Can Bell’s palsy lead to nonflaccid facial palsy in Lyme disease?

Bell’s palsy typically presents as flaccid facial palsy, where one or both sides of the face drops. However, Bell’s palsy can also lead to nonflaccid facial palsy. Lyme disease can cause either flaccid or nonflaccid facial palsy (NFFP).

Can Bell’s palsy lead to nonflaccid facial palsy in Lyme disease?. “Nonflaccid facial paralysis is a spectrum of hypokinetic and hyperkinetic movement,” wrote Markey and colleagues in the journal Otolaryngology

Hypokinetic movement involves less movement, while hyperkinetic movement involves more movement.

“Clinically, this manifests as contraction of the orbicularis oris muscle simultaneous with eye closure or blinking and/or contraction of the orbicularis oculi during speaking or chewing,” explains Rubin in the Handbook of Clinical Neurology.² Orbicularis oris muscles are the group of muscles in the lips that encircles the mouth.

“Patients affected by NFFP often have a narrowed palpebral fissure, prominent and misoriented nasolabial fold, neck and face tightness, and mentalis dimpling,” writes Miller and colleagues in the journal Facial Plastic Surgery & Aesthetic Medicine  “These muscles can make a smile asymmetry.”

[bctt tweet=”Lyme disease can cause either flaccid or nonflaccid facial palsy. ” username=”DrDanielCameron”]

A narrowed palpebral fissure is a narrowing of the eye opening between the eyelids. Mentalis are the chin muscles.

Bell’s palsy can lead to NFFP in 15–30% of patients, writes Miller. “Other common causes of NFFP include Ramsay Hunt syndrome, acoustic neuroma resection, Lyme disease, trauma, autoimmune disease.”

Patients can suffer from NFFP with significant functional, aesthetic, psychological, and social impairments,” writes Miller.

To view photos of patients with both flaccid and nonflaccid facial palsy, visit “The spectrum of facial palsy: The MEEI facial palsy photo and video standard set.”

Treatment of nonflaccid facial palsy

There is a wide range of treatments for NFFP including:

  • Physical therapy
  • Muscle relaxants
  • Facial massage
  • Acupuncture
  • Myectomy
  • Neurectomy
  • Botox

Editor’s note: I have treated Lyme disease patients in my practice with nonflaccid facial palsy and have seen first hand the “significant functional, aesthetic, psychological, and social impairments” it can cause, as described by Miller.

  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. Chapter 17 – Normal and abnormal spontaneous activity in the Handbook of Clinical Neurology. edited by Kerry H. Levin, Patrick Chauvel. Vol Volume 160, 2019, Pages 257-279: Science Direct; 2019.
  3. Miller MQ, Hadlock TA. Beyond Botox: Contemporary Management of Nonflaccid Facial Palsy. Facial Plast Surg Aesthet Med. 2020;22(2):65-70.

2 Replies to "Can Bell’s palsy lead to nonflaccid facial palsy in Lyme disease?"

  • Winter
    05/27/2020 (4:51 pm)

    My mother and her friend got bit in the 1950’s by mosquitos in White Plains, NY…they both developed Bells Palsey soon mothers doctor stuck a needle behind her ear back then. Must have been an antibiotic because it did go away. But it came back after having a baby in 1960! It went away forever since then. I believe I was born with it in 1967. My brothers were always healthy and dont seem affected though….but she has been completely out of her mind forever. I totally believe it’s been in her brain for 67 years.!

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