What’s the link between chickenpox and Justin Bieber’s facial paralysis? Are you at risk?
The virus that causes Ramsay Hunt syndrome is the same one that leads to chickenpox. We ask a doctor what that means, the potential treatments and what other viruses can potentially cause facial paralysis.
You don’t have to be a Belieber (that’s Justin Bieber’s fandom) to believe that the Canadian pop singer has a serious health trouble. In the widely-reported Instagram video he posted on Jun 10, the Grammy-winning artiste detailed the partial facial paralysis that has affected his ability to blink, smile and move his nostril and cheek on the right side of his face.
The Honest singer mentioned that his facial weakness or palsy was the result of Ramsay Hunt syndrome, which is caused by the varicella zoster virus – the same bug that leads to chickenpox. And according to Dr Ng Chew Lip, a consultant ENT (ear, nose and throat) surgeon at Ng Teng Fong General Hospital (NTFGH), who is trained in facial plastic surgery, Bieber’s condition “is pretty severe”.
“Based on the House-Brackmann score, which we use to grade facial paralysis from one to six (one is normal and six is complete paralysis), the upper part of his face is a five and the lower part is about a four,” he said.
WHAT ARE YOUR ODDS OF GETTING FACIAL PARALYSIS?
Since the virus that caused Bieber's condition is the same one that leads to something as common as chickenpox, you might be wondering: How likely are you to develop facial palsy if you've had the latter?
For the majority of recovered people, the varicella zoster virus is likely to be still lingering in the body in a very dormant state, said Dr Ng. “The virus likes to reside in the nerves and is very hard to eradicate. But for most people, it doesn’t cause any problem.”
In fact, Ramsay Hunt syndrome’s incidence is considered rare – five per 100,000 in the US population. Locally, Dr Ng sees about 10 to 20 cases a year.
Trouble arises when you are immuno-compromised and the virus seizes the opportunity to reactivate. You could be feeling very overwhelmed at work, or in Bieber’s case, perhaps stressed over the preparations for his world tour. “Or sometimes, it just happens without any reason,” said Dr Ng.
Depending on which nerve the virus reactivates in, it can result in shingles – a single stripe of painful blisters that wraps around either the left or the right side of the torso. “The reason why shingles present in this way is because there is a nerve that coils around the trunk like a snake. The virus travels along this nerve, causing injury and damage to it.”
Or in the singer’s case, the varicella zoster virus chose to strike the nerves on the right side of his face. There are five branches of nerves on each side of the face and each branch is responsible for animating a different part: The forehead, around the eye, mid face, mouth and neck.
“Facial palsy can affect all five or any of the nerve branches, depending on how severe the nerve injury is,” said Dr Ng. “When that happens, the signals from the brain do not get transmitted to the facial muscles and movements are disrupted.”
OTHER CAUSES THAT CAN PARALYSE YOUR FACE
The virus that causes Ramsey Hunt syndrome isn't the only one that can lead to facial paralysis. There are others such as the herpes simplex virus (it causes cold sores and genital herpes) and even the influenza virus. “We do see patients who have facial palsy after having a flu and they would have one or more affected branches of the facial nerves,” said Dr Ng.
Not every case of facial palsy can be traced to a known virus though. In such instances, doctors diagnose the unexplained facial muscle weakness as Bell’s palsy. “We don’t have any local data. In general, one in 65 people would have Bell’s palsy in their lifetime at least once. We see a number of such cases every week,” said Dr Ng.
FACIAL MOVEMENTS ARE COMPLEX
About 25 per cent to 30 per cent of the motor cortex (the part of your brain that controls movement) is devoted to facial movements. The reason your face gets allocated such a high CPU power is that there are 23 muscles and five branches of nerves on each side of your face. Together, they produce more than 2,000 facial expressions.
He added: “Ramsay Hunt syndrome is more severe than Bell’s palsy in my experience, with more severe facial paralysis and poorer recovery. The worst case I have seen was a patient who was admitted for seizures from Ramsay Hunt syndrome, developed varicella zoster meningitis (inflammation of the protective membranes that surround the brain and spinal cord) and had to be treated in the ICU”.
In patients with recurrent facial palsy over a short period of time, other causes need to be sought, such as nerve tumours, fibrous dysplasia, sarcoidosis and a very rare disease called Melkersson-Rosenthal syndrome, he said.
