Examination

The assessment of the child with facial nerve paralysis requires a full and thorough head to toe examination to ensure important clues to possible causes are not missed [10].

Examination of the ears includes:

Examination of the ears with an otoscope and tuning fork testing [3] is critical, otherwise the rash of Ramsay Hunt syndrome may be missed.

Detailed testing of hearing using the Rinne and Weber tests is useful to identify the presence of other cranial nerve abnormalities which suggest the necessity for further investigation at the outset.

Rinne test

• Rinne test is conducted by tapping a 512 Hz tuning fork and holding it adjacent to the ear (air conduction), followed by placing the base of the tuning fork to the mastoid process (bone conduction)
• Normally, air conduction>bone conduction, i.e. Rinne positive [11]
• In conductive deafness, bone conducts>air (reversed), and Rinne test is positive with neural deafness [11]

Weber test

• Weber test is conducted by tapping a 512 Hz tuning fork and holding the base against the vertex in midline
• In neural deafness, the tone will be heard better in the intact ear [11]
• In conductive deafness, it is heard better in the affected ear [11]

Examination of the face

Facial examination should include facial expression, inspection of the oropharynx for asymmetry [3], assessment of eye closing and inspection of the eye itself for inflammation, tearing, pain and visual impairment. Where the eye cannot be closed, fluorescein instillation and examination under cobalt blue light should be performed to exclude corneal abrasion and ulceration [1]

Rashes

Examine the skin for rashes. Specific relevant rashes include Erythema migrans, which may suggest Lyme disease (see photo), and Herpes zoster, which may suggest Ramsay-Hunt syndrome

Lymphadenopathy

Lymphadenopathy may be present with lymphoma or neoplasm and is an indication for specialist referral.

Blood pressure

Hypertension, when identified with facial nerve paralysis, requires specialist management and further investigation.

Joint examination

Examine the musculoskeletal system for pain and swelling, particularly in the major joints. Joint involvement may be seen with Lyme disease