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).

There is a broad range of findings. “Nonflaccid facial paralysis is a spectrum of hypokinetic and hyperkinetic movement,” writes 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.”

Lyme disease can cause either flaccid or nonflaccid facial palsy. CLICK TO TWEET

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.



The most important treatment NOT mentioned is anti-microbial treatment for Lyme disease.

In my experience, symptoms go away or lessen considerably with antimicrobial treatment.  From personal experience I can tell you I would have wasted a lot of money and time had I tried to treat each symptom with adjunctive therapies.  Of course if the symptom is debilitating it would probably be worth it, but many symptoms come and go throughout treatment, but good, effective antimicrobial treatment has always been and will always be where you should spend your money first.

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