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Facial paralysis and dysphaiga

In this section we shall look at the differences between central- and peripheral facial paralysis, and then focus on the latter. Finally, we will talk about how IQoro can help to retrain facial musculature.

Stroke swallowing difficulties and facial paralysisand

Every person that is affected by swallowing difficulties (dysphagia) after a stroke, also has a central facial dysfunction or paralysis central facialis pares: usually caused by an injury in one of the two brain hemispheres. The injury is indicated by paralysis in the lower half of the face on the opposite side to the injured hemisphere, and can be, for example, one side of the mouth drooping. [1–7]

Sudden paralysis or muscle weakness in one half of the face, peripheral facial paralysis – also known as Bell’s palsy has no identified cause and is the most common cause of facial paralysis. Bell’s palsy is the commonest cause of facial palsy, accounting for approximately 60 percent of all cases. It affects between 20 per 100,000 to 40 per 100,000 people per year (which in the UK means between 12,400 and 24,800 people per year). It is difficult to know the exact incidence of Bell’s palsy as not all people with the condition are diagnosed or recorded.

Facial paralysis is caused by injury to the facialis nerves or their cores in the brainstem. Usually 70 percent of the these people become healthy again without treatment within 3 to 4 months, but the remaining proportion may need treatment. [8]

Differences between central- and peripheral facial paralysis

Even if there are big differences between a central and a peripheral facial paralysis there are also some things in common.

In both cases it is the expressive musculature in the face which is affected and makes it difficult to convey emotions like happiness, sorrow, anger or bewilderment etc. The muscle activity is reduced, or non-existent in one half of the face. Sometimes both halves are affected.

Central facial paralysis

A central facial paralysis is caused by an injury; often in one brain hemisphere, but sometimes in both. The injury shows itself as a paralysis in the lower half of the face on the opposite side to the affected brain hemisphere, e.g. through a slack mouth on one side. [1–7] The reason can be, for example, a stroke, trauma to the head, or a brain tumour.

As long as the paralysis is only on one side, it is easy to distinguish between a central facial paralysis and a peripheral one. With a central injury the person can wrinkle his forehead or raise his eyebrows on both sides. With a peripheral injury the person has difficulty in performing these exercises on one side of the face.

A person with a central injury can wrinkle his forehead because the nerves leading to this area are doubled, and the undamaged hemisphere compensates. The latest research shows however that 74 percent of stroke survivors with swallowing difficulties dysphagia also have paralysis in the musculature of the forehead. It also shows that 52 percent have a facial dysfunction in all four quadrants. [1–3, 9] This should be observed carefully when performing a diagnosis.

Peripheral facial paralysis, peripheral facialispares

Sudden paralysis or muscle weakness in one half of the face, peripheral facial paralysis also known as Bell’s palsy has no identified cause. Facial paralysis is caused by an injury to the facial nerve facialis or its core in the brainstem. The nerve damage can have been caused by, for example,

  • A virus infection
  • Sitting in a draught
  • Lyme disease
  • Tick bite
  • Trauma
  • Tumour
  • Congenital deformities or syndromes (e.g. Möbius syndrome)

If a person with peripheral facial paralysis is asked to raise his eyebrows, close his eyes, and smile at the same time it can be seen in the paralysed half that the facial expressiveness is depressed and that the person can have difficulty in:

  • Closing one eye – the lower eyelid hangs down and reveals the white of the eye
  • The eyebrow on the affected side does not lift
  • The corner of the mouth on the affected side does not raise

Peripheral facial paralysis

The injured facial nerve, facialis, affects [8, 13, 14]:

  • The expressive musculature of the face
  • Tear glands
  • Sense of taste
  • Hearing

Usual symptoms are:

  • Weakness in the facial expressive musculature.
  • Dribbling or drooling.
  • Reduced tear flow.
  • Sensitivity for noise.
  • Reduced taste on the tongue’s front 2/3rds.
  • Speech difficulties.
  • Pain around and behind the ear.
  • Loss of motor function.
  • Involuntary muscle movements.

If the facial paralysis is on both sides, Borrelia is always suspected.

