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Interviewer: Bell's Palsy is a relatively uncommon condition that is typically characterized by a loss of motor function in one side of a person's face. And while it only lasts a relatively short time for most people and isn't as life-threatening as say a stroke, diagnosis and treatment are time sensitive.

And losing control of half of your face can be a serious detriment to your quality of life. Trust me, I've experienced it personally. To help us better understand Bell's Palsy, we are joined by Dr. Sarah Aina. She is an assistant professor of Facial Plastic and Reconstructive Surgery at the Department of Otolaryngology-Head and Neck Surgery and the director of the Facial Nerve Center at University of Utah.

Dr. Akkina: That's the main sign. That's the one that. A lot of people clue into, and of course there's recent celebrities such as Justin Bieber, who had photos out in the world of him having that facial droop on one side or just really not being able to move one side of the face.

Now, Bell's palsy can very rarely occur to both sides of the face. But that is more unusual.

Interviewer: So what exactly is going on here? It's not brain damage or a clot or something like what is it that causes this facial paralysis?

Dr. Akkina: Overall, we suspect that Bell's Palsy is related to swelling around the facial nerve, probably related to an unnamed or unknown virus. The nerve that travels from the brain to the face to control face movements is in a very small bony canal at the base of the skull. So swelling in that area can lead to compression and that can cause the dysfunction that we see.

Interviewer: So if I understand this right, the nerves that connect half of that face to the brain are kind of pinched off. So what all do these nerves control in the face?

Dr. Akkina: The facial nerve controls muscles in the face, but it also controls tear glands, saliva glands, a muscle in the ear and tastes to the front of the tongue, as well as sensation to the eardrum and parts of the ear canal. So outside of the obvious facial weakness, patients with Bell's palsy can also have dryness in their eyes and mouth. A change in taste, sensitivity to loud sounds, and a change in the sensation of the ear.

Interviewer: Wow. So it's not just like not being able to smile. I mean, these nerves do a lot of other things like what are some of the other symptoms that can come from this condition?

Dr. Akkina: So while patients recover, they can have debilitating functional losses in the short term, and that includes the inability to close their eye. Trouble keeping food and liquid in their mouth, nasal obstruction and overall difficulty expressing emotions so they can't smile on that side of the face, which obviously impacts everyone's day-to-day lives.

Interviewer: Typically in healing from Bells Palsy you in two to three weeks, a month or two, you should start to get your face movement back.

Dr. Akkina: That is totally correct. So for most patients who come in with facial paralysis, we say about 70% of those patients. So a big majority have Bell's Palsy, though that does mean that 30% of people who come in with a face droop may have something else going on, and that's why it is so critical if you or a loved one starts to have a strange movement in their face. They need to see a healthcare provider immediately, ideally within 72 hours.

Interviewer: Go to the ER?

Dr. Akkina: Yes. Either an emergency department, urgent care. If you can get into your family care, primary care provider's office, all of those things are great options as long as you can see a healthcare provider within 72 hours.

Part of that is because one of the main treatments of early Bell's Palsy is being able to start oral steroids. And Mitch, I know you had an experience of this, I'm curious. Were you able to see someone right away and did you start steroids?

Interviewer: Well, there's a long funny story and you can hear about it on one of our other shows.

But yes, I very quickly got to the hospital as quickly as I could. I thought I was having a stroke, et cetera. The doctors thought I was having a stroke. They went through the whole like "brain attack protocol" and then at the. Found out it was "just Bell's Palsy."

But they were expressing, it's really important that you came in. Because if it had been a stroke, there's a lot of other things we could do to help you. And then on top of that, with the Bell's Palsy, they gave me some antivirals and some some pretty intense steroids to try to get as much pressure off of that nerve as possible. As early as possible.

Dr. Akkina: And that is so critical. There are really good research studies that people have done in the past where they actually randomize people to either getting steroids, plus or minus antivirals or getting a placebo, and they really found that upwards of 10 to 20% more patients were able to get early recovery when they started the steroids. Interestingly, the antivirals did not show a very clear benefit. So in our recommendations we say you can certainly consider antiviral medicines, especially if you know there are no other contraindications for you, but we don't have great data that the antiviral medicine helps as much as we know the steroids really help.

