Bell’s Palsy in Children

Bell’s palsy is an idiopathic unilateral lower motor neurone facial nerve paralysis of acute onset [1] which includes:

• Inability to wrinkle the forehead on the affected side
• Inability to close the affected eye
• Flattening of the nasolabial fold on the affected side

The incidence of Bell’s palsy is:

• 20-25/100 000 per year in adults [2,3]
• 13-30/100 000 per year in all age groups [4]
• 1.6/100 000 per year in children [4]

There are no geographic, gender or race differences. [2]

The incidence in children is lower than in adults and needs careful assessment to look for potentially serious causes. [3]

Learning bite

Lower motor neurone paralysis of the facial nerve affects the entire face. Upper motor neurone weakness only affects the lower half of the face. [1]

Anatomy

The facial nerve (cranial nerve VII) supplies motor branches to the muscles of facial expression and supplies some sensory and parasympathetic fibres (see Table 1).

Fig.1 Image courtesy of the authors

Bell’s Palsy and Other Causes of Facial Nerve Paralysis

Diagnosis of Bell’s palsy is reached only once other causes are excluded. In children, Bell’s palsy is a much less common cause of lower neurone facial nerve paralysis than is the case in adults.

Other causes of facial nerve paralysis may include: 

Infection

Trauma [5]

VII cranial nerve is the most commonly injured nerve in head trauma:

• Typically, temporal fracture with nerve transection
• Basal skull fracture

 Systemic diseases [5]

Systemic diseases which may cause facial nerve paralysis include:

• Sarcoidosis [5]
• HIV [5]
• Polio 
• Tuberculosis 
• Multiple sclerosis 
• Guillain–Barré syndrome 
• Diabetes

 Neoplasm 

Typically progressive course over 3 weeks, but sudden onset does not rule out:

• Parotid gland tumours [5]
• Pontine tumours 
• Acoustic neuroma
• Leukaemia
• Developmental hypoplasia/aplasia [6]

Learning bite

Bell’s palsy is only one of many potential causes of facial nerve paralysis. [2,7]

Symptoms and Associated Features

A detailed history of symptoms and associated features should be reported.

Symptom onset includes:

• Date of onset [1]
• Rapidity of progression [1]
• History of preceding viral illness or trauma [1]
• Rash [3]
• Other evidence of infection

Associated features may include[3]:

• Ear pain 
• Sensory changes on affected side of face
• Reduced tears 
• Overflow of tears
• Hyperacusis 
• Altered taste sensation 

Neoplastic Origins

Fig.2 Image courtesy of the authors

Progression of paralysis beyond 3 weeks suggests a possible neoplastic cause and this is one of the reasons that follow-up is recommended for children presenting with facial nerve paralysis. [2,3,7,8]

The MRI is of a 7-year-old boy with astrocytoma causing facial weakness. Click on the MRI scan to enlarge.

Neoplastic origin in children is suggested by [7,8]:

• Gradual progression of paralysis beyond 3 weeks [2,3]
• No return of function after 6/12
• Ipsilateral recurrence [2,3]
• Facial hyperkinesia (particularly hemifacial spasm)
• Associated cranial neuropathies and other neurological signs [2,3]
• Pain
• Single branch involvement

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. [9]

It is important to distinguish between the following types of facial nerve paralysis (Table 2):

• Central facial nerve paralysis
• Peripheral facial nerve paralysis

Neurological examination should include:

• Cranial nerves and peripheral nervous system
• Testing of VIIn should reveal a lower motor neurone (LMN) pattern with inability to wrinkle the forehead. Preservation suggests a central cause

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. [9]

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 [10]
• In conductive deafness, bone conducts>air (reversed), and Rinne test is negative, indicating neural deafness. [10]

Weber test [10]

• 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
• In conductive deafness, it is heard better in the affected ear
• In normal hearing the tone will be heard equally between the two ears.

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.

A history typical of Bell’s palsy with normal findings on examination does not warrant investigation immediately.

Most children presenting with uncomplicated facial nerve paralysis need no investigation.

