Facial Palsy and the Ear

How facial palsy affects the ear: pain, hearing, and stapedial synkinesis

Quick links to sections in this article:

• Bell’s palsy and the ear
• Ramsay Hunt syndrome
• Vestibular schwannoma, middle ear infections, and/or middle ear surgery
• Why does muscle tightness and pain occur around the ear in the synkinetic stage of recovery?
• Stapedial Synkinesis: what is it and what can help?

Bell’s palsy and the ear

When a diagnosis of Bell’s palsy is made, this means that only the facial nerve is injured/inflamed. Symptoms associated with the ear and hearing in Bell’s palsy are described below.

The early stages of recovery (Flaccid and Paretic stages of recovery)

Click here to read our Facial Nerve Recovery Guide

The flaccid stage of recovery is characterised by weakness and immobility of the facial muscles on the affected side with loss of facial expression. The paretic stage is characterised by the return of muscle tone, so the face appears more symmetrical at rest. There is evidence of movement returning although this may initially be inconsistent and not uniform across all the facial muscles.

Symptoms:

• Pain in and around the ear. This is usually in response to inflammation of the facial nerve and generally resolves over days or weeks.
• Hyperacusis: when everyday sounds seem louder than normal. As the facial nerve travels through the skull, it gives rise to the nerve to the stapedius muscle.  This is the smallest muscle in the body and measures just 1 mm in length. Its function is to reduce the vibration of loud or high-pitched sounds as they pass through the ear known as the stapedius reflex. It dampens down sound to prevent damage to hearing. Damage to the facial nerve means this protective mechanism fails so ordinary sounds feel loud and/or distorted.

It is very normal for those with hyperacusis to try to avoid loud sounds. Although this may seem like common sense, it can lead to an increased sensitivity to sound. As people avoid sound, their environment becomes quieter. This causes the auditory system to become even more sensitive to sound due to the lack of input.

For that reason, it is not recommended to use ear protection for day-to-day activities. Whilst it is understandable that someone may wish to use earplugs or ear muffs when doing tasks which generates a sound they find unpleasant, it will not help with learning to manage hyperacusis in the long term. Read more about hyperacusis on the Tinnitus UK website.

Delayed recovery (Synkinetic stage of recovery)

Click here to read our Facial Nerve Recovery Guide

This stage is characterised by increased muscle tone on the affected side of the face which presents with tightening and shortening of the muscle fibres. The face feels tight and tender to touch and the affected muscles lose their elasticity and ability to move. Synkinesis (involuntary movements) occurs at this stage, for example, when smiling an involuntary muscle contraction occurs around the eye.

Click here to read our Synkinesis Advice Guide

Symptoms:

• Pain in and around the ear due to continual co-contraction of facial muscles (synkinesis).
• Pain in and around the ear from muscles which have shortened and thickened and have been held in this position for a long time.
• Stapedial synkinesis: this is a distortion of hearing which only occurs during facial movement. For example, a crackling sound in the ear when smiling or when blinking or closing the eye.
• Hyperacusis.
• Muffled hearing.

Ramsay Hunt syndrome and the ear

When a diagnosis of Ramsay Hunt syndrome is the cause of facial palsy, cranial nerves other than the facial nerve can be involved particularly the Vestibulochoclear nerve (the hearing nerve). People with Ramsay Hunt syndrome can experience all the symptoms described above plus additional symptoms as follows:

• Tinnitus (ringing in the ears).
• Hearing loss.
• Vestibular problems, for example, dizziness, nausea, and problems with balance.
• Pain on the roof of the mouth (due to vesicles from the virus).

Vestibular schwannoma (more commonly called an Acoustic Neuroma), middle ear infections, and/or middle ear surgery

When facial palsy occurs in presence of an acoustic neuroma/following removal of an acoustic neuroma, middle ear infection and/or surgery, the symptoms described above can occur in all these conditions to a greater or lesser degree.

Why does muscle tightness and pain occur around the ear in the synkinetic stage of recovery?

Synkinesis and increased muscle tone causes the affected muscle to be held in a shortened position for prolonged periods. Consequently, they become tight and painful causing constant discomfort and distraction. This occurs because all the muscles of the external ear/auricle are supplied by the posterior auricular branches of the facial nerve (CN VII). They are classified into two muscle groups, intrinsic and extrinsic.

Intrinsic muscles contribute to defining the shape of the auricle by passing between its cartilaginous parts. They are: helicis major, helicis minor, tragus, pyramidal muscle of auricle, antitragus muscle, transverse muscle of auricle, and oblique muscle of auricle.