Interviewer: Are there particular risk factors for someone to develop Bell's Palsy over, say one of these other conditions?

Dr. Akkina: There are and overall, Bell's Palsy affects 35,000 to a hundred thousand patients in the United States each year. So there are a decent number of patients, although overall rare. Patients who have diabetes, obesity, hypertension, or high blood pressure, other upper respiratory ailments and compromised immune systems are all at higher risk.

Importantly, patients who are pregnant are actually also at higher risk. Partly related to that compromised immune system. But yes, interestingly we do see a higher number of Bell's palsy in pregnant patients. They can also have a little bit more of a struggle with their recovery sometimes.

Interviewer: Talk me through recovery. So the person experiences facial group, ideally they go in, they get some pretty intense anti-inflammatories as fast as possible. What, a week or so?

Dr. Akkina: About 10 days. Seven to 10 days.

Interviewer: And then what's'the next thing? Like what happens after that?

Dr. Akkina: Yes. So overall, most patients show some sort of recovery within two to three weeks after their weakness starts. With a majority having complete recovery in three to four months. So it does take some time in patients who continue to have some movement at the time of their face droop, about 94% of those will completely recover in six months.

And that's one of the key things that we establish when we first see someone with facial paralysis is, "Do they have a complete paralysis or do they have partial weakness?" Because the recovery can be different for each of those patients. And again, for those with a little bit of weakness, but having some movement, the recovery is better and overall prognosis is better.

For patients who have complete paralysis and weakness. About 70% of those will recover completely in six months. So alternatively, 30% of those patients who start with complete weakness will continue to have some weakness in the long term or other disabilities.

Interviewer: Wow. And so during those times, during the recovery, what are some of the things that a patient can do to minimize some of the potential side effects that can come from having facial paralysis?I know that, myself included, I could not blink on that side of my face, could not keep food in the side of my mouth, et cetera. What are some of the things that can be done to minimize that?

Dr. Akkina: The number one thing we always wanna make sure for all of our patients who have facial nerve weakness is we're taking care of the eye.

And you even said that first, right? It's so important for us to make sure that the eye is protected, that it's getting enough lubrication and moisture. Otherwise, people can have permanent issues with either scratches of the eye or other disorders. So, number one, we always wanna make sure that patients with face weakness are taking care of the eye.

Number two is actually something that a lot of research is being done on because we don't have great evidence to say that some alternative therapies actually help in recovery. Overall, as we reviewed, most patients do recover, but things that have been tried, including physical therapy, acupuncture, and even electrical stimulation. We're still learning about. Currently we don't have enough evidence to recommend things like immediate physical therapy or acupuncture. But you know, we're still conducting studies on those aspects. So hopefully in the next five to 10 years we'll have more information on that. But at this time, I can't recommend those other aspects because of that.

Interviewer: So for a patient that recovers in six months or however long it takes. Is there a likelihood of recurrence?

Dr. Akkina: So there is a possibility of recurrence, and this is where it's really critical for us to make sure we know that a patient either does have Bell's Palsy or if they have any other factors that they come in with. We've identified that.

Because having a recurrent paralysis makes me more concerned that there might be another reason that that patient has facial paralysis. In other words, that maybe they were diagnosed with Bell's palsy for their initial paralysis, but it turns out they might actually have something like a skull-based tumor or a vascular reason to have other issues causing facial weakness.

So it is possible for patients to have recurrent Bells Palsy, but it does make us want to really carefully examine that patient on a physical exam and get a great history so that we can make sure we're not missing these other factors.

Interviewer: So say a patient who has been diagnosed with Bell's Palsy has experienced that facial droop, that facial paralysis it is now seven months. Eight months. We are past that six month ideal window of recovery. What kind of treatment options are available to them?

Dr. Akkina: And that's a great question because even as early as three months, if a patient is not fully recovered from what's been diagnosed as Bell's Palsy, they need to see a facial nerve specialist. Because there are, again, other reasons that might be causing that. Bell's Palsy as an overall phenomenon, part of the definition is that you recover. So if you don't recover, we need to evaluate other reasons why that might be.

