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Bell’s Palsy Reference: 1554 Written by: Ala Fadilah Peer reviewer: Rachel Riddell Approved: January 2018 Review Due: September 2021 Purpose To guide the management of Bell’s Palsy in children Intended Audience Clinicians involved in the treatment of Bell’s Palsy in children. Author: Ala Fadilah Review date: September 2021 © SC(NHS)FT 2017. Not for use outside the Trust. Page 1 of 7
CAEC Registration Identifier: 1554 Sheffield Children’s (NHS) Foundation Trust
Bell’s Palsy
Table of Contents
1. Introduction
2. Intended Audience
3. Guideline Content
4. References
1. Introduction
Bell’s palsy is an idiopathic lower motor neurone paresis/paralysis of the VIIth cranial nerve,
named after Sir Charles Bell, an 18th century Scottish anatomist.
Bell’s Palsy is the most common cause of unilateral facial nerve palsy, and the most
common acute mononeuropathy. Incidence in the 0-14 age group was estimated at 6.6 per
100,000 person-years of follow-up in a UK study period1, in comparison with an overall
incidence of 20.2 to 37.7 (in adults) per 100 000 person years of follow-up1,4. There are
less studies on Bell’s Palsy in children than in adults due to the relative difference in
incidence. There is therefore less evidence for treatment recommendations.
Bell’s palsy is diagnosed by exclusion of other causes of facial weakness. Facial weakness
may manifest as complete inability (paralysis) or partial inability (paresis) to move affected
muscles
2. Intended Audience
Clinicians involved in the treatment of Bell’s Palsy in children.
3. Guideline Content
Causes of Facial Nerve Palsy in Children6
Bell’s Palsy (40-70%)
Infectious Causes (13-36%): otitis media, mastoiditis, herpes zoster (Ramsay–Hunt
syndrome), chickenpox, encephalitis, meningitis, mumps, infectious mononucleosis
(glandular fever), malaria, tuberculosis, Lyme disease, HIV, tetanus, diphtheria,
Kawasaki disease
Trauma (19-21%) eg. skull base fractures, facial injuries, middle ear injuries,
barotrauma
ENT conditions eg. acute otitis media, cholesteotoma, mastoiditis, parotitis
Neoplastic. eg. haematological malignancies eg.nleukaemia, cerebello-pontine angle
tumours/Infratemporal fossa tumours/parotid gland tumours
Hypertension
CNS causes: Stroke, demyelinating conditions eg.multiple sclerosis
Author: Ala Fadilah Review date: September 2021
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Bell’s Palsy
Demyelinating polyneuropathies eg. Guillain-Barre syndrome,
Congenital : eg. Moebius syndrome
Post-immunisation (reported, no causal association established)
Melkersson–Rosenthal syndrome (recurrent alternating facial palsy, furrowed tongue,
faciolabial oedema)
In addition to establishing the presence of, and type of facial nerve palsy, the history and
physical examination should be focussed on neurologic, ENT, malignant, inflammatory, or
infectious causes; cerebello-pontine angle aetiologies; or vascular insufficiencies.
Examination should include blood pressure measurement, full systemic, neurological
examination and ENT examination.
Red Flag Features in History and Physical Examination:
Longer history of preceding ill-health
Pyrexia
History of trauma
Systemically unwell
Weakness or numbness of limbs, change in gait, clumsiness
Forehead sparing: indicative of upper motor neuron lesion (in CNS pathologies such as
stroke)
Bilateral facial nerve involvement
Other cranial nerve abnormalities or abnormality on neurology examination
Numbness/pain /paraesthesias
Earache, ear discharge, hearing disturbance
Disturbance of balance/coordination
Headache, neck stiffness, photophobia
Visual disturbance
Rashes/bruising/pallor
Lymphadenopathy
Any cold sores/blisters/presence of vesicular rash particularly external ear
Abnormality on otoscopy
Change in behaviour or school performance
Progression of weakness beyond 3 weeks
Recurrence of facial nerve weakness
Hypertension
Bell’s Palsy is diagnosed by exclusion of secondary causes of facial weakness.