As for the chart-topping singer, there are good and bad prognoses, according to Dr Ng. "The good thing is, he is 28 years old, so he is young and can recover well. The bad factor is, Ramsay Hunt syndrome patients don't recover as well as those with Bell's palsy. But with his age and early treatment, he should recover very well. It may take weeks or months before he recovers fully."
WHAT ARE THE PROCEDURES AVAILABLE?
Medication, especially for viral attacks on the nerve, forms the first line of treatment. “Studies have strongly supported that you need to get treated within three days for optimal prognosis and recovery,” said Dr Ng. Two kinds of medicine are commonly prescribed: High-dose oral steroids (1mg per 1kg of body weight) and anti-viral medication.
Physiotherapy is also used. "Treatment includes facial massage, stretching and strengthening exercises," said Kelly Chan, NTFGH's principal physiotherapist. "For mild impairment, recovery can be expected within a month. For moderate to severe impairment, recovery can range from three to six months. The prognosis and chance of recovery for most of the cases are significant."
It is only when the muscle weakness doesn’t turn around in six to 12 months that doctors consider the use of plastic surgery. “About 20 per cent of patients do not recover fully,” said Dr Ng. “These are usually elderly patients with poor regenerative potential and those with comorbidities like diabetes, for example.”
Here’s a look at the various procedures available to restore the facial muscles’ functions, according to Dr Ng:
- ENDOSCOPIC AND DIRECT BROW LIFTS
Targets: Droopy brow that obscures vision.
How: In the minimally invasive endoscopic brow lift, three small incisions are made behind the hairline. This allows the surgeon to insert the endoscope underneath the skin, reach the brow and separate skin from bone. Dissolvable bio-hooks are then implanted on the bone to let the surgeon anchor the skin at a higher position, creating a lifted effect.
The direct brow lift works on the same principle of lifting and securing the brow at a higher position, except that an incision is made directly above the brow. Excess tissue is removed and the area is stitched up. The direct brow lift provides a better lift that lasts longer than the endoscopic method but it can also scar more.
- PLATINUM IMPLANTS
Targets: Upper eyelid that doesn’t close completely, leading to dry eye and visual impairment.
How: Bits of platinum are implanted into the skin of the upper eyelid to weigh it down. The implants weigh between 0.6g and 2g each, and can be in chain or solid form. Gold implants are sometimes used but platinum is preferred as it is denser.
- LATERAL TARSAL SNIP
Targets: Lax lower eyelid that can also lead to dry eye and visual impairment.
How: This tightening procedure basically snips off a bit of the tarsal plate, which is a dense connective tissue that forms the supporting structure of the lower eyelid (FYI, the tarsal plate is also found in the upper eyelid), tightens up the loose lid and secures the tighter tarsal plate to the bone.
MID FACE: NOSE AND CHEEKS
- NASAL VALVE SURGERY
Targets: Collapsed nasal muscles that impede breathing.
How: When you breathe, the nasal muscles and valves on both sides of your nose are activated to prop up the nasal passages like the rafters in the roof. But if the muscles are paralysed, the nasal valves and passages remain narrow and you can't breathe well.
To prop up the collapsed nasal passage, donor cartilage or cartilage harvested from your nose, ear or rib is used. The “support” can be inserted at the lateral side of the nose or down the middle of the nose.
Targets: Lopsided or droopy cheek that pulls down the corner of the mouth.
How: There are opposing forces provided by the various muscles in your face known as elevators and depressors. Take the brow, for example. The elevators lift your brows when you look surprised, and the depressors pull the brows down when you close your eyes.
When these opposing forces are in balance, your features look symmetrical whether your face is at rest or smiling. But when the elevators are weakened by paralysis, for example, the depressors pull down unopposed. If this happens to your cheek, it ends up drooping and pulls the corner of the mouth along with it.
Botulinum toxin or botox can be injected into the cheek to restore symmetry. It does this by weakening the muscles on the functional or unparalysed side. By weakening these muscles, the smile looks more balanced.
Botox can be used for all parts of the face for the same purpose but only if the paralysis is mild. Also, you’ll need maintenance injections every couple of months.
LOWER FACE: MOUTH
- STATIC SLING
Targets: Lopsided smile and other mouth movements.
How: First, the skin and soft tissues is surgically lifted off the face. Then, a sling is attached to pull up the the mouth up and back to restore the symmetry of the face.
This sling can be created using a band of fibrous tissue taken from the thigh known as the fascia lata; the temporalis, a muscle from the side of the face; or it can be a synthetic material.