So things that you should definitely be referred to a facial nerve specialist for if you have Bells Palsy are: one, if you have incomplete recovery three months after. Two, if you have any new or worsening neurologic findings at any point.

And three, if you have ocular symptoms.

Interviewer: So if someone is out there listening or reading along with the transcript for this piece, there's a good chance that either they or a loved one are suffering from some of the side effects of Bell's Palsy. Maybe they're dealing with facial drooping. Maybe they're dealing with facial paralysis.What is something that you can tell them to give them a bit of hope? To give them a bit of understanding about their condition.

Dr. Akkina: I would focus on the prognosis and that's the most important part about Bell's Palsy. Most patients will recover, so hopefully there's always some comfort in knowing that for any patient who comes in with Bell's Palsy, the majority will get better.

It just takes some time and that timeframe is on the order of weeks to months. In the meantime, it's so important to take care of their eye and make sure they're getting enough, both moisture to the eye and protection of the eye, especially when they're sleeping. Wearing things like an eye patch or taping the eye is incredibly important for that.

Other things to know are that should you be in that small category of patients that have ongoing issues, we have a specialized facial nerve center that is built to take care of you and your loved one. We would love to see you at any stage at your disease to talk about prognosis, ensure that you've gotten the right diagnosis and that there's nothing else we need to look into. And be with you as you recover from this process.

We also, again, would love to eventually identify ways that we can help patients recover faster. So being plugged into our facial nerve center is our first step in us being able to track outcomes for people and make things better overall.

Interviewer: As patients and loved ones of patients who have suffered from Bell's palsy know, the loss of one's ability to move one's face can be really serious and impact their lives. And if it's lasted for longer than six months or so, a surgical option may be available to give back a loved one's smile and ability to move their face.

We're joined by Dr. Sarah Akkina. She is the Assistant Professor of Facial Plastic and Reconstructive Surgery at the Department of Otolaryngology and Director of the Facial Nerve Center at University of Utah Health.

Now, Dr. Akkina, briefly, what is Bell's palsy and why is facial paralysis so potentially life impacting?
What is Bell's Palsy?

Dr. Akkina: Bell's palsy is a rapid, or less than 72 hours, one-sided facial nerve weakness of unknown cause, meaning we don't have an alternative reason for a patient to have it.

It's really important to know that recovery from Bell's palsy should start two to three weeks after. So that as an entire category really classifies Bell's palsy.

There are other conditions that can cause facial weakness, and that includes stroke, brain tumors, salivary gland tumors, cancers, and infectious diseases, including things like Lyme disease or a tick-borne disease.

Overall, we suspect that Bell's palsy is related to swelling around the facial nerve, probably related to an unnamed or unknown virus. The nerve that travels from the brain to the face to control face movements is in a very small bony canal at the base of the skull. So swelling in that area can lead to compression and that can cause the dysfunction that we see.

The facial nerve controls muscles in the face, but it also controls tear glands, saliva glands, a muscle in the ear, and taste to the front of the tongue, as well as sensation to the eardrum and parts of the ear canal. So outside of the obvious facial weakness, patients with Bell's palsy can also have dryness in their eyes and mouth, a change in taste, sensitivity to loud sounds, and a change in the sensation of the ear.

So while patients recover, they can have debilitating functional losses in the short term, and that includes the inability to close their eye, trouble keeping food and liquid in their mouth, nasal obstruction, and overall difficulty expressing emotions. So they can't smile on that side of the face, which obviously impacts everyone's day-to-day lives.
Treatment Options for Bell's Palsy

Interviewer: Wow. And so for patients who are maybe suffering from these different symptoms, whether it be facial paralysis, or inability to tear, or asymmetry, etc., what options are available for patients who are still experiencing those types of symptoms longer than is typically expected for healing, say, six months or so?

Dr. Akkina: For overall treatment of patients who have Bell's palsy with incomplete recovery, meaning they still have some muscle weakness, some asymmetry of their facial movements, or some major functional issues like being able to keep food or liquid in the mouth or nasal obstruction, we have a series of treatments that we can provide for those patients.

