Bell’s Palsy After Lyme Disease

Lyme disease can cause facial nerve paralysis.
Some patients later develop facial tightness or abnormal movements.
Recovery is not always complete after Bell’s palsy.

Can Lyme disease cause Bell’s palsy? Yes. Facial nerve palsy is one of the most recognized neurologic manifestations of Lyme disease in endemic regions.

Some patients recover completely after facial paralysis. Others later develop persistent facial tightness, abnormal facial movements, or facial asymmetry during recovery.

This complication is sometimes called nonflaccid facial palsy (NFFP).

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What Is Nonflaccid Facial Palsy?

Nonflaccid facial palsy refers to abnormal facial muscle movement that develops after the facial nerve begins to recover.

Studies suggest that approximately 15–30% of Bell’s palsy patients develop nonflaccid facial palsy. :contentReference[oaicite:1]{index=1}

Patients may develop:

• facial tightness
• eye narrowing
• smile asymmetry
• abnormal facial muscle contractions
• involuntary facial movements

Some patients notice that the eye closes while chewing or speaking, or that facial muscles contract involuntarily during blinking.

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Lyme Disease and Bell’s Palsy

Lyme disease is an important cause of Bell’s palsy in tick-endemic regions.

When Lyme disease affects the facial nerve, patients may develop sudden weakness or paralysis on one side of the face. In some cases, both sides may be affected.

As the facial nerve recovers, some patients later develop nonflaccid facial palsy with persistent muscle tightness or abnormal facial movements.

For additional background, see Neurologic Lyme Disease.

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Symptoms of Nonflaccid Facial Palsy

Patients with NFFP may experience:

• facial asymmetry
• tightness of the face or neck
• difficulty smiling naturally
• eye narrowing
• chin dimpling
• abnormal muscle contractions

These symptoms may create functional, cosmetic, psychological, and social difficulties.

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Treatment Options

Treatment depends on symptom severity and the degree of facial muscle dysfunction.

Options may include:

• facial physical therapy
• facial massage
• Botox injections
• muscle relaxants
• acupuncture
• surgical procedures in selected cases

Some patients continue to experience persistent facial nerve dysfunction after Lyme disease treatment.

For related discussion, see Facial Nerve Dysfunction After Treatment for Lyme Disease.

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Is Bell’s Palsy Autoimmune?

Bell’s palsy may occur for several different reasons, including viral infections, inflammation, autoimmune conditions, and Lyme disease.

In Lyme-endemic areas, Lyme disease should remain part of the differential diagnosis when patients present with facial nerve paralysis.

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Clinical Takeaway

Bell’s palsy is one of the most recognized neurologic manifestations of Lyme disease.

Although many patients improve, some later develop persistent facial tightness, involuntary muscle movements, or facial asymmetry during recovery.

These complications may require specialized management beyond antibiotic treatment, including facial therapy, Botox injections, or surgical intervention in selected cases.

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Related Reading

• Understanding Pediatric Lyme Disease
• Treatment Varies for Bell’s Palsy in Children with Lyme Disease
• Steroids Harmful to Patients with Bell’s Palsy Caused by Lyme Disease
• Facial Nerve Dysfunction After Treatment for Lyme Disease

References

1. Markey JD, Loyo M. Latest advances in the management of facial synkinesis. Curr Opin Otolaryngol Head Neck Surg. 2017;25(4):265-272.
2. Rubin D. Normal and abnormal spontaneous activity. Handbook of Clinical Neurology. 2019.
3. Miller MQ, Hadlock TA. Beyond Botox: Contemporary Management of Nonflaccid Facial Palsy. Facial Plast Surg Aesthet Med. 2020;22(2):65-70.

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Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention