Bell’s Palsy (Facial Paralysis)

What is Bell's Palsy?

Bell's palsy is the most common cause of sudden paralysis of the facial nerve, which controls the muscles of facial expression on one side of the face.^[1] It is diagnosed after other causes of facial weakness, such as stroke, infection or tumor, have been excluded.^[2]

Common symptoms

Weakness on one side of the face usually appears over a day or two. Many people notice a dull ache behind the ear first, followed by a drooping face, difficulty closing the eye, drooling, and sometimes numbness or a change in taste.^[1]

• Dry or watery eye on the affected side
• Trouble smiling, chewing or drinking without spilling
• Sensitivity to sound in the affected ear^[1]

Causes and risk factors

The exact cause is unclear. Viral infection, inflammation, reduced blood supply to the nerve and an immune reaction have all been proposed.^{[2, 3]} The nerve swells inside a narrow bony canal, which is thought to compress it.^[2]

How it is diagnosed and treated conventionally

Diagnosis rests on history and examination, and it is a diagnosis of exclusion because 25 to 40 percent of facial palsies are not idiopathic.^[4] Most people recover on their own, and recovery is more likely with timely medical care.^[1]

Treatment is a corticosteroid started early, which improves the chance of full recovery. Antivirals are optional in severe cases and required if shingles virus is involved.^[4] Protecting the eye with artificial tears, lid taping or a night eye shield is the most important early step when the eye does not close.^{[1, 4]} Some people recover incompletely and develop synkinesis, in which parts of the face move together involuntarily. Physiotherapy, botulinum toxin and surgery can help.^{[1, 3]}

Why Bell's Palsy calls for a whole-person approach

Bell's palsy is a nerve problem, but recovery involves more than the nerve itself. Inflammation, infection, the blood supply to the nerve and the way the facial muscles are used may all affect how the face feels and moves during recovery.^{[2, 3]}

Medical care comes first and should start within days. Complementary care is then aimed at supporting function, comfort and well-being while the nerve recovers.

Inflammation and swelling of the nerve

Inflammation of the facial nerve is a leading explanation for the palsy, which is why corticosteroids are the standard treatment.^{[2, 4]}

Infection and the immune system

Viral infection is among the proposed triggers, and shingles virus must be excluded because it needs antiviral treatment.^{[3, 4]}

Facial muscles and movement retraining

After a palsy, facial exercise therapy tailored to the person has low-quality evidence of benefit, mostly in moderate and chronic cases.^[5] A later review of newer trials agreed that exercise therapy helps early in recovery and in chronic cases, and called for standardized studies.^[6]

Recovery of the brain's control of the face

Facial paralysis changes how the brain controls the face. In one small imaging study of patients with facial paralysis after cancer surgery, acupuncture was associated with changes in brain connectivity, but this does not show that it improves recovery.^[7]

Acupuncture for Bell's Palsy

What the research shows

Acupuncture is widely used for Bell's palsy, but the evidence that it helps is limited because many trials were small and poorly designed. A Cochrane review of 6 trials with 537 participants judged the trial quality too poor to draw any conclusion about acupuncture.^[8]

Later meta-analyses found higher response rates with acupuncture, with caveats. One pooled 14 trials (1,541 people) and found a higher response rate with acupuncture than with comparison treatments, but reported a high risk of bias and very uneven results across trials.^[9] Another pooled 11 trials (1,258 people) and found better recovery and response rates than drug treatment, again warning of poor quality and inconsistency.^[10] A review of 8 trials concluded that evidence was limited and too weak for firm conclusions.^[11] A 2021 meta-analysis of 17 trials compared acupuncture and moxibustion in the acute and non-acute phases and found a shorter time to full recovery and fewer sequelae when treatment began in the acute phase, although the full-recovery rate was lower than in the non-acute phase. Its authors called for larger, higher-quality trials.^[12]

For people left with lasting weakness, a trial of 39 people compared 8 weeks of acupuncture with a waiting list. The acupuncture group improved more on facial disability and facial nerve grading scores, with no severe adverse events. Because the control group received nothing, expectation may account for part of the difference.^[13] In 60 people whose palsy had not improved after 12 months, electroacupuncture improved facial symmetry more than electrical stimulation through the skin over 6 weeks, and the difference lasted through 24 weeks of follow-up. A second scoring system showed no significant difference at 6 weeks.^[14]

How acupuncture may work

How acupuncture might help facial paralysis is not established. One proposal is that it affects how the brain controls facial movement.^[7] In the one imaging study above, the group receiving acupuncture showed brain changes that a comparison group receiving a "pseudo intervention" did not, but the study was small and in a different type of facial paralysis.^[7] This remains a hypothesis.