We provide treatments that are focused on both moving, or dynamic, and non-moving, or static, facial reanimation. Static procedures are focused on improving the overall symmetry of the face at rest, and that includes procedures focused on the brow, the eyes, the nose, the mouth, and the cheek.

Dynamic procedures can bring back facial movement itself, and that includes surgeries that connect working nerves to non-working nerves, as well as surgeries that transplant nerves or muscles from nearby or separate areas of the body.

For patients that have developed abnormal facial movement after facial paralysis called synkinesis, we offer procedures to reduce that abnormal movement, including chemodenervation, or using botulinum toxin injections, or Botox/Dysport/Xeomin, as well as selective neurectomy. And this is cutting nerves that lead to the abnormal movements. We can also cut selective muscles that are moving abnormally.

So there's a variety of ways that we can really delve into exactly what is abnormal for a patient and help them in these matters.

Interviewer: Wow. So you just described quite a few procedures. These are all under the umbrella of facial reanimation?

Dr. Akkina: Correct. Yeah.
What is Facial Reanimation for Bell's Palsy?

Interviewer: Wow. So what kinds of patients are, say, eligible for these types of procedures? Is there anyone that for one reason or another would not be eligible for something like this.

Dr. Akkina: So by group, I'll say, for things like nerve transfers, it's important to know . . . For Bell's palsy, we don't assume that there are other nerves that are affected. But for patients who may have the facial paralysis because of other skull-based tumors or other pathologies that may then affect other nerves, we have to make sure that the nerve we connect to the non-working nerve is going to work, if that makes sense.

Interviewer: Sure. Okay.

Dr. Akkina: For muscle therapies, a lot of patients will qualify for different work such as cutting muscles that are abnormally moving. But for moving muscles, so sometimes if a patient has permanent, abnormal movement of their smile, we can transplant a muscle from their leg into their face to basically recreate their smile muscle movement.

That, of course, does require that that patient's a good candidate to be able to undergo a long surgery where we transplant that muscle. They have good arteries and veins in their face that we can connect it to and are otherwise healthy from other standpoints too.

So, as you can tell, it is pretty individual-based, and that's why it's so important to be able to see a specialist who can talk you through all these different options.

Interviewer: And the specialist that they're looking for is a facial nerve specialist in surgery?

Dr. Akkina: Correct.

Interviewer: I guess this might be a strange question, but considering how tailored and kind of unique it is per patient, what kind of success rates do you see with your patients?

Dr. Akkina: We can get great success rates, especially with nerve transfers. One critical part is that timing is super important. So we talked about for things like Bell's palsy, if you have abnormal movement after three months, you should get immediately referred to a facial nerve specialist. Because overall, for some of these nerve transfers to work, we only have 12 to 18 months before that facial nerve itself may not work very well even if we connect it to a better nerve that can give it more input.

So overall, for the nerve therapies, we really need to see patients, again, ideally within 12 months so we can start planning for whether they may be a candidate for the nerve surgeries.

That muscle transfer surgery can be done essentially at any time. That one we like to wait a little bit longer to know that they won't recover from the other standpoints and that they may not recover from things like the nerve transfers. But that is a really great option for patients who don't qualify for the nerve transfers themselves.

Interviewer: And for the static procedures, it's mostly for cosmetic, mostly for that kind of situation, or . . .?

Dr. Akkina: Both cosmetic and function. So the static procedures, they can really help with, for instance, for the eye work, again, closing the eye. So being able to maybe not necessarily use as many eye drops or have to tape the eye at night, things like that, our eye procedures can give that function back.

Another really great thing is . . . Outside of the symmetry, the nose can be droopy, so a lot of patients have nasal obstruction. And some of our static procedures, one called a static sling where I take fascia from the leg and reattach it to parts of the face, bring back basically support of the nasal valve and support of the mouth, so it's not drooping so much.

So it helps both the appearance of the face and the function in terms of that droopiness, which is why a lot of patients have difficulties with chewing food or keeping food and liquids in their mouth. So the static procedures can help both of those aspects.

