Paediatric Acute care Guidelines PMH Emergency Department

All patients presenting within 72 hours onset of Bell’s Palsy should be enrolled in the PMH Emergency Department Bell’s Palsy Study (BellPic).
Please contact the PMH Emergency Department Consultant for information.

Background

Bell’s Palsy is the unilateral lower motor neurone facial nerve palsy without detectable underlying cause. 

Differential Diagnosis 

  • Preceding trauma
  • General health / concurrent illness
  • Acute or chronic otitis media
  • Cholesteatoma
  • Mastoiditis / osteomyelitis
  • Herpes Zoster (Ramsay Hunt Syndrome)
  • Rare: congenital/metabolic/genetic/neoplastic

Assessment 

Bell’s Palsy is diagnosed by physically examining the child and excluding other causes of facial weakness and paralysis

Features include: 

  • Unilateral lower motor neurone facial nerve palsy
  • Upper respiratory tract infection in previous month
  • Posterior auricular pain in previous days
  • Poor tear clearance due to weakness 
  • Dry eyes
  • Hyperacusis
  • Rapid onset – most patients present within 48 hours

Examination

Bell's Palsy Examination

House Brackmann Facial Grading Scale
Grade Definition
1 Normal symmetrical function in all areas 
2 Slight weakness noticeable only on close inspection. Complete eye closure with minimal effort. Slight asymmetry of smile with maximal effort. 
3 Obvious weakness, but not disfiguring. May not be able to lift eyebrow. Complete eye closure; strong but asymmetrical mouth movement with maximal effort. 
4 Obvious disfiguring weakness. Inability to lift brow. Incomplete eye closure and asymmetry of mouth with maximal effort. 
5 Motion barely perceptible. Incomplete eye closure, slight movement of corner of mouth. 
6 No movement; loss of tone. 
Synkinesis (abnormal re-wiring of the nerves when healing) : will usually not be a clinical issue in ED. This will develop later in Bell’s Palsy

Investigations

  • Swab for PCR and blood for titres if vesicles are noted

Management of idiopathic facial palsy

  • Consider eligibility for enrolment in BellPic study
  • If less than two years of age and/or the diagnosis of Bell’s palsy is uncertain consider a neurology and/or ENT consult 
  • If not enrolled in BellPic study (not eligible or consent refused), consult with the on call Neurologist regarding use of steroids. 
  • Photographs of the face of the child at initial presentation and on follow up are useful to monitor progress. Instructions as per the Health Facts – Bell’s Palsy
  • Ensure eye protection advice is given. 
Eye Protection 

Gel based lubricant for use during the day

  • Option 1: Viscotears or GelTears (both carbomer 980 0.2%) – QID
  • Option 2: Genteal Gel (carbomer 980 0.2%, hypromellose 0.3%) or Refresh Liguigel (carmellose 1%) initially QID then reduce to TDS when back at school – for ease of use.

Ointment for night time until lid closure is complete

  • Lacrilube, Polyvisc or Ircal (all paraffin and wool fat)

Severe lid laxity/redness

  • Lacrilube, Polyvisc or Ircal (all paraffin and wool fat) can be used QID
Note 
If the eye becomes red (and fails to settle over a few days with increased lubricant) or the Bell’s is not resolving as expected over 4-6 weeks then ophthalmology should be involved to consider whether a tarsorrhaphy is required. 

Follow Up

  • Provide Bell’s Palsy Health Facts sheet to carer
  • Review in the Emergency Department in 2 weeks
    • If improving – no further follow up
    • If not improving – review history and examination as above and discuss with the on call Neurologist

References

  1. Lunan R, Nagarajan L. Bell’s palsy: A guideline proposal following a review of practice. Journal of Paediatrics and Child Health 44 (2008) 219‐220
  2. House JW, Brackmann DE. Facial nerve grading system. Orolaryngol – Head and Neck Surgery, 1996; 114:380-6

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