What treatment involves

Treatment uses fine, sterile, single-use needles placed on the face, scalp, hands and legs, usually left in place for about 20 to 40 minutes. A course is several visits with reassessment. The trial in people with lasting weakness used treatments over 8 weeks, and the chronic electroacupuncture trial gave 18 sessions over 6 weeks.^{[13, 14]}

Acupuncture is generally safe in trained hands. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, pain or redness at the needle site, and serious events occurred in about 1 in 10,000 patients.^[15] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture). Acupuncture should not delay seeing a physician or starting prescribed treatment.

Ayurvedic medicine for Bell's Palsy

The Ayurvedic view

Ayurveda describes a condition called Ardita, one of the Vata disorders, as the closest match to Bell's palsy.^[16] In this traditional framework Vata is the principle said to govern movement and nerve function. This is a traditional category, not a biomedical diagnosis.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine intended to calm Vata, such as warm, regular meals and steady sleep hours
• Gentle warm oil massage of the head, neck and face, and nasal oil application (nasya)
• Herbal preparations chosen by a qualified practitioner
• Panchakarma procedures, only where traditionally appropriate and medically sensible

Panchakarma is not appropriate during pregnancy, acute illness or frailty. Because Bell's palsy usually begins as an acute illness, such procedures would only be considered after medical assessment and when you are stable.

What the research shows

The research on Ayurveda for Bell's palsy is very limited. A PubMed search found no clinical trials and no systematic reviews, only a single case report. It described one man treated in hospital in India for 14 days with a package that included therapeutic vomiting, oral medicines, nasal oil and physiotherapy, who recovered fully.^[16] One case cannot show that the treatment caused the recovery, because most people with Bell's palsy improve on their own.^[1]

Herbal medicine for Bell's Palsy

Herbs and formulas that have been studied

No trial of a specific herb or formula for Bell's palsy was found. Chinese herbal medicine is traditionally combined with acupuncture in some East Asian clinics. A Korean hospital program describes using acupuncture and herbal medicine, with moxibustion and cupping, alongside corticosteroids.^[17]

What the research shows

The evidence for herbal medicine for Bell's palsy is very limited. In a Taiwanese database study of 238 patients, those who used Chinese herbal medicine and acupuncture had a lower risk of later stroke than those who did not. The authors warned that the retrospective design and database limits restrict what can be concluded.^[18] Observational data like this cannot show that the treatment lowered the risk.

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Case reports describe bleeding when warfarin was combined with herbs including dang gui (Angelica sinensis), dan shen (Salvia miltiorrhiza), ginger, ginseng and Boswellia.^[19] People taking blood thinners need a practitioner's review before using herbs.

In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, have liver or kidney disease, or take prescription medicines such as the steroids commonly used for Bell's palsy.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine often describes facial paralysis as wind and cold invading the channels of the face and blocking the flow of qi and blood. Researchers study things that loosely parallel this picture: nerve inflammation and swelling, reduced local blood supply, and how the brain controls facial muscles.^{[2, 7]}

Ayurveda's aggravated Vata describes loss of normal movement in one side of the face.^[16] No study has shown that a dosha or a pattern corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for Bell's palsy is complementary. See a physician promptly, since corticosteroid treatment is recommended early, and follow your eye-care instructions.^{[1, 4]} Do not stop or change prescribed medicines without your prescriber. We do not diagnose the cause of facial weakness.

Facial exercise therapy from a trained therapist has some supporting evidence, though mostly of low quality, and acupuncture can be used alongside it.^{[5, 6]} Please bring your diagnosis, a list of all medicines and supplements, any test results, and notes from your eye doctor or physical therapist.

When to seek urgent medical care

Facial weakness can be a sign of stroke or another serious condition, so it needs prompt evaluation.^[1]

• Facial weakness together with arm or leg weakness, trouble speaking, confusion or sudden severe headache
• Weakness that does not involve the forehead, or that began suddenly with other neurological symptoms
• A painful rash in or around the ear, or hearing loss or vertigo with facial weakness (possible shingles virus infection)^[4]
• An eye that will not close, or eye pain, redness or blurred vision
• Facial weakness after head injury or with fever or a tick bite
• Weakness that is getting worse after several weeks or has not begun to improve after a few months (contact your physician promptly)

For any of the other signs above, call 911 or go to the nearest emergency department.