Facial nerve palsy: etiology and approach to diagnosis and treatment

Overview of pediatric peripheral facial nerve paralysis: analysis of 40 patients

Peripheral facial nerve paralysis in children might be an alarming sign of serious disease such as malignancy, systemic disease, congenital anomalies, trauma, infection, middle ear surgery, and hypertension. The cases of 40 consecutive children and adolescents who were diagnosed with peripheral facial nerve paralysis at Baskent University Adana Hospital Pediatrics and Pediatric Neurology Unit between January 2010 and January 2013 were retrospectively evaluated. We determined that the most common cause was Bell palsy, followed by infection, tumor lesion, and suspected chemotherapy toxicity. We noted that younger patients had generally poorer outcome than older patients regardless of disease etiology. Peripheral facial nerve paralysis has been reported in many countries in America and Europe; however, knowledge about its clinical features, microbiology, neuroimaging, and treatment in Turkey is incomplete. The present study demonstrated that Bell palsy and infection were the most common etiologies of peripheral facial nerve paralysis.

Clinical practice guideline: Bell's palsy

OBJECTIVE

Bell's palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mono-neuropathy, or disorder affecting a single nerve, and is the most common diagnosis associated with facial nerve weakness/paralysis. Bell's palsy is a rapid unilateral facial nerve paresis (weakness) or paralysis (complete loss of movement) of unknown cause. The condition leads to the partial or complete inability to voluntarily move facial muscles on the affected side of the face. Although typically self-limited, the facial paresis/paralysis that occurs in Bell's palsy may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential eye injury. Additional long-term poor outcomes do occur and can be devastating to the patient. Treatments are generally designed to improve facial function and facilitate recovery. There are myriad treatment options for Bell's palsy, and some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, numerous diagnostic tests available are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy.

PURPOSE

The primary purpose of this guideline is to improve the accuracy of diagnosis for Bell's palsy, to improve the quality of care and outcomes for patients with Bell's palsy, and to decrease harmful variations in the evaluation and management of Bell's palsy. This guideline addresses these needs by encouraging accurate and efficient diagnosis and treatment and, when applicable, facilitating patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell's palsy. The target population is inclusive of both adults and children presenting with Bell's palsy. ACTION STATEMENTS: The development group made a strong recommendation that (a) clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute-onset unilateral facial paresis or paralysis, (b) clinicians should prescribe oral steroids within 72 hours of symptom onset for Bell's palsy patients 16 years and older, (c) clinicians should not prescribe oral antiviral therapy alone for patients with new-onset Bell's palsy, and (d) clinicians should implement eye protection for Bell's palsy patients with impaired eye closure. The panel made recommendations that (a) clinicians should not obtain routine laboratory testing in patients with new-onset Bell's palsy, (b) clinicians should not routinely perform diagnostic imaging for patients with new-onset Bell's palsy, (c) clinicians should not perform electrodiagnostic testing in Bell's palsy patients with incomplete facial paralysis, and (d) clinicians should reassess or refer to a facial nerve specialist those Bell's palsy patients with (1) new or worsening neurologic findings at any point, (2) ocular symptoms developing at any point, or (3) incomplete facial recovery 3 months after initial symptom onset. The development group provided the following options: (a) clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell's palsy, and (b) clinicians may offer electrodiagnostic testing to Bell's palsy patients with complete facial paralysis. The development group offered the following no recommendations: (a) no recommendation can be made regarding surgical decompression for patients with Bell's palsy, (b) no recommendation can be made regarding the effect of acupuncture in patients with Bell's palsy, and (c) no recommendation can be made regarding the effect of physical therapy in patients with Bell's palsy.

Effect of aging on the prognosis of Bell's palsy

OBJECTIVES

A large case study of patients with Bell's palsy was conducted to identify the difference in epidemiologic characteristics and trends according to age and to ascertain whether age is a significant prognostic factor in recovery.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral center.

INTERVENTIONS

From 1998 to 2011, 1,362 patients diagnosed with Bell's palsy were enrolled in this study. Age-based epidemiologic characteristics, associated diseases and associated symptoms, results of electrophysiologic testing, and impact of age on the final outcome were assessed.

