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Early diagnosis key to treating facial paralysis by Heather Woolwine Public Relations Andrew Fowler, M.D., Cardiology fellow, remembers the very second things changed. Like any Sunday, he and wife, Sara, and their toddler, Andrew, went to church Jan. 8. When they arrived home, Sara noticed that Fowler’s right eye was not blinking along with his left. Rushing to the mirror, Fowler immediately knew something was wrong. He was later diagnosed with Bell’s palsy.   Bell’s palsy is described as unilateral facial paralysis with sudden onset and rapid development until the right or left side of the face is weak or completely paralyzed.    “During my training, I had actually diagnosed a guy with Bell’s, and as it turns out several of my family members have also experienced facial paralysis that healed with time,” Fowler said.   According to Ted Meyer, M.D., Ph.D., Otolaryngology-Head and Neck Surgery, facial paralysis can have different causes, including Bell’s palsy, cancer, benign tumors, viral infections, severe ear infections, central nervous system problems, or autoimmune responses. The facial nerve reaches out from the brain stem, winds its way through the temporal bone, and branches into five arms that stretch across the face and are responsible for raising eyebrows, puckering lips, blinking, smiling and other normal facial functions. “It’s not all Bell’s palsy, and that term gets thrown around a lot,” Meyer said. “Facial paralysis is not a life or death situation, but it can really affect a person’s quality of life. You want to do as much as you can up front to treat it, otherwise the long-term sequella can be bad when they don’t need to be.”   Fowler was immediately referred to Meyer, as all patients experiencing facial paralysis need a referral to an otolaryngologist. He underwent specific diagnostic testing to determine the possible cause of his paralysis and evaluate his facial nerve. “You want to know to what degree the facial nerve isn’t working, so you can plan your treatment,” Meyer explained. With Fowler’s first nerve conductivity test, his right facial nerve operated at 40 percent compared to the nerve on the left side. Two weeks later, at the end of January, Fowler’s nerve functioned at only 10 percent. Throughout those first two weeks, Fowler experienced sharp shooting pains at the base of his neck and across his scalp, possible symptoms associated with facial nerve paralysis. He was treated with a combination of anti-viral and steroid medications while he and Meyer discussed the next possible steps.   Most patients with facial paralysis recover, including those with Bell’s palsy. The problem lies in playing the waiting game and trying to decide if it’s worth waiting on function to return, or undergo major surgery to relieve the pressure from the swollen nerve. In a lot of paralysis cases, the facial nerve is pinched against bone through swelling caused by viral infection or by a tumor’s growth.   “The key to treating facial paralysis is getting an accurate diagnosis as soon as possible. Patients with Bell’s palsy who have a 90-percent neural degeneration have only a 50-percent chance of normal recovery when treated with medication,” Meyer said. “Surgical decompression of the labyrinthine segment of the facial nerve through a middle fossa approach (intracranial surgery) for these patients improves their chance of recovery with normal facial function to 90 percent. It can be a difficult decision to make, especially for a physician in training.”   With an intracranial surgical approach, surgeons can relieve the pressure on the nerve and restore function to the paralyzed side, but not without risk. “For me, they would have to uproot the bone that lies over the facial nerve, which is heavy duty surgery,” Fowler said. “You run the risk of causing permanent damage or injury to the facial and/or auditory nerve, which can not only result in hearing loss or permanent paralysis, but could also affect your balance, ability to walk and so on. I would also have been out of work for a month, which just wasn’t going to work in trying to complete my fellowship. It just made more sense to try and wait it out and hope that it got better.”   Part of Fowler’s daily routine now includes special care for his right eye. Because he is unable to blink, he must use special eye drops to keep it moist, and remain vigilant to protect it from corneal injury. At night, he tapes the lid shut to protect his cornea from exposure.   The hardest part of having facial paralysis according to Fowler is not the physical limitations it causes. When he meets new people, his condition makes him a little more reserved, or  more self conscience then he used to be. In the beginning, he would often eat by himself to avoid the inevitable glances toward someone only able to use one side of his mouth.   “The first time I was back in clinic after it happened, I had a patient with right facial paralysis. His was the result of having a tumor removed. We bonded pretty quickly, and I’ll admit we commiserated a good bit. I have a very strong faith and I believe that this experience has taught me to be more empathetic with my patients. I’m less wrapped up in getting the charts done and more aware of what each person is going through,” he said. “It also opened my eyes to what my father has dealt with for more than 20 years as a result of his battle with Gullain-Barre syndrome. He has residual weakness in his arms and legs as a result of the ascending paralysis related to that virus, and my own paralysis really made me appreciate what he’s had to endure and admire how upbeat he still is about everything.”   Fowler conceded that facial paralysis can get a person down with the question, “why me?,” lingering in the back of one’s mind. But, at some point you have to look around and realize how bad some other people have it and become grateful for what you’ve got. You have to accept it, and how you deal with it becomes a testament to your character,” he said.   Fowler will continue the wait-and-see approach and possibly undergo an imaging study in the coming months to ensure that Bell’s palsy is the cause of his paralysis, as well as further diagnostic testing to evaluate the facial nerve’s conductivity.  He's  optimistic. Fowler said he looks forward to the future, his career as a physician, and the birth of his second son in May, regardless of whether his paralysis heals itself.       Friday, April 7, 2006 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to catalyst@musc.edu. 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