However, there are exceptions. Some ENT and Haematological specialists recommend performing a full blood count with film in all cases at the outset to identify serious causes such as leukamia early. [2,11]

Children with a history of travel to or living in an area where Lyme’s disease is endemic and a history of exposure to a tick prone environment such as field or forest, should have Lyme serology performed.

Lyme disease distribution can be found here.

Suggestive history, central or UMN CNVII palsy, other focal neurology peripherally, or other cranial nerve abnormality on examination should all prompt imaging. MRI is preferable for investigating a possible underlying neoplasm [1]; CT is preferable if an acute traumatic cause is suspected.

Formal follow-up is essential, irrespective of investigations performed. Nerve conduction studies, electromyography and electroneurography, and acoustic reflex determination (ipsilateral and contralateral) are not investigations required in the emergency department, however, these may have a role during follow-up. [2]

Features atypical of Bell’s palsy require referral [12] for exclusion of an alternative diagnosisand include:

• Insidious and painful onset. Gradual progression is more likely to be associated with a neoplastic or infectious cause of facial palsy.
• A progressive and prolonged (more than 3 months) duration of symptoms with frequent relapses (indicative of a neoplastic process).
• Predisposing factors for facial palsy, for example, previous stroke, brain tumour, parotid tumour, skin cancers of the head and face, or facial trauma.
• Systemic illness or fever.
• Vestibular or hearing abnormalities (other than hyperacusis), otorrhoea, diplopia or dysphagia.
• Sparing of forehead movement (which may indicate an upper motor neurone lesion such as stroke) and bilateral signs (may be indicative of Lyme disease or sarcoidosis). Lower motor neurone lesions (such as Bell’s palsy) do not spare the upper face.
• A recurrent episode.
• Paralysis of individual branches of the facial nerve or other cranial nerve involvement.
• Parotid gland masses, vesicular skin rashes, and lesions suggestive of skin cancer.

Refer to a facial nerve specialist (for example, a neurologist or ear, nose, and throat specialist) if there is doubt about the diagnosis or a person with Bell’s palsy has:

• No improvement after 3 weeks of treatment.

Management of Bell’s Palsy

There is very little evidence specifically from paediatric populations on the management of Bell’s palsy, despite a growing adult evidence base.

Corticosteroids

In the management of adult Bell’s Palsy, following a Cochrane review in 2015 there is a clear recommendation to use corticosteroids if the patient presents within 72 hours of the onset of symptoms. The dosage regimen, however, remains unclear.

There is very little data pertaining to Bell’s Palsy in the paediatric population, and no RCTs until one study published in 2024. BellPIC [13] was a multicentre, placebo-controlled randomized trial conducted in Australasia, later described and critically appraised by Don’t Forget the Bubbles, [14] suggested that there is no more than a marginal likelihood that prednisolone is beneficial when used in children with Bell’s palsy.

Follow-up Strategies

If no other cause of acute facial paralysis is identified, in the absence of risk factors for underlying malignancy or other causes, the patient may be discharged from the ED with a suitable follow-up plan:

GP

• Ideally the child should be seen within 3 weeks by their GP or a doctor in the ED for review
• If, at this stage, there are any signs of progression or any other worrying features have become apparent, then referral to a specialist should be made and arrangements made for further testing (electro/neurophysiology testing)

Follow-up

• If there are signs of recovery by 1 month, routine follow-up at 3, 6 and 9 months is recommended. [1]
• Monitoring should be for a minimum of 1 year (risk of missing long term sequelae if not done). [3]

 Prognosis

• Examination to determine if paresis (incomplete paralysis) or complete paralysis is present is the most important prognostic test at the outset.
• Paresis at onset can be followed up clinically, because prognosis is invariably good.
• Further testing is recommended in cases of complete paralysis or if no signs of recovery within 3 weeks of disease onset. [1]
• In patients who recover without treatment, major improvement occurs within 3 weeks in most cases. [3]

Natural history of Bell’s palsy in children states that [15]:
“True Bell’s palsy is thought to be more benign, with a tendency toward complete resolution in many cases within 2 months of onset of facial paralysis and by 6 months in most cases.”