Extrinsic muscles play a role in positioning the auricle, originating from the skull and attaching within the auricle itself. They are: auricularis anterior, auricularis superior, and auricularis posterior.

What can help?

Stretches and relaxation are the best ways to relieve tightness and pain around the ear and within the auricle (shell) itself.

Stretches

First of all, test for anterior auricular muscle tightness using the video below.

Below are links to four exercises (release and stretches) to help reduce and relieve pain from muscle tightness in these areas.

Anterior auricular release

Posterior release

Superior release

Auricular release (downward stretch)

Relaxation

Muscle tightness occurs due to overstimulation from the recovering facial nerve. The recovering facial nerve has lost its ability to know when to act and when to rest. Teaching the facial nerve to ‘dial down’ its overactivity can help it learn how to rest and therefore stop the cycle of over stimulation and consequential muscle tightness. There are several resources listed below to help with relaxation so dip into these and see which ones work best for you. Using relaxation techniques little and often throughout the day is better than one long practice. Try and make facial relaxation part of your daily routine just like brushing your teeth, in doing so you are more likely to keep doing it.

Here are some facial relaxation resources from the Facial Palsy UK website:

Relaxing meditation for synkinesis

Breath and meditation practice

Calming practice for the face and neck

Relaxation resources from the Queen Victoria Hospital:

Leaves on the Stream:  This can be a gentle introduction to becoming aware of thoughts as ‘passing creations of the mind’ and practising the skill of letting go of difficult thoughts.

Mindful Sitting

Relaxation Practice: Body, Breath and Guided Visualisation

Compassion Exercise

Mindfulness Practice for People Who Experience Pain

The psychological impact of facial palsy: how stress and anxiety have an impact on our mind and body especially our face

The webinar on the link below educates us on techniques and strategies to calm the nervous system in the short term and how this can help in managing facial conditions long term. The webinar allows opportunities to practice calming strategies.

Link to webinar

Stapedial Synkinesis: what is it and what can help?

Stapedial synkinesis is a less well documented consequence for people when recovery is delayed or incomplete. It is a very specific symptom that does not occur when the face is at rest. It was first described by Watanabe et al, in 1974. It can occur during any facial movement and resolves when the face is neutral or relaxed. Stapedial synkinesis causes a distortion of hearing due to abnormal regeneration of some of the nerve fibres (axons) originally supplying the muscles of facial expression. These axons have regrown along the nerve to the stapedius muscle. The synkinesis is experienced as an abnormal sound and or pressure in the ear during facial expressions and/or when speaking. It can be described as a crackling/rumbling sound or muffled hearing (Williams et al, 2018). It may also cause conductive hearing loss throughout the duration of the facial movement.

What can help?

 Stapedial synkinesis can be difficult to treat although relaxation and auricular stretches and release exercises, as previously described, are still very worthwhile doing. 

• In addition, breathing techniques can be useful in trying to ‘dial down’ the overactivity on the affected side. The Oxford University Hospital NHS Trust has produced a useful booklet – ‘Facial Palsy: managing anxiety’.  There is a great deal of useful information, but page 26 has an easy-to-follow breathing exercise that may be helpful.  Click here to access this booklet.
• If you have not been seen by a specialist facial palsy clinician, then please ask your GP or consultant to refer you to your local specialist facial palsy service. In doing so, you can access facial therapy and other potential interventions. Click here to find out more about getting a referral to a specialist.
• You can ask for a specialist referral to an Ear, Nose, and Throat consultant to assess your hearing. Results from previous studies have shown a range of responses. In some cases, there were no abnormal audiometric findings whilst other have observed the presence of conductive hearing loss when comparing hearing test results with the face at rest versus hearing test results with sustained facial movement (Hutz et al, 2020).
• In some cases, surgical intervention may be suggested which may include transection of the stapedial tendon to relieve stapedial synkinesis. All surgeries carry risks and may or may not be successful. Before considering any surgical intervention, you should have a conversation with your surgeon about the possible risks involved.

References:

Hutz M, Aasen M, Leonetti J. Facial-stapedial Synkinesis following Acute Idiopathic Facial Palsy – link

Williams T, Tungland B, Stobbs N, Watson G. Oculostapedial synkinesis following idiopathic facial palsy: something to listen out for. J Laryngol Otol. 2018;132(8):757-758. doi:10.1017/S0022215118001147.