Facial Nerve Disorders-from Tics to Bells Palsy to Hemifacial Spasm

Nitin K Sethi, MD, MBBS, FAAN


In this blog post, I shall discuss a number of disorders that affect the facial nerve.

The movements of the face are controlled by the facial nerve. This is the nerve which makes us smile, laugh, frown controlling numerous other facial expressions which humans possess. Facial nerve is a cranial nerve (cranial nerves, a set of 12 nerves originate in the brain). Facial nerve is cranial nerve VII (seven). The right facial nerve controls the muscles of facial expression on the right side of the face while the left facial nerve does the same for the left side of the face).

Innervation of the muscles of the face by facial nerve (cranial nerve VII) Henry Vandyke Carter and one more author – Henry Gray (1918) Anatomy of the Human Body. Image source: Facial Nerve Wikipedia. The image is on public domain and is reproduced here for educational purposes only.

There are a number of disorders which can affect the facial nerve. Some of these disorders cause twitching of the face (tics, hemifacial spasm) while others cause weakness/drooping of one side of the face (stroke, Bells palsy).


Facial tics are repeated spasms which involve different muscles of the face (such as rapid eye blinking, nose twitching, head jerking, shoulder shrugs). Tics can be classified into simple motor tics (such as those listed above) and complex motor tics (in a complex motor tic, a series of movements are performed in the same order repeatedly). While tics occur involuntary, most patients are able to stop their tics (for a short period of time) if asked to do so. “Holding the tic in” though causes distress which is relieved by performing the tic. Tics are usually considered to be harmless but they may occur multiple times during the day causing distress and become socially disabling to the patient and those around). As a result, not all tics need to be treated. If the tics are not bothering the patient per se, I usually educate the patient/family on facial tics and what can exacerbate them (stress/anxiety, lack of sleep) and keep the patient under my observation. Many children/ youth may exhibit a transient tic disorder and then grow out of it. Tourette’s Syndrome is a chronic tic disorder characterized by multiple motor and vocal tics. If tics need treatment, behavioral therapy and medications are prescribed.


As the name suggests, in hemifacial spasm the patient exhibits facial muscle contractions (spasms) involving one side of the face. The disorder is characterized as a movement disorder of the facial nerve in which muscles of one side of face twitch involuntary. Hemifacial spasm occurs when something irritates the facial nerve and the cause needs investigation. The diagnosis of HS is made by a neurologist based on observing the facial movements and results of test such as MRI brain (to look and see if anything is irritating the facial nerve/its branches inside the brain).

The treatment of HS depends on the cause. Various treatment options include use of medications (anticonvulsant drugs are sometimes prescribed), botulinum toxin (BOTOX) and surgery.

Bell’s Palsy-what to expect- a question and an answer


varad Submitted on 2013/10/05 at 3:29 pm | In reply to braindiseases.

I’ve been diagnosed with bells palsy and its been around 2 and a half months. Recovery is very slow and at the moment I’m undergoing homeopathic treatment. Kindly advice that what shall I do for fast recovery



Submitted on 2013/10/08 at 1:28 pm | In reply to varad.

Dear Varad,
recovery from Bell’s Palsy at times is slow but in most instances near full recovery takes place. So these are a few things you can do to speed recovery:
EXERCISE YOUR FACIAL MUSCLES: stand in front of the mirror and exercise all your facial muscles-the one that makes you smile, the one that makes you frown, the one which makes you purse your lips and whistle, the one that makes you close your eyes tight shut. You can look up some of these exercises on the Internet and start doing them 3-4 times a day.
–to my knowledge and in my experience-massaging the face with oil does not help or speed up recovery. Likely it does not hamper recovery in any way also.
–eat a healthy diet.
–if you drink or smoke, I would advise you to stop smoking and drinking alcohol as that hampers recovery of facial nerve function.

–supplement your diet with 2 tabs of a good multivitamin every day.

–I am not aware of any homeopathic treatment especially for Bell’s palsy but then my knowledge of homeopathy is limited.

Remain in follow up with your doctor/ neurologist.

I wish you good luck and hope you make a speedy recovery.

Nitin K Sethi, MD

Bell’s palsy–a patient’s story

Just received this from an unknown reader. Just goes to show how the onset of Bell’s palsy might be subtle and patient’s frequently think they may be having a stroke.

