A woman a little over 30 got caught in the rain, and that night she also showered late. Afterward she had a mild fever and a headache on one side, then her mouth twisted to one side, the eye on that side would not close fully, and eating and drinking became difficult. She thought it was minor, so she only came to the clinic on the fourth day. The clinical examination and tests showed severe damage to her facial nerve, along with inflamed lymph nodes at the angle of the jaw.
By the fourth day, she was already past the 72-hour mark that studies on corticosteroid medicine in facial palsy use as their standard. Waiting like that, people can easily miss the examination that rules out a stroke, and miss the best time to start medicine.
What is peripheral facial palsy?
Each half of the face has one facial nerve (cranial nerve VII) that controls the muscles of the forehead, around the eye, the cheek and the lips. When this nerve itself becomes inflamed and swollen, that whole half of the face weakens, usually over a few hours to a few days. When no specific cause is found, it is called Bell’s palsy, the form the studies below refer to.
The mouth pulls toward the healthy side, drinks dribble out of the corner of the mouth, and food collects in the cheek on the weak side. The eye on the weak side does not close fully and is watery or dry and stinging; the forehead lines on that side fade. Some people have pain behind the ear, ringing in the ear, or find sounds louder and harsher on that side.
Traditional medicine calls this condition deviated mouth and eyes (“deviated mouth and eyes”, 口眼歪斜 / 口眼喎斜, kǒu yǎn wāi xié), meaning the mouth and eye are pulled crooked, and usually places it in the group of wind-cold invading the meridians of the face at a time when the body’s upright qi (its resistance) is weak. In everyday Vietnamese, people often call it being “struck by wind”.
If you can still wrinkle your forehead, think stroke first
The forehead muscle on each side is controlled by both halves of the brain together. When the damage is inside the brain, as in a stroke, the forehead can usually still wrinkle, and the drooping is concentrated in the lower half of the face. When the damage is in the facial nerve, the whole half of the face, including the forehead, is weak: you cannot raise that eyebrow, the forehead on that side is smooth, and the eye does not close fully.
You can look in a mirror, raise both eyebrows as if surprised, and look at both sides of your forehead. This check helps you spot danger early, but it is not enough to diagnose yourself. Call emergency services (115) right away, without waiting to see whether it gets better on its own, if:
- Your mouth suddenly droops but both sides of your forehead can still wrinkle;
- A drooping mouth comes with weakness in an arm or leg, even on just one side;
- A drooping mouth comes with difficulty speaking or slurred speech;
- A drooping mouth comes with dizziness.
If you are not sure whether your forehead can wrinkle, do the same.
Why the 72-hour mark matters
In 2007, Sullivan and colleagues enrolled 551 people with Bell’s palsy in a double-blind randomized trial, all of them started within 72 hours of onset. After 3 months, 83% of those who took corticosteroid medicine early had recovered facial function, compared with about 64% in the group that did not; after 9 months it was about 94% compared with 82%. Antiviral medicine, alone or added on, showed no benefit.
The Cochrane review by Madhok and colleagues (2016) pooled 7 trials with 895 people. After 6 months or more, 17% of those who took corticosteroid medicine still had facial weakness, compared with 28% in the control group; for every 10 people treated, one fewer person had an incomplete recovery. The medicine also reduced synkinesis, an aftereffect in which the eye on the affected side closes when you smile. Side effects were no more common than in the placebo group.
For this reason, the 2013 guideline of the American Academy of Otolaryngology–Head and Neck Surgery (Baugh et al.) recommends an examination to rule out other causes, then oral corticosteroid medicine within the first 72 hours for people aged 16 and older. The type of medicine, the dose and the number of days are decided by the doctor who examines you in person, based on your underlying conditions and the medicines you are taking.
The numbers also show that most people who do not take medicine still recover gradually; taking medicine early reduces the number of people left with facial weakness.
