Facial nerve palsy can be congenital or acquired: this page refers to acquired only. This is characterized by rapid onset of unilateral facial weakness, and is particularly troublesome if it causes inability to close the eye or mouth (drooling). The severity can be variable between the particular facial areas (eyes, nose, mouth).
The most important grading and management decision is the ability to close the eye. If eye closure is not possible or restricted, the cornea is at risk of drying out and injury and the eye needs to be protected.
In children facial nerve paralysis can be secondary to middle ear pathology, in particular acute otitis media. Most commonly no underlying pathology is detected (idiopathic) and the diagnosis is Bell’s Palsy.
Acquired facial nerve palsy is rare in children (approximately 6/100.000). The prognosis is good with about 70% spontaneous resolution within 3 months of onset. Improvement is expected within the first 3 to 6 weeks.
Causes of Facial Nerve Palsy:
- Bell’s (idiopathic) – see Primary Care Management for more information
- Viral
- Acute otitis media (AOM)
- Chronic suppurative otitis media (CSOM) – with cholesteatoma a very rare pathology
- Otitis media effusion (OME) (very rarely)
- Lyme borreliosis can present with lower motor neurone facial nerve palsy. If any history of tick bites (particularly, but not exclusively, within the last 30 days); if any suggestion of erythema migrans particularly of head and neck area; or if history of the progression of palsy is unusual.
- If that is a possibility, discuss with infectious diseases.
G.T & C.M – 12-10-26
- Refer to A&E: AOM, CSOM, systemic illness, parotid/neck mass
- Refer to A&E or medical/neurology: neurological symptoms or atypical features (cranial nerve, limbs), bilateral or recurrent episodes, gradual progression
- If Lyme borreliosis is suspected, discuss with infectious diseases
- If Idiopathic (Bell’s): if no improvement at 1 month with treatment, refer to Neurology.
- If eye symptoms (incomplete closure / pain / erythema) discuss with ophthalmology urgently – will need eye protection.
Treat underlying condition if identified.
Idiopathic lower motor neurone cranial nerve VII palsy (absence of forehead wrinkles).
Treatment:
- Should be ideally commenced within 72hours if no contraindications
- Prednisolone 1mg/kg OD 10 days on reducing regime (NB NO Acyclovir if Bell’s)
- Add Acyclovir if Ramsey Hunt (vesicles on TM/Soft palate)
- Eye protection – due to lack of eye closure consider:
- Tape eye shut at night
- Topical eye tears / ointment day and night
- Patching when outside (protection from grit).
NICE CKS – Bell’s palsy Bell’s palsy | Health topics A to Z | CKS | NICE
Facial Palsy UK provide a wealth of information in Facial Palsy recovery / analysis and local and online support.
