Paediatric Bell s Palsy Paediatric Update November 2014

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1 Paediatric Bell s Palsy Paediatric Update November 2014 Richard Webster, Paediatric Neurologist Children s Hospital at Westmead

2 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

3 Definition Bell s palsy Acute idiopathic peripheral facial nerve palsy 1. Assessment 2. Differential diagnosis 3. Treatment 4. Monitoring

4 ..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

5 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)

6 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

7 Bell s palsy algorithm? Facial palsy? LMN UMN

8 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

9 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

10 Bell s palsy algorithm Facial palsy? LMN UMN Neurological exam Isolated Other signs

11 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

12 Neurological differential diagnosis 1. Nerve disease Infiltration Inflammation/infection Compression bone/neoplasm 2. Muscle disease Myasthenia

13 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

14 Bell s palsy algorithm Facial palsy? LMN UMN Neurological exam Isolated No cause Examination/Ix Other signs BP - hypertension FBC - leukaemia Middle Ear- OM/mastoiditis, Herpes

15 Further examination Check ears? Otitis media? Evidence of vesicles (Ramsay Hunt) Systemic examination BP Hepato-splenomegaly/pallor FBC evidence of leukaemia

16 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

17 Bell s palsy algorithm Facial palsy? LMN UMN Neurological exam Isolated Examination/Ix No cause Treat Other signs BP - hypertension FBC - leukaemia Middle Ear- OM/mastoiditis, Herpes

18 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

19 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)

20 Review Bell s palsy algorithm Facial palsy? LMN UMN Neurological exam Isolated Examination No cause Treat Other signs BP - hypertension FBC - leukaemia Middle Ear- OM/mastoiditis, Herpes

21 4. When to review? Review 1 week after diagnosis Weekly until clear improvement Follow-up to make sure of resolution

22 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

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