RESULTS

Bell's palsy was much more common in men aged 11 to 40 years, after which, it became more common in women (p = 0.021). The proportions of patients with pain around the ear, hyperacusis, diabetes, and hypertension all increased with age (p < 0.001), but recovery rate did not differ among age groups (p > 0.05). However, we found that final recovery was influenced by lower initial grade, accompanying hypertension and younger age, in that order.

CONCLUSION

Although younger age were thought to be a major prognostic factor for recovery, the effect of age may be small because recovery rates were similar among age groups.

Clinical Features of Bell’s Palsy in Children and Outcomes of Physical Therapy: A Retrospective Study

The aim of this study was to describe clinical features of Bell’s palsy (BP) in children and outcomes of physical therapy interventions. Medical records of 186 patients with diagnosis of BP were reviewed. The severity of facial nerve dysfunction was graded according to House Brackmann Facial Nerve Grading Scale (HB FGS). After one month, patients who had HB FGS grade three or more were included in a physical therapy programme consisting of superficial heat, massage, exercises, and electrical stimulation. Among 186 children with BP, 167 children had a severity of HB FGS grade three or more and 19 had the incomplete type at the time of the diagnosis. After one month follow-up, 144 patients fully recovered, 35 patients recovered partially, while 7 patients had no recovery. Patients who had not fully recovered one month after onset of paralysis were included in the physical therapy programme. There was statistically significant difference between pretreatment and posttreatment HB FGS scores in patients who had not fully recovered one month after onset of paralysis. We concluded that the prognosis of BP in children seems to be good with higher recovery rate and physical therapy programme might be an effective method to facilitate recovery in patients with poor prognosis.

Do children with Bell's palsy benefit from steroid treatment? A systematic review

OBJECTIVE

To conduct an updated systematic review on the outcome of Bell's palsy (BP) in children following steroid treatment.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Library and BIOSIS Previews electronic databases were searched obtaining articles published between 2000 and 2010 without any language restriction.

REVIEW METHODS

Articles describing children aged 0-18 years with BP treated solely with corticosteroids were included. In studies including various etiologies for facial palsy; cases of BP treated with steroids were selected and when available, untreated patients as well for comparison. The outcome measure was facial movements following steroidal treatment based on different clinical scales. Controlled clinical trials, prospective and historical cohort studies, cross sectional studies and case series were included.

RESULTS

A total of 2293 papers were initially identified. Following review by two authors, 68 papers were analyzed in a hard-copy format. Finally, 6 studies were eligible to be included in the systematic review. Four of the studies included children with BP exclusively while the remaining studies described various etiologies of facial palsy. Type of steroid and duration of treatment were inconsistently specified. Outcome measures used include the House-Brackmann scale, Yanagihara grading system and clinical evaluation. Studies analyzed were retrospective cohorts or case-series and were categorized as level 4 of evidence.

CONCLUSION

There were no controlled trials and level 4 publications predominate. Therefore, the role of steroid treatment for BP in children is still inconclusive. Further studies are required.

Immunization and Bell's palsy in children: a case-centered analysis

Bell's palsy (BP) is an acute and idiopathic paralysis of the facial nerve, with an estimated incidence ranging from 11.5 per 100,000 person-years to 53.3 per 100,000 person-years in different populations. BP has been reported following immunization with inactivated trivalent influenza vaccine (TIV) and hepatitis B virus (HBV) vaccine. Epidemiologic studies examining this association among children are lacking. From 2001 through 2006, all children aged ≤18 years diagnosed with BP within the Kaiser Permanente Northern California population were identified using International Classification of Diseases, Ninth Revision, code 351.0. All electronically identified cases were reviewed and adjudicated by an otolaryngologist (n = 233). Using a case-centered approach, the authors examined the risk of BP during 3 risk intervals. Immunization with TIV (odds ratio (OR) = 0.7, 95% confidence interval (CI): 0.2, 2.8), HBV vaccine (OR = 0.8, 95% CI: 0.2, 2.4), or any vaccine (treating all vaccines combined; OR = 0.9, 95% CI: 0.6, 1.4) was not associated with increased risk of BP 1-28 days after immunization. Similarly, no association was found between vaccines and BP during the periods 1-14 and 29-56 days following immunization. Results of this study suggest that there is no association between immunization and BP in children.