Paediatric Bell’s Palsy Paediatric Update November 2014 Richard Webster, Paediatric Neurologist Children’s Hospital at Westmead
Paediatric Bell’s Palsy Paediatric Update November 2014
Richard Webster, Paediatric Neurologist
Children’s Hospital at Westmead
Typical history
Unilateral LMN facial weakness
Acute onset
– over a day or two
– progressive worst within 2-4 weeks
Preceding ear canal pain
Recovery of function
– starts within 3 weeks
– resolution within 6 months
Definition Bell’s palsy
Acute idiopathic peripheral facial nerve palsy
– 1. Assessment
– 2. Differential diagnosis
– 3. Treatment
– 4. Monitoring
..but first some anatomy
Facial nerve motor nucleus
– Lower pons
– Fibres of VIn curve around the VIIn nucleus
– Bilateral supranuclear inputs for upper face control
Facial nerve
– Leaves pontomedullary junction
– Sensory/autonomic fibres join in facial canal
– Passes through the facial canal
Facial nerve anatomy
Functions of facial nerve – 1. Facial expression
– 2. Lacrimal gland – greater petrosal nerve
– 3. Nerve to stapedius
– 4. Taste fibres to anterior 2/3 tongue (chorda tympani)
– 5. Sensation external auditory meatus
– 6. Salivation – (chorda tympani)
1. Assessment: facial expression
1. Observe
2. Look up
3. Eye closure
4. Muscles of facial expression
– Smile – emotional/voluntary
– Blow out cheeks – lip closure
5. Platysma
– Difficult
Bell’s palsy algorithm? Facial palsy?
LMN UMN
Face assessment
1. What is weak?
– One side or both sides
– Is it all consistent with VIIn?
2. Is the forehead involved?
– UMN lesions spare the forehead
– Get the child to look up
1. Where in the nerve is the lesions?
1. Dry eye?
2. Hyperacusis?
3. Loss of taste (difficult in most children) ant 2/3 of tongue
4. Test for auricular sensation
Bell’s palsy algorithm Facial palsy?
LMN UMN
Neurological exam
Isolated Other signs
Is this isolated facial n palsy?
Cranial nerves
– II – papilloedema
– VI + gaze – nuclear lesions
– VIII – hearing
– IX, X – swallowing, palate
– XI,XII
Cerebellum
Long tract signs
Gait
Neurological differential diagnosis
1. Nerve disease
– Infiltration
– Inflammation/infection
– Compression – bone/neoplasm
2. Muscle disease
– Myasthenia
Case
8 yo girl with R LMN VII weakness
– Gradual onset
Treated with steroids for 1/52 no improvement then given a second course
No improvement within 3 weeks
Then developed unsteady gait
– Limitation of eye movement to right
– Deviates to right on tandem gait
Bell’s palsy algorithm Facial palsy?
LMN UMN
Neurological exam
Isolated Other signs
Examination/Ix
No cause
BP - hypertension FBC - leukaemia Middle Ear- OM/mastoiditis, Herpes
Further examination
Check ears
– ? Otitis media
– ? Evidence of vesicles (Ramsay Hunt)
Systemic examination
– BP
– Hepato-splenomegaly/pallor
FBC – evidence of leukaemia
Warning signs
Young age
Bell’s palsy uncommon in infants and young children
3/100,000 < 10, 25/100,00 adults
Malignancy/ diseases predisposing to
malignancy
History of recurrent otitis media
Syndromes associated with facial
dysmorphism
Bell’s palsy algorithm Facial palsy?
LMN UMN
Neurological exam
Isolated Other signs
Examination/Ix
No cause
BP - hypertension FBC - leukaemia Middle Ear- OM/mastoiditis, Herpes
Treat
3. Treatment
Eye protection
– Avoid corneal abrasions if the patient with facial palsy is unable to close the eye.
– Artificial tears during the day
– Ointment at night
– Eye patch if needed
Treatment
Steroids
– No definite evidence but strong adult data
– Prednisolone 2mg/kg/day (max 60-80mg)
– Give for 5 days and then taper for 5 days
– (Up to date)
Bell’s palsy algorithm Facial palsy?
LMN UMN
Neurological exam
Isolated Other signs
Examination
No cause
BP - hypertension FBC - leukaemia Middle Ear- OM/mastoiditis, Herpes
Treat
Review
4. When to review?
Review
– 1 week after diagnosis
– Weekly until clear improvement
– Follow-up to make sure of resolution
Imaging/referral
Unusual history
– Slow onset
Progression beyond 3 weeks
Failure to improve after 4 weeks
Associated history/signs suggesting a more sinister cause for Bell’s palsy