Keep the eye on the affected side from drying out
Baugh’s guideline stresses eye protection for people whose eye does not close fully, because a cornea not covered by the eyelid dries out and is easily damaged. During the day, use moisturizing eye drops as your doctor instructs and wear glasses when you go out; at night, cover the eye on the affected side while you sleep. If the eye is red or painful, feels gritty, or your vision is blurred, see an eye doctor right away.
Signs that need a specialist check
The following signs need further examination by a neurologist or an ear, nose and throat (ENT) specialist, sometimes with electromyography (EMG) or imaging when ordered:
- Blisters in or around the ear;
- Weakness on both sides of the face;
- Weakness that gets steadily worse over several weeks;
- A swelling you can feel in the area in front of the ear (the parotid region);
- New neurological signs appear;
- After 3 months, the face has still not fully recovered.
Acupuncture, herbal decoctions and Applied Kinesiology alongside the early stage
Acupuncture, herbal decoctions and AK come second; the examination to rule out stroke and corticosteroid medicine in the early stage still come first. If your mouth started drooping only a few days ago and you have not yet been examined to rule out a stroke, see a neurologist first or at the same time.
Baugh’s guideline makes no recommendation for or against acupuncture. At Tam Duc, acupuncture is a supporting part, using points around the face and distant points chosen by pattern; the herbal decoction is modified for each person, and for the wind-cold pattern it aims to warm and open the meridians.
During an Applied Kinesiology session, the doctor does muscle testing before and after each adjustment step to follow how the nervous system responds from session to session; how badly the nerve is damaged is still answered by a neurological examination and electromyography. For facial palsy, the doctor often uses two techniques.
NeuroVascular means lightly touching and holding neurovascular reflex points, mostly on the head, to help support the circulation that nourishes the area of the nerve. NeuroLymphatic means stimulating neurolymphatic reflex points on the chest and back, to help support drainage of inflammatory fluid, which suits people who also have inflamed lymph nodes. Each point is muscle-tested again right afterward to see whether the body responds; why a muscle is used as the measuring stick is explained in our article why doctors use muscle testing.
For the woman described above, we combined AK (NeuroVascular, NeuroLymphatic) with acupuncture. After 9 sessions, her eye and cheek had almost recovered, the muscle around her lips was working well, and she was eating, drinking and talking normally again. One case does not speak for everyone; results also depend on how severe the initial damage is and when treatment starts.
Worth keeping
- A drooping mouth while the forehead can still wrinkle, or with weakness in an arm or leg, difficulty speaking or dizziness: call 115 right away;
- Weakness of the whole half of the face including the forehead still needs a doctor the same day; don’t let it go past 72 hours;
- Take corticosteroid medicine only as prescribed by the doctor who examined you;
- If your eye does not close fully, keep it moist during the day and cover it while you sleep;
- If you have not fully recovered after 3 months, go back to a neurologist or ENT specialist.
Dr. Dinh Ngoc Duc (MD, MSc in Traditional Medicine) will look at your prescription and your electromyography results (if you have them), then discuss how to combine acupuncture and herbal decoctions to help your face recover.
References
- Sullivan FM, Swan IRC, Donnan PT, Morrison JM, Smith BH, McKinstry B et al. Early treatment with prednisolone or acyclovir in Bell’s palsy. N Engl J Med. 2007;357(16):1598-1607. https://doi.org/10.1056/NEJMoa072006
- Baugh RF, Basura GJ, Ishii LE, Schwartz SR, Drumheller CM, Burkholder R et al. Clinical practice guideline: Bell’s palsy. Otolaryngol Head Neck Surg. 2013;149(3 Suppl):S1-S27. https://doi.org/10.1177/0194599813505967
- Madhok VB, Gagyor I, Daly F, Somasundara D, Sullivan M, Gammie F, Sullivan F. Corticosteroids for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2016;7(7):CD001942. https://doi.org/10.1002/14651858.CD001942.pub5
