Bell’s Palsy Management Guideline

Bell’s Palsy is a unilateral lower motor neurone facial palsy without a detectable underlying cause, therefore it is a diagnosis of exclusion.
The incidence is about 6 per 100,000 in the paediatric population.

Clinical features: • Unilateral lower motor neurone weakness
• Upper respiratory tract infection in previous month
• Posterior auricular pain in previous days
• Increased tearing (poor tear clearance due to weakness)
• Dry eyes
• Hyperacusis
• Rapid onset – most patients present within 48 hours.

Other diagnoses to consider: Facial nerve trauma following facial/skull trauma
Hypertension
Lyme disease
Acute or Chronic Otitis Media
Cholesteatoma
Mastoiditis/Osteomyelitis
Herpes zoster (Ramsay Hunt Syndrome)
Leukaemia
Stroke
Disseminating encephalomyelitis

Examination

General examination including BP

Full neurological examination:
Consider acute imaging and neurology referral if:
Weakness not involving forehead. (upper motor neuron signs)
Retention of emotional smile
Other cranial nerves abnormal
Neurological exam abnormal

ENT exam including otoscopy: Consider acute ENT referral if:
Tympanic membrane inflamed, has vesicles or is granulomatous
Parotid swelling

Management in the acute phase

1. Eye protection:
Hypermelose eye drops 4 × per day
Eye patch with hypermelose drops overnight if incomplete eye closure

2. Steroids
Currently no evidence for steroid use in children, discuss with a consultant)
In adults, steroids expedite recovery a if given within 72h of onset
Prednisolone 1 mg/kg OD (max 50 mg) 7 days

3. If vesicicles/signs of herpes zoster (and within 72 h of onset)
Aciclovir (2 years to adults) 200 mg per dose 5 × per day 5 days

Follow Up

Review in paediatric outpatients or by GP in 1-2 weeks. If the symptoms continue to improve then no further follow up needed

If signs/symptoms suggestive of an alternative diagnosis then investigate as appropriate and book follow-up- neurology clinic

Patient information for idiopathic facial palsy (Bell’s palsy)

Simple analgesics for pain (Paracetamol)
Some people experience sensitivity to sounds during acute stages.
Weakness may initially worsen then stabilize before improvement.
Most children recover fully by 6 weeks, some take up to 1 year.
Around 10% will get some continuing weakness or the nerve grows back to the wrong areas.

Seek medical advice if;
Red or painful eye
Continued progression of weakness after 48 hours
Different or new symptoms eg
Headache
Vomiting
Temperature
Disturbed vision
Weakness or abnormal sensation in another part of the body or affecting other areas of the head or neck
No improvement after 4-6 weeks

References:

Bell’s Palsy: A guideline proposal following a review of practice Journal of Paediatric and Child Health 44 (2008) 219-220 Robert Lunan1 and Lakshmi Nagarajan2
1Fraser of Allander Neurosciences Unit, Royal Hospital for Sick Children, Glasgow, UK, 2Department of Neurology, Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia

Cochrane Database Syst Rev. 2010;(3):CD001942.
Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Treatment of Bell’s palsy: should antiviral agents be added to prednisolone? Mattar S. St Michael’s Hospital, Bristol
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