If you have facial palsy, which department should you see first? I believe most people will say: neurology! Yes, facial palsy is a problem with the facial nerve, so it is natural to see a neurologist. But today, we might as well change our thinking. First of all, according to international practice, the study and treatment of facial nerve belongs to the domain of otology, because after the facial nerve emanates from the brainstem, it has to zigzag in a narrow bony canal in the ear (facial nerve canal) for a long distance before entering the facial muscles; secondly, otolaryngologists know the structure and function of the facial nerve like the back of their hand, and when medication “can’t save” the facial nerve, they can also see a neurologist. “Secondly, ENT doctors know the structure and function of the facial nerve well, so when medication cannot save the facial nerve, they can also “pull out the knife to help”. So it seems that ENT doctors have an advantage over internal medicine doctors when dealing with facial palsy! Every day, we encounter all kinds of happy or unhappy things, our knitted brows, a smile, a happy and an angry, none of them are expressed through facial expressions. All this is the work of the facial muscle, and the movement of the facial muscle cannot be separated from a normal structure and function of the facial nerve. Facial palsy occurs when the facial nerve is affected by various pathological factors. The facial nerve emanates from the brainstem and travels in a narrow bony canal in the ear (facial nerve canal). When the facial nerve becomes congested and edematous, the canal will compress the facial nerve, causing occlusion of the nerve tubules within the facial nerve, degeneration of the facial nerve, and facial palsy will then occur. Normally, when the facial nerve degenerates, new nerve fibers will regrow from the facial nerve nucleus in the brain, allowing facial palsy to recover. However, if the nerve tubules in the facial nerve are severely occluded, the newly grown nerve will not pass through the occluded area, and irreversible nerve necrosis will occur, and the facial palsy will never recover. The nature of facial palsy can be divided into two categories: peripheral and central, depending on the location of facial nerve damage. Central facial palsy is usually characterized by a skewed corner of the mouth, but the muscles in the upper part of the face are not paralyzed, and eye closure, eyebrow raising and frowning are normal. Central facial palsy is often a manifestation of stroke and patients should consult a neurologist promptly. Peripheral facial palsy can cause paralysis of all facial muscles on the same side of the lesion, resulting in symptoms such as inability to close the eyelids fully, upward movement of the eyeballs when closing the eyes, white out, drooping of the corners of the mouth, restricted eyebrow raising, shallowing or disappearance of the frontal lines, enlargement of the lid fissures, and skewing of the corners of the mouth to the healthy side when showing the teeth or laughing. In bilateral peripheral facial palsy, the patient’s face is expressionless, bilateral frontal lines disappear, eyes cannot be closed tightly, bilateral nasolabial folds become shallow, corners of the mouth leak, and speech is slightly ambiguous. Usually, for every patient with facial palsy who comes to the clinic, the otolaryngologist will prescribe a facial nerve electrographic examination, which is a necessary prerequisite for determining the treatment of facial palsy. The doctor can see through the monitor that the amplitude of the waveform on the side with facial palsy is lower than that on the normal side, and by comparing the amplitude of the waveform on the diseased side with that on the normal side, the degree of facial nerve degeneration can be known. Generally speaking, if the facial nerve degeneration exceeds 90%-95% within 2-3 weeks after the onset of facial palsy, it indicates that irreversible damage to the facial nerve has occurred, and it is difficult to be cured by medication or injection, so surgery should be performed immediately to open the facial nerve canal and decompress the facial nerve. 1. Facial nerve degeneration below 90% – drug therapy Generally speaking, 80% of patients with peripheral facial palsy can recover on their own to varying degrees, and drug therapy can improve the recovery effect and shorten the recovery time. As mentioned before, the basic prerequisite for drug treatment is to go to a qualified ENT department for facial nerve electrographic examination. If you are more fortunate and the facial nerve degeneration is below 90%, medication can be administered; otherwise, not only is the treatment ineffective, but it will also cause permanent facial paralysis. The early stage of drug treatment is to improve local blood circulation and eliminate inflammation and edema of facial nerve, while the later stage is to promote nerve function recovery. The main drugs available are hormones (prednisone or dexamethasone orally for 7-10 days), mannitol (intravenous drip for 7-10 days), neurotrophic metabolic drugs (such as nimodipine, mikepro, etc.), and antiviral drugs (such as interferon, virazole, etc.). In addition, it is necessary to protect the exposed cornea with eye shields, eye drops, and eye ointment to prevent conjunctivitis and keratitis; and to massage the paralyzed side frequently to prevent facial muscle atrophy. It should be reminded that strong stimulation should not be performed in the early stage of the disease to avoid causing facial muscle spasm. Generally speaking, most facial paralysis can be recovered within 2-3 months. In mild cases without nerve degeneration, recovery starts in 2-3 weeks and heals within 1-2 months. 85% of cases can recover completely without sequelae. In cases of partial nerve degeneration, it takes 3-6 months to recover. In more severe cases, recovery is slow or even incomplete, and those who have not recovered for more than 6 months have a poor prognosis, because the longer it takes to recover the facial nerve function, the greater the possibility of sequelae. 2. 90% or more facial nerve degeneration – surgery According to statistics, 15%-20% of facial palsy is irreversible facial palsy. If the electrophysiological indexes confirm that the facial nerve degeneration reaches 90%-95%, it means that the lesion is irreversible, so the patient should not wait unnecessarily and should receive facial nerve decompression surgery immediately. During the surgery, the surgeon opens the facial nerve canal, “liberates” the facial nerve from the narrow “room” and allows the nerve fibers above the injury to grow downward, so that facial paralysis can be restored as much as possible. It is important to note that 70%-80% of patients with irreversible facial palsy have extremely severe lesions from the beginning, with over 90% of the facial nerve fibers already degenerated at the beginning of the disease, so conservative treatment alone will only delay the disease. If the facial nerve is completely necrotic, it will be too late. After surgery, the facial nerve generally grows from the facial nerve above the lesion to the facial muscles at a rate of 1 mm per day in adults and 2 mm per day in children, and most patients recover from facial paralysis 3 months after surgery. The degree of facial nerve recovery is closely related to the timing of surgery. Generally speaking, the best time for surgery for facial palsy is within half a month after the onset of the disease, and the surgical effect gradually decreases as the duration of facial palsy increases. Beyond three months, the surgical effect is only about 50%.