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Treating Acute Facial Paralysis

Treating acute facial paralysis, either from Bell’s palsy, Ramsay Hunt Syndrome, Zoster Sine Herpete, Lyme disease or a facial nerve injury is a slow and complicated process that requires expertise from a therapist, a facial specialist therapist.See, over 98% of physiotherapists worldwide never learn nor even once treat a facial paralysis patient in their career.

It can be quite rare for a patient to be referred by a physician to physiotherapy for the rehabilitation of facial paralysis. The subtleties of the treatment require a trained eye, that knows the anatomy of the facial musculature, that knows the difference between facial muscles and common muscles in the rest of the bodies ( hint: they behave very different, and so they require a very different treatment approach).

1 Buccinator Muscle Sebastian Kaulitzkiscience Photo Library

If you are struggling with recovering from facial paralysis, it could be due to many reasons. Muscle tightness and formation of fibrosis in the soft tissue of the face result from the lack of active muscles contraction and activity. It is in my opinion an original reason for the complications that affect a significant amount of facial paralysis patients down the road when recovery from Bell’s palsy is not full ( which is a high number in my opinion, 29%).

Today we will look at one muscle of the face in particular that is extremely important to maintain normal facial symmetry (particularly as the face regain movement), normal mouth opening, regaining a normal smile and preventing synkinesis between the eye and mouth. That little devil is called the Buccinator.

Screen Shot 2022 10 13 At 5 16 01 Pm

The function of the buccinator is to maintain the tightness of the cheeks and press them against teeth during chewing. Ialso assists the tongue to keep the bolus (mass of chewed food) centered in the oral cavity. It is also used in blowing and whistling. ( Think blowing a horn or playing the trumpet).

During facial paralysis, it becomes very tight, both on the involved and uninvolved side, as initially only the non involved side is working, with the act of chewing becoming one sided and overloading the strong side.
​It becomes essential to stretch the buccinator on both sides of the face to maintain cheek and mouth symmetry, even before movement is available.

In patient with advanced facial paralysis sequelae, like synkinesis, when mouth movement creates involuntary eye movement, or the opposite, when eye movement/ blinking creates involuntary mouth movement, an hyper activity of the buccinator is often observed. For example, when asked to close their eye, the synkinetic side will reveal a contraction of the buccinator upon eyelid closure.

Picture of live human's inside of mouth with ink marking the location of the buccinator

It is beyond the scope of this article to discuss Synkinesis in details but sometimes, the tone and activity of the buccinator are so serious that chemical denervation, like a Botox injection is necessary to control the buccinator:

Inside of mouth with syringe to inject botox into the buccinator

The hyperactivity, or hyperkinesis, of the buccinator that is often observed fairly early on, even in the flaccid paralysis stage of facial paralysis, becomes problematic as it’s fiber blend with many other muscles of the face and chronic tightness can prevent other muscles from contracting properly, leading to asymmetry with specific movement as movement return in the paresis stage of facial paralysis.The best way to prevent this is to massage, extra and intraorally, and stretch this muscles. It becomes a key part of a physio program and patient home program in order to prevent facial paralysis complications. The buccinator is also often a location for what we called trigger point. On the diagram below, this area of the buccinator is a common trigger point. That needs to be carefully approached due to tenderness, then massaged/kneaded gently and finally stretched.


I summarized in the video at the top of the page how to approach this muscles with trigger point release, massage and release in easily understandable words.

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