he onset of paralysis is sudden with Bells palsy and Ramsey Hunt syndrome, although symptoms can worsen during the early days. Bell’s palsy symptoms typically peak within a few days, although it can take as long as 2 weeks. Ramsey Hunt syndrome symptoms will peak within 3 weeks. If paralysis develops slowly, tests for other causes of the palsy must be done. Patients with recurrences, particularly if within close time frames, should also be re-evaluated as a precautionary measure.

Psychologically, facial paralysis can be devastating, particularly in cases that extend for a long period, or where residuals are significant. Friends, family and doctors often have no true concept of how deeply the patient’s sense of self and self-esteem is affected. You will also find that they have little or no understanding of your physical discomfort, difficulty and frustration as you struggle to do seemingly simple things that they take for granted.

There are many physical symptoms associated with facial paralysis, but the effects will differ between individuals. They can vary in accordance with the degree of nerve damage, and the location of the damage.

Muscle weakness or paralysis
Forehead wrinkles disappear
Overall droopy appearance
Impossible or difficult to blink
Nose runs
Nose is constantly stuffed
Difficulty speaking
Difficulty eating and drinking
Sensitivity to sound (hyperacusis)
Excess or reduced salivation
Facial swelling
Diminished or distorted taste
Pain in or near the ear
Eye closure difficult or impossible
Lack of tears
Excessive tearing
Brow droop
Tears fail to coat cornea
Lower eyelid droop
Hearing deficit
Severe pain
Long lasting pain
Blisters in ear or other areas
Eye appears smaller
Blink remains incomplete or infrequent
Tearing abnormalities
Asymmetrical smile
Mouth pulls up and outward
Sinus problems
Nose runs during physical exertion
Post paralytic hemifacial spasm
Hypertonic muscles
Co-contracting muscles
Synkinesis (oral/ocular well known, but can affect any muscle group)
Sweating while eating or during physical exertion
Muscles become more flaccid when tired, or during minor illness
Muscles stiffen when exposed to cold, when tired, or during illness

Although the damage that causes the paralysis is specific to the 7th nerve, other nerves may be temporarily irritated. For example, temporary facial numbness or pain can result when CN-V is irritated.

Recovery is not consistent among patients. For some people the mouth may move before the ability to blink returns; in others it will be eyelids first and mouth last. Twitching may precede movement, but it doesn’t always. Pain in areas starting to “wake up” may occur, or may not. The sense of taste can be odd as the sensation returns, or the sense of taste may return without any awareness of the change. Recovery can be gradual, rapid, or hit occassional plateaus. Et cetera.


Residuals may be due to one, or a combination of several factors. Initial trauma to the nerve can be minor and temporary, or significant and long lasting. When the damage is minor, recovery is likely to be essentially complete, and rapid. With more extensive damage, other factors begin to effect recovery.

In longer recoveries, other cranial nerves may try to take over for the 7th nerve, growing into passageways formerly occupied by the 7th nerve. Also, the 7th nerve can regenerate incorrectly, taking some different paths than it had followed before Bells palsy. The result is “crossed wiring” and synkinesis, which is further described in the next section.

After paralysis facial muscles have a tendancy to become hypertonic. This means they tend to be overactive, contracting when they should be at rest. Typical signs are a squinty eye, the mouth pulling up, a sore or swollen cheek, and deepened creases. Unlike skeletal muscles, facial muscles lack spindles. Muscle spindles sense when a muscle is in a contracted state, and nerves can send the appropriate signal to the muscle telling it to relax. Without these spindles, there is no awareness of the contraction, and the muscles remain in a state of tension. A muscle that can not fully relax also can not fully contract, so the range of motion becomes limited.

Learned misuse and disuse of the muscles also can effect both appearance and mobility. While the muscles are paralysed, it’s natural to try to eat, drink and speak, etc., as well as you can. New habits may be learned while you’re compensating for the nonworking muscles. You may inadvertantly call on inappropriate muscles to join forces and work together to accomplish movements that aren’t happening on their own (learned misuse). Or you may become accustomed to compensating without using the lazy muscles (learned disuse). The effects of both may remain after nerve function returns. Both can also effect the “good” side, which may have learned unnatural patterns while its muscles were assisting the nonworking muscles.

Physical therapy can minimize asymmetrical appearance and improve mobility, even when therapy is started years after the initial paralysis.