Clinical Review

Girl, 6, With Facial Weakness

Clinician Reviews. 2011 January;21(1):14, 16-18

References

1. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg. 1985;93(2): 146-147.

2. Finsterer J. Management of peripheral facial nerve palsy. Eur Arch Otorhinolaryngol. 2008;265(7):743-752.

3. Lunan R, Nagarajan L. Bell’s palsy: a guideline proposal following a review of practice. J Paediatr Child Health. 2008;44(4):219-220.

4. Blosser CG, Reider-Demer M. Neurologic disorders. In: Burns CE, Dunn AM, Brady MA, et al, eds. Pediatric Primary Care. 4th ed. St. Louis: Saunders Elsevier; 2008:634-672.

5. Singhi P, Jain V. Bell’s palsy in children. Semin Pediatr Neurol. 2003;10(4):289-297.

6. Tiemstra JD, Khatkhate N. Bell’s palsy: diagnosis and management. Am Fam Physician. 2007;76(7):997-1002.

7. Lorch M, Teach SJ. Facial nerve palsy: Etiology and approach to diagnosis and treatment. Pediatr Emerg Care. 2010;26(10):763-769.

8. El-Hawrani AS, Eng CY, Ahmed SK, et al. General practitioners’ referral pattern for children with acute facial paralysis. J Laryngol Otol. 2005;119(7):540-542.

9. Shargorodsky J, Lin HW, Gopen Q. Facial nerve palsy in the pediatric population. Clin Pediatr (Phila). 2010;49(5):411-417.

10. Wang CH, Chang YC, Shih HM, et al. Facial palsy in children: emergency department management and outcome. Pediatr Emerg Care. 2010;26(2):121-125.

11. Evans AK, Licameli G, Brietzke S, et al. Pediatric facial nerve paralysis: patients, management and outcomes. Int J Pediatr Otorhinolaryngol. 2005;69(11):1521-1528.

12. Lockhart P, Daly F, Pitkethly M, et al. Antiviral treatment for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2009;(4):CD001869.

13. Grogan PM, Gronseth GS. Practice parameter: steroids, acyclovir, and surgery for Bell’s palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56(7):830-836.

14. Khine H, Mayers M, Avner JR, et al. Association between herpes simplex virus-1 infection and idiopathic unilateral facial paralysis in children and adolescents. Pediatr Infect Dis J. 2008;27(5):468-469.

15. Tsai HS, Chang LY, Lu CY, et al. Epidemiology and treatment of Bell’s palsy in children in northern Taiwan. J Microbiol Immunol Infect. 2009;42(4):351-356.

16. Cha CI, Hong CK, Park MS, Yeo SG. Comparison of facial nerve paralysis in adults and children. Yonsei Med J. 2008;49(5):725-734.

17. Linder TE, Abdelkafy W, Cavero-Vanek S. The management of peripheral facial nerve palsy: “paresis” versus “paralysis” and sources of ambiguity in study designs. Otol Neurotol. 2010;31(2):319-327.

18. Rahman I, Sadiq SA. Ophthalmic management of facial nerve palsy: a review. Surv Ophthalmol. 2007;52(2):121-144.

19. Skogman BH, Croner S, Odkvist L. Acute facial palsy in children: a 2-year follow-up with focus on Lyme neuroborreliosis. Int J Pediatr Otorhinolaryngol. 2003;67(6):597-602.

20. Siegler RL, Brewer ED, Corneli HM, Thompson JA. Hypertension first seen as facial paralysis: case reports and review of the literature. Pediatrics. 1991;87(3):387-389.

21. Surgical Advisory Panel, American Academy of Pediatrics. Guidelines for referral to pediatric surgical specialists. Pediatrics. 2002;110(1 pt 1):187-191.

22. Chen WX, Wong V. Prognosis of Bell’s palsy in children: analysis of 29 cases. Brain Dev. 2005; 27(7):504-508.

The Case Patient
The child’s facial nerve function gradually returned over a three-week period, with no residual deficit (see Figures 1a, 1b, and 1c). Results of the audiometry screening on day 10 were normal, showing a positive stapedial reflex. An MRI, performed four months after the initial paralysis to rule out any tumors, yielded normal results.

This case highlights the differing management of pediatric Bell’s palsy among emergency, pediatric, and specialized providers. This child was managed more aggressively under the care of an otolaryngologist with a two-week course of steroids, antiviral medication for 10 days, and a follow-up MRI to rule out any evidence of a tumor. The need for further research to guide practice in the pediatric patient with Bell’s palsy is apparent.

Conclusion
FNP in the pediatric population is rare and more likely to have an identifiable cause than among adults. Careful examination should reveal differential diagnoses that warrant treatment and referrals. The main causes of FNP that should not be missed are otitis media, hypertension, varicella zoster virus (Ramsay Hunt syndrome), neoplastic processes, and Lyme disease.

Practitioners should have a high index of suspicion for nonidiopathic causes of FNP when a child has a neurologic exam that includes facial paresis of gradual onset, abnormal function of other cranial nerves, lack of forehead muscle weakness, or peripheral abnormalities. In addition to the history and exam, blood work and radiologic imaging can aid the practitioner in ruling in or out nonidiopathic causes of FNP.

Grading of facial palsy severity using the House-Brackmann scale helps guide prognosis and referral choices. Referral to a specialist in otolaryngology is appropriate and recommended by the AAP. Referral should be made to an ophthalmologist if any suspicion of corneal abrasion exists.

Treatment in children should consist of eye care and steroids. Antiviral therapy should be considered on an individualized basis and when evidence of HSV or varicella exists. Parents should be advised about the importance of eye care in a child with FNP (see Table 3^{5-7,9,17,18,22}).

The emotional stress associated with FNP can be significant for both children and adults; fear of lifelong facial deformity can be psychologically debilitating. Yet a favorable prognosis for recovery of facial nerve function can be relayed to anxious parents.