Interviewer: We're just not necessarily replacing muscles or reconnecting nerves.

Dr. Akkina: Exactly.

Interviewer: We're doing structural things. Okay. Interesting. So what are some of the potential complications that come with these types of surgeries?

Dr. Akkina: Yeah, one of the main complications is sometimes for the nerve transfers, the nerves unfortunately don't connect as we like or don't eventually function as we like. But we do like to work with our physical therapists very intimately for those procedures as well, to teach patients how to use those new nerve connections.

One example is that we can connect a nerve that controls one of the muscles of mastication, or one of the muscles that's responsible for us closing the jaw, back to the facial nerve. But that does mean that a patient essentially has to clench their jaw to activate their smile. So there are different physical therapy things to learn about that, to teach a patient how to use their new nerves correctly.

Some of the complications that always exist for surgeries are things like bleeding, infection of the site, sometimes failure of the static sling procedures where we don't get as much of a lift of the face as we want, as well as ultimately relaxing of the face again.

Gravity wins always at the end, so even if we do these procedures when a patient is, say, in their 30s or 40s, over time the face will continue to droop and may need additional procedures in the future.
The Cost of Facial Reanimation for Bell's Palsy

Interviewer: Well, this is kind of really exciting to hear about all the potential ways that we can work on this, but what does this kind of procedure cost and is this something that is covered by insurance?

Dr. Akkina: Great question. So this procedure is typically covered by insurance. That's the number one thing, especially for things related to overall facial paralysis. Typically, insurance will cover any procedure related to that facial nerve motor dysfunction.

There are insurances that won't cover some smaller procedures. Sometimes things like the brow lift on that side of the face, because it is very focused on the symmetry and appearance of the face, has difficulty getting covered by insurance. But for the most part, a lot of these advanced procedures we've discussed will be covered.
How to Choose a Facial Nerve Specialist

Interviewer: So we've got a patient, and they're dealing with this kind of long-term facial paralysis. What should they be looking for in a doctor? If they want to explore some of these potential facial reanimation options, what kind of doctor are they looking for, and are there any particular trainings or certifications or something that they should be searching for?

Dr. Akkina: Absolutely. The first thing I'll note is that taking care of facial nerve disorders is a team sport. So we have, in our facial nerve center, multiple specialists from different aspects that all come together to collaborate and care for our facial nerve patients.

So our team includes experts in facial plastic surgery, neurotology, otolaryngology, head and neck surgery, oncology, ophthalmology, facial nerve rehabilitation. So you can get a sense that there are so many different aspects that we can come together to treat for patients.

And each specialist focuses on their area, but certainly in a facial nerve center setting, we can all basically collaborate on our individual aspects.

Initially, I think it is important to see a specialist who's at least aware of many of the procedures and treatments that we can offer. So, typically, facial plastic surgeons or even some neurosurgeons are focusing their practice on these areas.

This is an exciting field where we do have development of new techniques and new practices that are coming out each year. So being at an academic center can also really help because specialists in these centers are usually up to date on the latest knowledge, if not performing some of these trials and experiments ourselves. So going to folks who are most up to date on what's going on, I think, is also important.

For facial plastics, there are board-certified surgeons who have additional training and are, again, certified on a particular level with that training. So I would recommend always seeking a board-certified surgeon, especially moving forward with the surgical treatments.

Interviewer: So I guess look for a board-certified surgeon maybe at an academic center, or just look for that doctor that will be able to help you get the type of treatment that you need.

Now, as a patient who might be first starting out onto this, first looking into potential options, or a loved one of a patient, what is the message that you have for them in kind of starting this journey towards facial reanimation?

Dr. Akkina: Yeah, my main message is that, one, you're not alone, and two, there are ways that we can help. Even if that's mainly connecting a patient with a therapist to work on facial retraining or discussing some of these more advanced, both surgical and injection options, there is likely a way that we can help. And we want to work with you and evaluate all these aspects that you're going through.

Places like a facial nerve center will have multiple specialists who are all geared towards helping this very special patient population. So we want to help you. Please come find us.