Facial nerve palsy is caused by temporary or permanent damage to the seventh cranial nerve, which controls the muscles of the face. When no specific cause is found, it is called Bell’s palsy.
Symptoms
The main symptom is a sudden change in the movement of the facial muscles, both at rest and in motion. One half of the face is affected: loss of muscle tone, inability to move the eyelids, changes in salivation and tear production, and partial loss of taste.
Causes and consequences
Older medical texts describe it as “a frigore”, linking it to exposure to cold. In fact facial palsy has several causes: neurosurgery on the brain (acoustic neuroma), surgery to remove tumours of the parotid gland, and herpes infection of the facial canal (Ramsay Hunt syndrome).
Depending on whether it affects all the muscles supplied by the facial nerve (peripheral palsy) or only those of the lower half of the face (central palsy), it can affect eyelid opening and closing, tear production, salivation and speech.
One of the most serious consequences is paralytic lagophthalmos, the inability to close the eyelids. The eye cannot tolerate this for long: it dries out and is exposed to serious problems such as ulcers and infections, which can permanently damage its function.
Treatment
When the palsy is caused by an infection, it and the resulting lagophthalmos usually resolve on their own or with medication, generally within a week to about two months. When it follows surgery or trauma and nerve function cannot be restored, paralytic lagophthalmos can still be improved considerably with eyelid surgery.
A tarsorrhaphy (partial or complete suturing of the eyelids) protects the exposed cornea and stops the eye from drying out, but it should only be considered a temporary solution. If the palsy lasts more than six months, it is better to move to techniques that keep the eye open and working.
A gold weight implant placed within the upper eyelid, combined with raising the lower eyelid, allows the eye to open normally and to close well enough to avoid prolonged exposure, while keeping the patient’s appearance as natural as possible.
Read a clinical case: restoring eyelid function with a gold weight implant.
Correction of ectropion and paralytic lagophthalmos.
Photo 1: before surgery, facial palsy on the left. The left eye is more open than the right because the lower eyelid has dropped (paralytic ectropion). The cornea on the left is cloudy in the centre as a result of the lagophthalmos.
Photo 2: before surgery, showing the extent of the paralytic lagophthalmos.
Photo 3: the same patient one month after a gold weight implant in the left upper eyelid and simultaneous correction of the paralytic ectropion of the lower eyelid. The two eyes are now symmetrical, including the lower eyelids, and the corneal cloudiness has improved. The gold weight in the upper eyelid is not visible.
Photo 4: the lagophthalmos has much improved on the left. A slight residual gap of 1-2 mm is normal in these cases and does not cause problems for the eye.
Photo 1: before surgery, facial palsy on the left with a tarsorrhaphy (eyelids sutured together at the outer corner). Note the marked asymmetry between the two eyes; the tarsorrhaphy also limits side vision to the left.
Photo 2: before surgery, with the tarsorrhaphy. The lagophthalmos is still evident and the patient has many symptoms caused by corneal dryness.
Photo 3: the same patient after removal of the tarsorrhaphy, a gold weight implant in the upper eyelid and raising of the lower eyelid. The eyes are symmetrical and the left eyelids open fully.
Photo 4: the lagophthalmos is corrected, with a residual 1-2 mm that causes no symptoms.
Photo 1: facial palsy on the left. Looking straight ahead, the left eye is more open than the right because the lower eyelid has dropped, which always accompanies and worsens paralytic lagophthalmos.
Photo 2: marked lagophthalmos and corneal exposure on the left.
Photo 3: looking straight ahead after the gold weight implant and correction of the paralytic ectropion of the lower eyelid. The lower eyelids are now at the same height and protect the cornea much better. The gold weight is not visible.
Photo 4: the lagophthalmos is corrected and the cornea is well protected.
Photos 1 and 2: before surgery, the lower eyelid has dropped (paralytic ectropion).
Photos 3 and 4: before surgery. A test weight applied to the outside of the eyelid helps find the right weight, one that allows normal eyelid opening without mechanical ptosis.
Photo 5: after surgery. Correction of paralytic lagophthalmos with a gold weight implant in the upper eyelid and correction of paralytic ectropion of the lower eyelid: looking straight ahead, the eye is symmetrical with the other one.
Photo 6: after surgery, the eyelids close completely without effort.
Consultations
Prof. Francesco P. Bernardini sees patients in Milan and Genoa; a first video consultation is also possible.