Personal Regards,

Nitin Sethi, MD



A patient’s story follows…..


well i am on my first full day and my storie goes like this.
starting yesterday at about 7:30 am I started to learn a new appreciation for life. It all started on Saturday night I felt a sinus headache coming on and later a pain in the left side of my neck & ear. I then proceeded to get a few Excedrin and a cup of hot coffee. I had a great time at a Halloween party that night woke up on Sunday felt fine other than a little sinus pressure. So I proceeded to take some Tylenol multi symptom sinus medicine which I rarely take because I hate man made drugs! Went to bed woke up Monday and felt some pressure in my left side of my face, had some breakfast, kissed the wife and kids goodbye and was off to my hour drive down to West Palm Beach. Got to work and felt a little sleepy, I ended up sleeping for like the first hour at work. Then sally called me up to the front office for something and when I got there she said “what is wrong with your face” of course I laughed and said “nothing more than normal why is it killing you LOL” she said
no your left eye looks weird and your face looks swollen . Well to cut it shout I was having a severe allergic reaction to the Tylenol multi-symptom medicine. So I called the doc and they said to take some Benadryl, so I did. Shortly after I noticed I started to have a numbing in my left side of my face. I could not close my left eye by its self and when I took a drink of water it streamed down the left side of my face. I went to the mirror to find that the left side of my face was droopy and is seemed to be paralyzed. I was freaking out by now of course thinking I was having a stroke. I went to the doctor and found out that between a pinched nerve in my neck that was a result of a dislocating rib under my shoulder blade and a Sinus infection I had damaged my 7th cranial nerve resulting in a condition called Bell’s palsy.

Bells Palsy: what to expect

Let us talk a little about Bells palsy a relatively common neurological condition affecting the function of the seventh cranial nerve (that is the facial nerve).  The muscles of the face are suplied by the facial nerve. It is this nerve which helps you to smile, frown, wrinkle up your forehead, purse your lips and all other facial expressions. The facial nerve is also the nerve which supplies taste sensation to the anterior part of the tongue. It suppiles a muscle called stapedius in the middle ear which helps in damping loud sounds and also supplies the lacrimal gland (helps in tear function).

In Bells palsy patients develop weakness of all the muscles of one half of the face (they cannot close their eye on that side, have a crooked smile as the face gets pulled to the normal healthy side when they attempt to smile, cannot puff their cheeks or purse their lips to whistle). Depending upon the site of involvement of facial nerve, they may also be unable to tear (complaint of dry eye), unable to taste food or complain of excessive loud sounds in the ear on the side of the facial nerve palsy.

In Bells palsy there is inflammation of the facial nerve somewhere along its course from the brainstem to the muscles of the face. In Bells palsy, this inflammation is idiopathic (no definite cause for inflammation is found) though inflammation by the herpes group of viruses has been implicated in its etiology. Some patients have developed Bells palsy after been exposed to cold air (this has never been proved though). Bells palsy is not life threatening but can be quite socially disabling especially if severe (you can imagine how socially disruptive it might be to have one half of your face paralysed and be unable to smile or emote with your face).

Diagnosis and management of Bells palsy: the diagnosis of Bells palsy is clinical (can be made by a clinical examination by a neurologist). In the typical case no further investigations are warranted, though in some cases if the history is atypical (slow onset with addition neurological findings) your doctor may order an MRI study of the brain. 

Most of the patients recover spontaneously from Bells palsy. All that we advise them is to cover the eye at night with an eye patch and wear sunglasses when they go out during the day (this is to protect the eye from keratitis as the eye does not shut). If you present acutely to your doctor with Bells palsy, he may recommend a course of steroids and acyclovir (antiviral drug with efficacy against herpes virus). It is thought that this hastens recovery though some studies have shown that the recovery is the same whether or not acyclovir is used or not).

Your doctor shall also recommend facial exercises (just as you undergo physical therapy if you have a stroke, in the same way we want to encourage facial exercises to hasten recovery). Facial exercises are easy to do and I usually recommend my patients to stand in front of the mirror and attempt to smile, frown, pout and whistle. I ask them to do this for at least 10 mins two times a day. Massaging the face has not been shown to be beneficial. In case the recovery is slow or incomplete your doctor might order a nerve conduction study of the facial nerve to assess the degree of damage to the nerve.

As I stated earlier most patients have a good recovery. At times when the facial nerve regenerates, it regenerates in an arbitary fashion. Patients develop crocodile tears (they start tearing when attempting to eat) or have synkinesis (all the muscles of the face contract at once when attempting to smile that is the fine control of individual facial muscles is lost). If you have these problems you should contact your doctor and ask for advise.

I hope this short post on Bells palsy shall be helpful to some of you.

Personal Regards,

Nitin Sethi, MD