People of all ages can be affected

Peripheral facial paralysis, where the cause is unknown, can affect people of all ages, but is more common between the ages of 15 to 45. Pregnant women and people with diabetes can be seen to have an increased risk. Usually 70 percent become well again without treatment within 3 to 4 months, but the remainder can need treatment.

Treatment

An early intervention with cortisone treatment has been shown to have a positive effect against Bell’s Palsy.

If the peripheral facial paralysis has been caused by Borrelia the patient will be given antibiotics, if the sickness can be traced to a virus infection he can expect virus repressive medicine.

If one eye is affected with a drooping lower eyelid this will be treated with different types of protection for the eye depending on the degree of seriousness. In the first case, protection can be in the form of eyedrops or eye salve, or in more difficult cases taping of the eye, closely-fitting spectacles (ski goggles) or a transparent plastic screen.

Long-term reduced power in the facial muscles

Within six months, 70 percent of people regain their normal facial functions. The remainder, 30 percent, develop chronic problems in the form of reduced strength in the face muscles, involuntary movements following deliberate ones, synkinesis, other involuntary muscle movements and ticks (spasms) or tears in the eye on the affected side. They also have difficulties with speech and in being able to eat. [11]

In order to regain as much as possible of the face’s mobility and function they often combine physiotherapy, surgery and Botox treatment. People that still have total paralysis at their one month follow-up visit are often referred to a physiotherapist, or a speech therapist specialising in this area. After assessment, muscle training or other expressive exercises can begin with a physiotherapist.

Persons with severe palsy 3 to 4 months later, and with problems around the eyes or mouth, may find that plastic surgery is necessary. If the person has a pronounced problem with synkinesis synchronisation of the musculature –  where treatments with the physiotherapist have had insufficient effect – treatment with Botox may be considered.

IQoro strengthens the facial musculature

It is not scientifically proven that training with IQoro has an effect on peripheral facial paralysis. But, that IQoro can function effectively as an alternative treatment, or as a complement to other treatments, is credible from all clinical experience and over 20 years’ research, which shows that, amongst other things, paralysed musculature in the face and pharynx regains its function.

The same research also shows that IQoro actively stimulates the sensory nerves in the mouth and by doing this reaches the brain’s control system for the swallowing process, which is closely linked to other bodily functions including breathing, the ability to form speech sounds, facial expressions, postural control, and more. 

Why IQoro has an effect

This explains why exercising with IQoro is able to have an effect even on peripheral facial paralysis, because this type of paralysis is caused by an injury, of varying degree, to the facial nerves. 

If neuromuscular training with IQoro is to be used as a treatment for peripheral facial paralysis, it should initially be performed more gently, and for shorter duration than is recommended for all other conditions. A guideline is to start with 3 seconds’ pull, repeated twice, and these two repetitions are performed two times per day.

If this feels comfortable, continue like this for the rest of the first week; during the second week the regime can be increased by one second to 4 seconds for each of the two pulls. If this causes discomfort, roll back the regime to the former level, or stop the treatment. Training is best done in front of a mirror to check for balance and symmetry in the pulling action. Contact IQoro customer service with any doubts or questions that you may have.

There is a requirement for further research in this area, not least because peripheral facial paralysis reduces the quality of life of those affected.

Text by: Mary Hägg

Associate Professor of Experimental Research in Ear, Nose and Throat diseases at Uppsala University, and Hospital Dental Surgeon specializing in orofacial medicine.

Mary has worked for 12 years as a hospital dentist and for 31 years as Head of the Speech & Swallowing Centre, Department of Otorhinolaryngology, Hudiksvall Hospital, Sweden.

