Forging ahead: Penn State Health multidisciplinary Facial Nerve Disorders Clinic improves care of patients with facial nerve paralysis

Care for facial nerve paralysis is advancing with great speed at Penn State Health Milton S. Hershey Medical Center. Multiple minimally invasive and surgical techniques allow for facial reanimation and an accompanying increase in confidence as paralysis-related symptoms decrease in patients. Many of these improvements are dependent on swift and accurate diagnosis and early intervention. Some patients present with an incorrect diagnosis that detrimentally affects their outcomes or are referred many years after their diagnosis, limiting the treatment options to larger, more involved surgeries. Additionally, some patients have been receiving inappropriate treatments, leading to worse outcomes.

For example, “some patients with facial nerve paralysis get referred to physical therapy and receive treatment at the hands of someone without expertise in facial rehabilitation and biofeedback,” said Dr. Jessyka G. Lighthall, division chief of facial plastic and reconstructive surgery and director of the Penn State Health multidisciplinary Facial Nerve Disorders Clinic at the Milton S. Hershey Medical Center. “Instead of finding improvement, these individuals can be detrimentally affected, resulting in abnormal and often disfiguring involuntary facial movements (synkinesis).”

Diagnosing the problem

Those with facial nerve paralysis often suspect stroke during initial onset and present at the ED or their primary care provider.¹ The patient may then receive an extensive and often unnecessary workup, including lab work, consultations, admissions and multiple imaging scans — even when presenting with classic symptoms of idiopathic facial paralysis (Bell’s palsy). According to Lighthall, this approach drives up the cost of care. Even with a correct diagnosis, however, there is no guarantee that appropriate treatment will follow. In some cases, patients can undergo months of inappropriate and ineffective care or simply “observation” to see if the paralysis will resolve. In some cases, a patient may go eight to 12 months with an incorrect diagnosis of Bell’s palsy, without recognition of the true underlying disease process. At times, facial nerve paralysis can be caused from an undiagnosed cancer and delay in treatment allows the cancer to grow and spread, limiting available treatment options once properly diagnosed.

Lighthall opened the Facial Nerve Disorders Clinic in 2016 to address the void in health care for patients with facial nerve paralysis. The multidisciplinary team includes two facial nerve-trained therapists, facial plastic and reconstructive surgery, otolaryngology and plastic and reconstructive surgery. When appropriate, oculoplastic surgeons, ophthalmologists, neurologists, neurosurgeons and neurotologists aid in care.

Timely healing

Delay in care is a chief cause of poor outcomes for people with facial paralysis. This limits reanimation options and may result in permanent deformity, speech difficulties, poor oral competence and other issues. Despite this, with appropriate treatment, patients may get substantial improvement from intervention even years after the onset of symptoms.

One patient sought care from Lighthall at 70 years of age. After seven decades of living with facial weakness, she underwent successful reanimation and found renewed confidence. Others live decades with poor facial function, but within months of proper therapy, begin to experience increased function and return to everyday life.

Optimal outcomes also depend on timely care for Bell’s palsy. With classic Bell’s palsy symptoms, standard of care is a high-dose steroid taper, with or without antiviral medication.² Results are optimal when treatment begins within 72 hours of the onset of symptoms.

Of those treated this way, two-thirds of patients will improve without further treatment. For those who do not see satisfactory results, immediate referral to specialized care ensures an optimal outcome. Whereas traditional approaches required a full year prior to considering reanimation, new findings suggest an earlier and more aggressive approach for effectiveness.

“Those with poor recovery early on may benefit from early reanimation,” Lighthall said.

Expansive options

Reanimation is not always appropriate. Fortunately, advances in facial nerve paralysis have resulted in an ever-expanding treatment armamentarium, though most advanced treatment modalities require access to a specialty clinic.

“Advances in this field are developing regularly, and it’s hard to maintain updated options without a distinct interest in serving this population,” Lighthall said. “That’s why there is a growing number of facial nerve centers and why these multidisciplinary care centers are so critical.”

Today, specialized biofeedback therapy can optimize outcomes, antibiotics target underlying causes, such as Lyme disease, and new medication therapies are being researched for efficacy based on presentation.³

Surgical interventions have also increased. Depending on the need, the surgeon may transpose the hypoglossal or masseter nerve for reanimation purposes. In cases where paralysis has been present for more than 18 to 24 months, the patient’s native facial muscles have likely atrophied. This renders new nerve inputs ineffective. Instead, new muscle is introduced. The most commonly utilized muscle for this purpose is gracilis muscle from the groin or thigh, which the surgeon places in the face and connects to an alternate nerve, such as the masseter or a nerve placed from the unaffected side of the face to the paralyzed side.

Static procedures serve elderly patients and those who are unhealthy or unable to relearn function with a therapist. These surgeries improve symmetry, decrease drooling, improve speech, protect against permanent visual impairment and improve breathing ability.

“We work with patients to determine their goals to ensure their procedures will allow them the quality of life they desire,” Lighthall said. “Most of the time, we use a combination of treatments based on patient needs, but every aspect of their care involves a shared decision-making process between experts who treat facial nerve paralysis and the patient.”

References

1. Taylor DC. Bell palsy treatment & management. https://emedicine.medscape.com/article/1146903-treatment#d1. Accessed January 21, 2022.
2. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell’s palsy. Otolaryngol Head Neck Surg. 2013 Nov;149(3 Suppl):S1-27. https://journals.sagepub.com/doi/full/10.1177/0194599813505967. Accessed January 21, 2022.
3. Kim, JY. Facial nerve paralysis. https://emedicine.medscape.com/article/1290547-overview#showall. Accessed January 21, 2022.