Bell’s palsy carries a good prognosis in children with the majority of cases resolving
spontaneously. In children recovery rates are reported to be approximately 90% 2.3
Although typically carrying a good prognosis, Bell’s palsy can result in significant temporary
Author: Ala Fadilah Review date: September 2021
© SC(NHS)FT 2017. Not for use outside the Trust. Page 3 of 7CAEC Registration Identifier: 1554 Sheffield Children’s (NHS) Foundation Trust
Bell’s Palsy
oral incompetence and incomplete eye closure, leading to exposure keratopathy 5. Long-
term effects of incomplete recovery of facial nerve (although rare in Bell’s palsy in children
and young people), can have negative effects on psychological well-being. Recurrence rate
is estimated at 6-10%6,11. Recurrence generally warrants further investigation into a
possible underlying aetiology, as it could be indicative if an underlying neoplasm or
Melkersson–Rosenthal syndrome
Management
Treatment is aimed at improving facial muscle function and at eye protection.
Treatment of Bell’s Palsy with corticosteroids, antivirals or both in children is controversial.
Corticosteroids have been the mainstay of treatment for many years, based on
extrapolation from adult data. In adults, there is fairly robust evidence that steroids started
within 72 hours of the onset of paresis are of benefit 9 , in reducing risk of incomplete
recovery, and motor synkinesis. There is, however, a lack of evidence for benefit in
children, largely due to lack of trials in the paediatric age group. Several reports have
suggested there is little evidence to support the routine use of steroids in children, but do
state that large paediatric RCTs are needed10. Prednisolone use can be considered if child
presents within 72 hours, causes other than Bell’s Palsy have been excluded, and in the
absence of contraindications. There is no consensus on the prednisolone dose to be used
in Bell’s palsy, a total 10 day course is often recommended in adults, with a tapering dose
after 5-7 days, for the remaining 3-5 days of the course.
The use of antivirals, mainly aciclovir, has been historically linked to the apparent
association of Bell’s Palsy with herpes simplex and/or varicella zoster.
In age group above 14 years, there is evidence that indicates the combination of antivirals
and corticosteroids has some benefit and reduces sequelae of Bell's palsy compared with
corticosteroids alone, but that use of antivirals alone does not seem to be more beneficial
than using placebo8. There is no evidence published to date supporting its use below 14
years age, and there is a need for RCTs to assess this 8.
USEFUL CONTACTS
ENT Registrar- via SCH switch 9-5pm, via RHH switch out of hours
Ophthalmology- Bleep 250 9-5pm for urgent reviews or queries, via RHH out of hours or for
advice
If any Red flag features are present, needs to be reviewed by General Paediatric team.
Neurology Registrar- Bleep 164 for advice ONLY after review by General
Paediatricians.
Author: Ala Fadilah Review date: September 2021
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Bell’s Palsy
QUICK REFERENCE SUMMARY
Patient referred by
A&E/GP
All patients
General Medical ENT Review within
Team 24hrs
HISTORY Do not treat as Bell’s
Bell’s Palsy: Palsy.
Acute history, unilateral facial Red Manage accordingly
weakness, systemically well, no flags -Consider further
identifiable indicator of cause of facial present investigations and
nerve weakness admission
-Consider referrals to
RED FLAGS other team dependent
History more than few days systemically
unwell on symptoms/signs
Pain/headache eg., ENT, Neurology
Fever Haematology
History of trauma
Forehead sparing/bilateral involvement
Earache, ear discharge, hearing disturbance
Abnormalities on neurological examination
Headache, neck stiffness, photophobia Do not treat as Bell’s
Visual disturbance Palsy
Rashes/bruising/Pallor/Swollen glands
Hypertension -Neurology opinion if
Cold sores/blisters abnormalities on
Weakness, numbness of limbs, change in neurological
gait, clumsiness examination
Change in behaviour or school performance
Progression beyond 3 weeks/recurrence -Medical/Cardiology/
Renal opinion if high
BP
-Ophthalmology
