin and again eyelid margin and coming out through the skin and then we'll pass through the bolster and we can tie it.

[00:15:50]The disadvantage of this is that it can become loose with the time and giving the inadequate protection to the cornea.

[00:16:00]Now this is another u uh the external eyelid weights. This is available with the FCI and they they are very good for the immediate non-surgical uh treatment of the lag of thillness. So these weights are they made up of tantelum and uh we can stick these weights to the tarsus here. So before uh this we have to find which uh the appropriate weight which will help us which will reduce the lag of the at the same time patient is able to completely open and close the eye. So we are going to stick the weights first and then we'll ask the patient to blink and we'll see whether the eyelid is completely closing and patient is able to bling and once you find the appropriate weight then you can order a box like this which with the about 100 weights which is matching the skin tone of the patient.

[00:16:59]Now if the lag of theness is more than grade three and the there is no recovery in the next 6 months or if the recovery is not expected from the very beginning then we can do a permanent surgical procedure. We have to deal with the lag of the ectropion and the cosmosis when we do the surgery. So the principle of this procedure is to reduce the palpibbral fissure height by either bringing the upper lid down or taking the lower lid up.

[00:17:27]So these are the permanent procedures for upper lid we have levator recession because levator is here overacting muscle. So we can weaken the levator muscle with levator recession. We can also do levator recession with a scleral spacer graft full thickness bleertomy and the gold with gold weight implantation. I usually do this levator recession with scaral graft and full thickness blottomy and the lower lid procedures are required such as lower lid retractor recession, lower lid retractor recession with the hard pallet graft. Here we use the cartilage graft mostly and these patients may also uh need the lower lid tightening procedures and also they may need the lateral or medial canthoplasty.

[00:18:13]So leviator recession is a very simple procedure for these patients. So this is a normal anatomy. Uh this is this one is a levator. This one is a tacus and this is leviator muscle. So what we have to do is we we need to cut from the superior border of the tassus. Uh we have to separate this levator muscle from the tacus and this will uh lengthen the upper lid. So that this procedure can be done either from the skin side or this can be done from conjunctable side also. But when we are doing from conjectable side you need to be very well well versed with the anatomy because this will reverse the entire anatomy when you the so this is a small video which is showing the from the this is a video showing uh the from the conjectile side. So you give a conjectile incision and then you then you cut the levator from the upper border of the tassus and then you give a traction suture for around 48 hours.

[00:19:22]Now if your levator if your eyelid retraction is more then you can do levator recession along with the spacer graft. So we are again going to do similarly we are going to do a levator recession then we can put a graft like this in between can suture here to the levator suture here to the tarsus. So for this purpose we can use the scleral donor scleral graft. This donor scaral graft is usually preserved in 70% alcohol. So you need to wash out with several changes of the solution and uh 2 hours before doing the surgery you need to put it in an antibiotic solution.

[00:19:59]Then you need to fashion out the graft uh which should be slightly less than the horizontal uh lid length and vertically it should be twice the amount of the lid retraction and then you suture it on one side to the uh tassels and the other side to the levator and then close the uh incision.

[00:20:19]So this is a patient of facial nerve paly where um I have done the levator recession with the scaral graft. So you can see the pre-operative lag of the post-operative complete closure of the lid.

[00:20:33]This is another patient where did the levator recession with the scaral graft.

[00:20:38]So the right side you notice the this vertical palpibbral aperture and here uh the it has reduced significant amount also the you see the upper lid height here and upper lid height here. This is a um showing the lag of the pre-operatively and this is a lag of the post-operatively but this remaining lag of them is due to the lower lid sagging which can be corrected at the second stage.

[00:21:05]Now similarly we can do the lower lid spacer. So here we need to put a cartilage graft and it's so you have to do first lateral canthottomy and then avert the lower lid put the traction suture cut the conjuctiva and then separate the lower lid retractors from the conjuctiva till the inferior phonics. Then take a cartilage graft and again you have to suture it to the lower border of the tacus on one side and the uh capsular palpibbral fasia on the other side.

[00:21:45]Okay. Another procedure which we can do is a full thickness bleotomy. Full thickness blerotomy you are cutting the skin you are cutting the orbicularis leviator and mers still conjunctiva full thickness of the lid you are cutting and leaving just the small stump in the center okay so I'll show you this video so I'm giving this a skin incision first and then you have to separate the orbicularis and the skin and then this is you're separating the levator from the tacus Then you go to the superior border of the tassus and you cut a full thickness of the leviator mullers and conjuctiva.

[00:22:27]Then the lateral side you're doing same you're cutting the levator mulus and the conjuctiva full thickness leaving this small stem here and then you will close the surgical incision. You'll close the orbicularis and then you will close the skin.

[00:22:52]So this is a patient in which I I have done full thickness bleotomy. You can see the particular palpibal fissure height here and this here it is much reduced and this is a lag of them pre-operatively. This is a very minimum amount of lagness post-operatively. So patient was happy with this. So we did not go for lower lid procedure.

[00:23:14]Okay. Another thing which uh will help these patient is a gold weight. So taking the rising prices of the gold I don't think anybody will like to get it done. So but still as a student you need to know this procedure. So how does this work? So this will uh narrow the particle pressure height and it will reduce it will act against the levator action in a gravity dependent fashion.

[00:23:39]Okay. So what we are going to do gold is a uh it is ideal because it is inerted and it matches very much with the tone of the skin and it doesn't show through the skin. So we usually use the gold.

[00:23:52]Now you so you make a skin crease incision and then you set you make a go to the tassus and you take this gold weight and uh the gold weight uh uh you have to determine it before like uh the how much gold weight is required. So this will be having the holes you can stitch this to the tarsus and with the proline suture and you should see that the proline suture is not going in depth. It's it's just a partial thickness suture and uh it is very well tolerated gold weight except for it can sometimes migrate or extrude.

[00:24:33]Okay. So there are so many different procedures are there but the surgeon should do the procedure within which he feels comfortable and is he has a good expertise. Okay that's all. Thank you very much. These are my references.