Facial Nerve Palsy

Bell's Palsy

There are many conditions that exist in both Pediatric and Adult patients who present to the ED.  Some of them require special consideration when you are evaluating the special population of pediatric patients (please don’t say “kids aren’t little adults”… that drives me crazy).  For instance, DKA management often requires different considerations in children.  Another entity that requires some additional considerations is Facial Nerve Palsy.


Facial Nerve Palsy in Kids – Basics:

  • Facial Nerve Palsy is commonly encountered throughout one’s lifetime, but is relatively rare in kids.
    • Less common in younger children and infants than it is in teenagers and adults.
    • So don’t be cavalier when diagnosing a young child with “Bell’s Palsy.”
  • Outcomes are related to underlying cause as well as severity upon presentation.


Facial Nerve Palsy Severity Grading

  • The House-Brackmann Facial Nerve Grading System is used to grade the severity of the palsy.
    • Grade 1Normal function
    • Grade 2 – Mild dysfunction: normal symmetry at rest, able to completely close the eye with minimal effort.
    • Grade 3 – Moderate dysfunction: noticeable but not severe synkinesis, with effort can close eye, asymmetric mouth movement with maximal effort.
    • Grade 4 – Moderately severe dysfunction: obvious weakness, incomplete eye closure, asymmetric mouth movement.
    • Grade 5 – Severe dysfunction: only barely perceptible motion, asymmetric at rest.
    • Grade 6No movement.


 Facial Nerve Palsy Causes to Consider in Kids

Abridged list– but the big ones to consider are:

  • Idiopathic (Bell’s Palsy) 
    • Often reported to be the most common cause of Facial Nerve Palsy in kids (40-70% of cases).
    • More recent literature demonstrate lower percentages, likely from being able to detect other potential infectious cause.
  • Infection
    • Otitis media, mastoiditis, parotitis, meningitis
    • EBV, Mycoplasma pneumoniae, HSV, VZV, tuberculosis, HIV, poliomyelitis, mumps
    • Lyme Disease (the most prevalent causes in endemic areas!)
    • Ramsay-Hunt Syndrome (Herpes Zoster cephalicus) – look for vesicles on TM or in mouth
  • Inflammatory Conditions
  • Trauma
    • Fracture of the temporal bone
    • Skull base fractures
    • Perinatal trauma (compression from forceps)
    • Trauma to parotid / cheek region
    • Barotrauma
  • Neoplasm
    • Leukemias
    • Parotid tumors
    • Brainstem masses
    • Cholesteatoma
  • Others


Facial Nerve Palsy Evaluation

  • The evaluation is predicated upon a thorough history and physical exam, mindfully considering the above potential causes.
  • Key Points to Contemplate:
    • Condition is progressively worsening over 3 weeks or lacks improvement after 3 months – concerning for CNS or neoplastic process.
    • Recurrent Facial Nerve Palsy – is rare, therefore warrants specialty evaluation.
    • Bilateral Facial Nerve Palsy – likely due to a Lyme Disease or EBV infection or neurological cause (Guillan-Barre Syndrome).
    • Aural Symptoms – Bell’s Palsy can have this, but so too can Ramsay-Hunt Syndrome, Otitis Media, Cholesteatoma, or tumors! Be thorough with your physical exam.
    • Recent Immunizations – Facial Nerve Palsy has been related to rabies, polio, tetanus, and influenza vaccinations. Causation is a different story.
    • Failure to Thrive, Persistent Fever – Consider occult neoplasms.
    • Other Cranial Nerves Involved or Abnormalities on Neuro Exam – No longer a simple Facial Nerve Palsy… investigate for badness.
  • Imaging?
    • Neuro-imaging would be recommended for:
      • Any signs of Central Nervous System involvement,
      • Suspect malignancy,
      • Suspect trauma,
      • Evidence of Middle Ear Cholesteatoma,
      • Peripheral Facial Nerve Palsy progressing beyond 3 weeks,
      • Peripheral Facial Nerve Palsy without improvement after 6 months,
      • Recurrent Facial Nerve Palsy
    • Be cautious with a patient who is younger than 2 years of age… Bell’s Palsy is less likely.


Idiopathic Facial Nerve (Bell’s) Palsy Treatment

  • Eye Care!
    • The most important therapy consideration!
    • Artificial Tears during daytime.
    • Moisturizing eye ointment (ex, Lacrilube) during sleep.
  • Steroids?
    • There is adult literature that supports the use of steroids; however the literature does not contain many pediatric patients.
    • In addition, the vast majority of children with Bell’s Palsy improve without therapy, so studies are often underpowered to determine a difference between those who received steroids and those who did not.
    • If you elect to use steroids:
      • Prednisolone 1 mg/kg (max 60mg) per day x 7 days and then taper off.
      • Best to initiate within first week of onset.
      • Consider other comorbidities (diabetes, hypertension, occult leukemia) before prescribing.
        • Some would advocate for a screening CBC because of this.
  • Acyclovir
    • Has not been shown to be helpful on its own with adults or children.
    • In adults, there is some evidence that it is beneficial when used with steroids.




Ozkale Y1, Erol I, Saygı S, Yılmaz I. Overview of Pediatric Peripheral Facial Nerve Paralysis: Analysis of 40 Patients. J Child Neurol. 2014 May 8. PMID: 24810082. [PubMed] [Read by QxMD]

Malik V1, Joshi V, Green KM, Bruce IA. 15 minute consultation: a structured approach to the management of facial paralysis in a child. Arch Dis Child Educ Pract Ed. 2012 Jun;97(3):82-5. PMID: 22315344. [PubMed] [Read by QxMD]

Pavlou E1, Gkampeta A, Arampatzi M. Facial nerve palsy in childhood. Brain Dev. 2011 Sep;33(8):644-50. PMID: 21144684. [PubMed] [Read by QxMD]

Wang CH1, Chang YC, Shih HM, Chen CY, Chen JC. Facial palsy in children: emergency department management and outcome. Pediatr Emerg Care. 2010 Feb;26(2):121-5. PMID: 20093994. [PubMed] [Read by QxMD]

Shih WH1, Tseng FY, Yeh TH, Hsu CJ, Chen YS. Outcomes of facial palsy in children. Acta Otolaryngol. 2009 Aug;129(8):915-20. PMID: 18923943. [PubMed] [Read by QxMD]

Bilavsky E1, Scheuerman O, Marcus N, Hoffer V, Garty BZ. Facial paralysis as a presenting symptom of leukemia. Pediatr Neurol. 2006 Jun;34(6):502-4. PMID: 16765834. [PubMed] [Read by QxMD]

Singhi P1, Jain V. Bell’s palsy in children. Semin Pediatr Neurol. 2003 Dec;10(4):289-97. PMID: 14992461. [PubMed] [Read by QxMD]

Salman MS1, MacGregor DL. Should children with Bell’s palsy be treated with corticosteroids? A systematic review. J Child Neurol. 2001 Aug;16(8):565-8. PMID: 11510926. [PubMed] [Read by QxMD]

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

Articles: 583

One comment

Comments are closed.