Not simple Bell’s opinion if red, painful,
EXAMINATION Palsy swollen eye or visual
-Blood pressure-Systemic disturbance
examination
-ENT examination
-Full neurological examination
-Consider
Neuroimaging if other
neurological findings,
Bell’s Palsy history of trauma or
other concerning
history (seek
INVESTIGATIONS neurology advice)
-No investigations if simple -Consider bloods if
Bell’s Palsy systemically unwell,
infection or
malignancy suspected
Author: Ala Fadilah Review date: September 2021
© SC(NHS)FT 2017. Not for use outside the Trust. Page 5 of 7CAEC Registration Identifier: 1554 Sheffield Children’s (NHS) Foundation Trust
Bell’s Palsy
QUICK REFERENCE SUMMARY
Management/Follow-Up
MANAGEMENT If eye red, painful, swollen,
Eye Care: visual disturbance, eye
-Artificial tears: eg. Viscotears closure significantly affected Refer to
0.2% eye drops during Ophthalmology
daytime
Lacrilube eye ointment at
night
-Advise covering eye at night
Steroids:
-Consider if less than 72 Advise to seek
hours since onset & no urgent medical
contra-indication advice if:
-Prednisolone 1mg/kg (max -Worsening
50mg) for 5 days, then taper weakness
over next 5 days -Severe Headache
-Ear discharge or
Antiviral: earache
-Only if clinical evidence of -Red or painful eye
herpes simplex or varicella Advice to parents
or visual disturbance
zoster infection: -Severe Facial
Aciclovir (see BNFC for doses numbness or pain
according to age, weight, viral -Vesicles in ear or
aetiology) mouth
-Development of
new neurological
symptoms or signs
-Recurrence of
weakness following
recovery
No further follow-up
FOLLOW-UP Improving if near complete
resolution
-For simple Bell’s Palsy:
ENT follow-up 4 weeks
-Ophthalmology follow-up as Consider neurology
needed opinion or referral to
Possible alternative appropriate specialty
diagnosis/progressing by 3 +/- Neuroimaging
weeks, no improvement at 3
months
Author: Ala Fadilah Review date: September 2021
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Bell’s Palsy
4. References
1. Rowlands S, Hooper R, Hughes R, et al. The epidemiology and treatment of Bell’s palsy
in the UK. Eur J Neurol 2002;9:63–7
2. Peitersen, Erik. "Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve
palsies of different etiologies." Acta Oto-Laryngologica 122.7 (2002): 4-30.
3. Wolfovitz, Amit, Noam Yehudai, and Michal Luntz. "Prognostic factors for facial nerve
palsy in a pediatric population: A retrospective study and review." The
Laryngoscope 127.5 (2017): 1175-1180
4. Morales DR, Donnan PT, Daly F, et al Impact of clinical trial findings on Bell's palsy
management in general practice in the UK 2001–2012: interrupted time series
regression analysis BMJ Open 2013;3:e003121. doi: 10.1136/bmjopen-2013-003121
5. Baugh, Reginald F., et al. "Clinical practice guideline: Bell’s palsy." Otolaryngology—
Head and Neck Surgery 149.3_suppl (2013): S1-S27.
6. Malik, Vikas, et al. "15 minute consultation: a structured approach to the management
of facial paralysis in a child." Archives of Disease in Childhood-Education and
Practice 97.3 (2012): 82-85.
7. Mutsch, Margot, et al. "Use of the inactivated intranasal influenza vaccine and the risk
of Bell's palsy in Switzerland." New England journal of medicine350.9 (2004): 896-903.
8. Gagyor I, Madhok VB, Daly F, Somasundara D, Sullivan M, Gammie F, Sullivan F. Antiviral
treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database of Systematic
Reviews 2015, Issue 11. Art. No.: CD001869. DOI: 10.1002/14651858.CD001869.pub8
9. Madhok VB, Gagyor I, Daly F, Somasundara D, Sullivan M, Gammie F, Sullivan F.
Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database of
Systematic Reviews 2016, Issue 7. Art. No.: CD001942. DOI:
10.1002/14651858.CD001942.pub5
10. Pitaro, Jacob, Sofia Waissbluth, and Sam J. Daniel. "Do children with Bell's palsy
benefit from steroid treatment? A systematic review." International journal of pediatric
otorhinolaryngology 76.7 (2012): 921-926.
11. Eidlitz-Markus, Tal, et al. "Recurrent facial nerve palsy in paediatric patients." European
journal of pediatrics 160.11 (2001): 659-663.
Author: Ala Fadilah Review date: September 2021
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