Balance Issues and Facial Palsy

Why may facial palsy affect balance?

The human body generally has two facial nerves, one on each side of the face. The facial nerve carries electrical impulses to specific facial muscles, those that make us laugh, cry, smile or frown. It also carries nerve impulses to the tear and saliva glands, as well as the muscle of the small inner ear bone (the stapes). In addition, it transmits sensory fibres from the front of the tongue and the ear canal.

The facial nerve travels from the brain through the temporal bone (ear bone) and, for almost 4 cms, through a small bony tunnel (the internal ear canal). It is positioned very close to the nerve responsible for hearing and balance (the VIII^th cranial nerve), which transmits sound and balance information from the inner ear to the brain. The nerves all float in cerebrospinal fluid.

If a patient develops a condition which irritates the facial nerve, the nerve becomes dysfunctional and swells. In some adults the tiny bony canal the nerve travels through is narrower than others. The smaller the diameter of the canal which the different nerves have to pass through, the less room there is to accommodate swelling and consequently results in compression of the nerve. This can then compromise the function of the facial nerve and/or adjacent nerves.

For patients with Bell’s palsy, steroid tablets taken within 72 hours following the onset of symptoms, are proven to help reduce swelling of the facial nerve and improve recovery outcomes. Women in the third trimester of pregnancy are a vulnerable group more susceptible to Bell’s palsy because they naturally tend to retain more fluid.

Ramsay Hunt syndrome looks similar to Bell’s palsy but is normally much more painful, it is caused by the shingles virus (Herpes Zoster). Vesicles (shingles blisters) can sometimes be seen in the ear, mouth or hairline, but they are not always visible. This is why it is important for health professionals to understand associated symptoms, such as increased levels of pain, which could point to Ramsay Hunt syndrome rather than Bell’s palsy. Unfortunately, due to lack of awareness, our 2018 survey of patients with Ramsay Hunt syndrome found more than half (57%) were initially misdiagnosed¹. This means many people with Ramsay Hunt syndrome miss out on the recommended high dose antiviral medication, and only receive steroids. There is poorer evidence for the use of antivirals for Bell’s palsy, so they are not routinely given for this diagnosis.

Without prompt and appropriate treatment for Ramsay Hunt syndrome including steroids to reduce swelling and antivirals to reduce infection, patients may develop long-term debilitating vestibular problems (balance disorder).

Other causes of facial palsy can also cause balance problems depending on whether the additional nerves have been compressed by swelling, impacted by growths, or damaged during surgery.

How might balance issues make you feel?

These are examples given by people who have directly suffered:

• When the symptoms are most severe, you might feel like you need to stay in bed.
• Getting up in the morning can be very difficult as the room can spin and cause sickness feelings.
• Depth perception can be a problem. This is worse when walking on light reflective surfaces, like marble or a light floor, especially if it is wet. Stairs are also difficult.
• Getting out of a chair can be difficult, you have to concentrate to steady yourself.

• There is an underlying feeling of being off-balance.
• It can be very tiring, even when lying down, trying to cope with dizziness.
• Things you could do before, like use a garden swing, suddenly become more difficult, because the swinging feeling doesn’t go away when you get off.
• Wearing a headset, such as for work, can cause the problem to recur.
• Activities requiring head movements such as looking to cross the road, turning to respond to sound, bending to tie shoes can provoke unsteady sensations.

Who can help?

There are many causes of balance issues which can be difficult to diagnose and it is very important to be properly assessed by a health professional. Balance issues that start as a result of facial palsy are normally caused by problems in the inner ear.

The Meniere’s Society (https://www.menieres.org.uk/ ) have a lot of useful resources about dizziness and balance disorders including a list of specialists in balance conditions.

This Balance Disorder Spectrum shows a range of causes, but this should not be used for self-diagnosis.

http://www.balancedisorderspectrum.info/circular.html

Balance tests

There are a variety of balance tests called a Vestibular Assessment that vestibular specialists can carry out to help diagnose and manage any dizziness or balance problems you are experiencing. You can ask your GP or hospital consultant for more information.

How to seek a referral to a vestibular specialist?

If you have problems with your balance you should ask your GP to refer you to your local vestibular specialist for assessment.  Do not attempt any balance exercises without seeking specialist advice.  There are a range of possible clinicians/departments your GP can refer you to depending on your local services, for example:

• Specialist physiotherapists
• Audiologists
• Ears, Nose and Throat (ENT) services

What can you do whilst waiting for an appointment?

• Relaxation: anxiety can increase symptoms of dizziness and balance problems. Following a relaxation programme as part of your daily routine may be helpful.
• Maintaining a healthy lifestyle can maximise your potential to recover including getting adequate amounts of sleep, having a balanced diet, and drinking plenty of fluids. Minimising caffeine intake may help reduce feelings of anxiety. Alcohol may make balance problems worse so is best avoided or kept to a minimum.
• Try not to avoid situations that provoke or trigger dizzy spells. Keep a diary to track what the triggers are and the severity of your responses. Perhaps put them in order of severity, for example, turning your head and bending down may trigger the worst symptoms and getting out of a chair may trigger the least symptoms. This will be helpful information to give the clinician when you go for an assessment. Once you are aware of these triggers  approach those activities with greater care rather than avoiding them altogether.

[1] https://facialpalsy.org.uk/news/ramsay-hunt-syndrome/