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Reference sources

  1. Hägg M.,Tibbling L. Four-quadrant Facial Function in Dysphagic Patients after Stroke and in Healthy Controls. Neurology Research International Volume 2014, Article ID 672685, 5 pages, https://www.hindawi.com/journals/nri/2014/672685/
  2. Hägg M., Tibbling L. Effect of oral IQoro® and palatal plate training in post-stroke, four-quadrant facial dysfunction and dysphagia: A comparison study. Acta Otolaryngol. 2015 Sep;135(9):962-8. doi:10.3109/00016489.2015.1042043. Epub 2015 May 7. PMID: 25947252 
  3. Hägg MK., Tibbling LI. Effects on facial dysfunction and swallowing capacity of intraoral stimulation early and late after stroke. NeuroRehabilitation. 2015;36 (1):101-6. doi: 10.3233/NRE-141197. PMID: 25547771 
  4. Stroke – Riksförbundet, https://strokeforbundet.se/in-english/
  5. Fokusrapport dysfagi, Stockholms läns landsting, 2005, ISBN 91-85211-00-1(English translation: ”Focus report: dysphagia”). 
  6. S. Broadley, A. Cheek, S. Salonikis et al., “Predicting prolonged dysphagia in acute stroke: the Royal Adelaide Prognostic Index for Dysphagic Stroke (RAPIDS),” Dysphagia, vol. 20, no. 4, pp. 303–310, 2005. 
  7. R. T. Sorensen, R. S. Rasmussen, K. Overgaard, A. Lerche, A. M. Johansen, and T. Lindhardt, “Dysphagia screening and intensified oral hygiene reduce pneumonia after stroke,” Journal of Neuroscience Nursing, vol. 45, pp. 139–146, 2013. 
  8. Läkartidningen (2015), Bells pares ger resttillstånd hos 30 procent av vuxna patienter, Hämtad: 2016-10-07, https://lakartidningen.se/klinik-och-vetenskap-1/artiklar-1/klinisk-oversikt/2015/01/bells-pares-ger-resttillstand-hos-30-procent-av-vuxna-patienter/ (English translation: ”Bell’s palsy leaves enduring problems in 30% of adult patients”). 
  9. Cumhur E., Gaye E., et al. Orbicularis oculi muscle activation during swallowing in humans. Exp Brain Res (2013) 224:79–91, DOI 10.1007/s00221-012-3290-6 
  10. Katusic SK, Beard CM, Wiederholt WC, et al. Incidence, clinical features, and prognosis in Bell’s palsy, Rochester, Minnesota, 1968–1982. Ann Neurol. 1986;20:622-7. 
  11. Peitersen E. Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl. 2002;(549):4-30. 
  12. Yanagihara N. Incidence of Bell’s palsy. Ann Otol Rhinol Laryngol Suppl. 1988;137:3-4. 
  13. Internetmedicin.se, (2016), Med dr, ST-läkare plastikkirurgi A. Falk-Delgado, Verksamhetsområde plastik- och käkkirurgi/Akademiska sjukhuset, Med dr, överläkare A. Rodriguez Lorenzo, Områdesansvarig för Mikrokirurgi/Verksamhetsområde plastik- och käkkirurgi/Akademiska sjukhuset, https://www.internetmedicin.se/behandlingsoversikter/onh/facialispares-kirurgisk-rekonstruktion/
    (English translation: ”Internet medicine”).
  14. Internetmedicin,se, (2016) Docent, överläkare M. Engström, Öron-,näs-, halsmottagningen, Läkarhuset/Akademiska Sjukhuset, Uppsala; Docent, överläkare L. Jonsson, Verksamhetsområde öron-, näs- och hals/Akademiska Sjukhuset, Uppsala.
    https://www.internetmedicin.se/behandlingsoversikter/onh/facialispares-akut-idiopatisk-perifer-bells-pares-hos-vuxna/
    (English translation: ”Focus report: dysphagia”).
  15. Hägg M., Tibbling L. Effect of IQoro® training on impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke. Acta Otolaryngol 2016; 136 (7):742-748. DOI:10.3109/00016489.2016.1145797 https://www.tandfonline.com/doi/full/10.3109/00016489.2016.1145797
  16. Ekberg O, (2011), Röntgendiagnostiska avdelningen, Universitetssjukhuset MAS, Malmö, Normal sväljning inklusive anatomi och fysiologi, (pdf). Hämtad 2015-12-05, kl 15.00,
    http://media1.dysfagi.se/2011/06/svaljningssvarigheter.pdf 
    (English translation: ”Normal swallowing including anatomy and physiology”)

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