Discharge advice needs to contain information on worrying features so that parents/patients themselves can return early if such features develop. [9]

Upon discharge, the following should be explained:

• Administer analgesia for pain as needed (paracetamol)
• Child may experience sensitivity to sounds during acute stages
• Child may initially worsen before improving
• Most children recover fully by 6 weeks, although may take up to 1 year
• 10% will get some continuing weakness or the nerve may grow back to the wrong area
• Medical advice should be sought if any concerning symptoms occur

Concerning symptoms

• Red/painful eye
• Progression of weakness after 48 hours
• Different or new symptoms such as:
  • Headache
  • Vomiting
  • Temperature
  • Disturbed vision
  • Weakness
  • Abnormal sensation in another area of the body or head or neck

•  No improvement in facial paralysis after 1 month.

1. Singhi P, Jain V. Bell’s palsy in children. Semin Pediatr Neurol. 2003 Dec;10(4):289-97.
2. Pancioli A. Part Three Medicine and Surgery, Section VII Neurology. In: Rosen, ed. 99 Brain and Cranial Nerve Disorders: Facial Nerve Paralysis. 5th Ed Vol 2. Oxford: Oxford University Press, 2006:1488-1489.
3. El-Hawrani AS, et al. General practitioners’ referral pattern for children with acute facial paralysis. J Laryngol Otol. 2005 Jul;119(7):540-2.
4. Wyatt JP, Illingworth RN, et al. Chapter 12: Ear, Nose and Throat In: Oxford Handbook of Emergency Medicine, 4th Ed. Oxford: Oxford University Press, 2012:545.
5. Hope RA, Longmore JM, McManus SK et al. Chapter 10: Neurology, Cranial Nerve Lesions Bell’s Palsy. In: Oxford Handbook of Clinical Medicine. 4th Ed. Oxford: Oxford University Press, 1998:460-461.
6. Grundfast KM, Guarisco JL, Thomsen JR, Koch B. Diverse etiologies of facial paralysis in children. Int J Pediatr Otorhinolaryngol. 1990 Aug;19(3):223-39.
7. Lunan R, Nagarajan L. Bell’s palsy: a guideline proposal following a review of practice. J Paediatr Child Health. 2008 Apr;44(4):219-20.
8. Thomas J, Monaghan T. Chapter 10: The Nervous System Cranial nerve VIII: vestibulocochlear. In: Oxford Handbook of Clinical Examination and Practical Skills. 4th Ed. Oxford: Oxford University Press, 1997:314.
9. Bhattacharyya AK, Ghosh S. Paediatric facial paralysis. Current opinion in evaluation and management. Indian J Otolaryngol Head Neck Surg. 1999 Jul;51(3):21-7.
10. Ciorba A, Corazzi V, Conz V, Bianchini C, Aimoni C. Facial nerve paralysis in children. World Journal of Clinical Cases. 2015;3(12):973-979.
11. Ashtekar CS, Joishy M, Joshi R. Do we need to give steroids in children with Bell’s palsy? Emergency Medicine Journal 2005;22:505-507.
12. National Institute for Health and Care Excellence (NICE), Bell’s palsy: NICE CKS. Last revised: February 2023.
13. Mulcaire, J. Habgood, E. Bells Palsy, Don’t Forget the Bubbles, 2023.
14. Babl FE, Herd D, et al. Facial Function in Bell Palsy in a Cohort of Children Randomized to Prednisolone or Placebo 12 Months After Diagnosis. Pediatr Neurol. 2024 Apr;153:44-47.
15. Teixeira LJ, Valbuza JS, Prado GF. Physical therapy for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2011 Dec 7;(12):CD006283.
16. Babl FE, Mackay MT, Borland ML, et al. Bell’s Palsy in Children (BellPIC): protocol for a multicentre, placebo-controlled randomized trial. BMC Pediatr. 2017 Feb 13;17(1):53.