A CASE REPORT:

BELLS PALSY IN AN 11 MONTH-OLD INFANT

*

Lina LingChooi, MS ,**Abu BakarZulkiflee, MS*,***Narayanan Prepageran, FRCS

ABSTRACT
Objective: To report a rare case of infantile facial nerve paralysis.
Case Report:An 11 month old boy presented with history of sudden right facial asymmetry of 1 day duration.
Mother denied any history of fall or trauma. Otherwise, he was active, except for the dripping of the milk on the
affected site on feeding. On further examination, child had right facial palsy involving loss of the nasolabial fold.
However child was still able to close the eyes while sleeping. Other cranial nerve findings were normal. Child
was admitted for observation with no worsening of the facial nerve function. He was started on oral steroid
therapy for 1 week duration. Facial nerve function recovered fully after 2 weeks with no other further intervention.
Conclusion: Bells palsy in infant is relatively rare and regards as diagnosis of exclusion. Clinical improvement
is favourable within two weeks and usage of steroids remains controversial.
Keywords: Facial Nerve Palsy, Bells Palsy, Paediatrics Nerve Palsy, Steroids.

INTRODUCTION

Vol.-9, Issue-II, July-Dec. - 2015

Paralysis of the facial nerve is usually immediately

obvious. Whether it develops in a child or an adult,
facial nerve paresis or paralysis has a tremendous impact
on the patient as well as the family, particularlywhen a
paediatric patient is involved.It results in weakness of
the musculature of the face, impacting verbal
communication, social interaction with respect to facial
expression, oral competence, taste and, most
importantly, protection of the cornea and vision2.
Facial paralysis can be caused by numerous
conditions, all of which should be excluded before a
diagnosis of Bells palsy is reached. Facial nerve paralysis
which was observed, ranging in age from birth to 18
years shows that Bellspalsy was the most common cause
(42%), followed by trauma (21%), infection (13%),
congenital (8%) and neoplasm (2%)1.
CASEREPORT
An 11 month-old boy brought to the paediatrics
emergency by his parents with history of sudden right
facial asymmetry of 1 day duration. The child had 1
episode of fever the previous day and on the day of
presentation was afebrile. Mother denied any history
of fall or trauma. Otherwise, he was active, except for
28

the dripping of the milk on the affected site on feeding.

He had no other ear or nose symptoms. On further
examination, child had right facial palsy involving loss
of the nasolabial fold(Figure 1), however child was still able
to close the eyes while sleeping. Other cranial nerve
findings were normal. Ears, nose and oral cavity were
normal. His complete blood count was normal.
Otoacoustic emission(OAE), tympanometry and
stapedial reflex were all normal.
Child was admitted to the paediatric ward for 1
day for observation with no worsening of the facial
nerve function. He was started on oral steroid therapy
for 1 week duration. Facial nerve function recovered
Affiliations:
:*
Medical Registrar/Fellow,
**
Clinical Specialist and Lecturer,
***
Consultant Otolaryngologist, Skull Base, Head and Neck Surgeon,
Department of Otolaryngology,Faculty of Medicine,
University of Malaya Medical Centre,
Pantai Valley, 50603 Kuala Lumpur,
Malaysia.
Address of Correspondence:
Dr. Mohd. Zulkiflee Abu Bakar (AB Zulkiflee),
Department of Otolaryngology,
University of Malaya Medical Centre,
50603 Kuala Lumpur, MALAYSIA.
Tel: +603 7949 2062
Fax: +603 7955 6554
Email: abzulkiflee@yahoo.com

Fig.1: An 11 month-old child presented with right facial

palsy.

Fig. 2 : Right Facial Nerve fully recovered after 2 weeks.

fully after 2 weeks with no other further

intervention(Figure 2).

location of nerve injury. Presence of the stapedial reflex

in cases of incomplete paralysis or return of the
stapedial reflex within 3 weeks of disease onset predicts
complete recovery of the nerve by 3 to 8 weeks2.

A child presenting with acute-onset facial palsy

requires a detailed history and physical examination to
rule out recognizable and treatable causes. The history
should detail the date of onset, rapidity of progression,
any preceding history of viral illness or trauma, and
associated systemic symptoms to rule out traumatic,
infectious, neoplastic, or hematologic causes. Bells palsy
is generally a diagnosis of exclusion.
The prognosis for patients with Bells palsy is
generally excellent, particularly in children, in whom
the risk of recurrence is only 7% to 10% 1. Most children
will recover within two to four weeks 3. Clinical
examination to determine whether the child has paresis
or complete paralysis, is the most important prognostic
test. Prognosis for the child presented with paresis at
onset, is invariably good.
Children with uncomplicated Bells palsy may not
usually require further testing. However,further testing
is recommended when the child presents with complete
paralysis or when no signs of initial recovery are
apparent within 3 weeks of disease onset 1 .
Topodiagnostic test which include Schirmers tear test,
the stapedial reflex test, and evaluation of salivation and
taste on the involved side is performed to assess the

Different electrophysiological tests have been

applied in adults with facial palsy to assess the
prognostic significance as it provide a more accurate
and objective prediction of subsequent improvement.
Electroneu-rography (ENoG), electromyography and
blink reflex (BR) had been found to be useful 3.
However, the value of ENoG and BR had rarely been
reported in children, probably because the majority of
children recovered, and thus they were seldom referred
to the paediatric neurologist or neurophysiologist4.
Radiologic imaging such as MRI is not routinely
indicated, because determining the site of facial nerve
involvement is not useful in predicting recovery. MRI
may be recommended in patients with apparent Bells
palsy who have paralysis persisting for more than 3
months, recurrent facial palsy, or single facial nerve
segment involvement, to rule out a neuroma or any
underlying neurologic disorder5.
It has been proposed that Bells palsy results from
inflammation and edema of the facial nerve, most likely
initiated by infection with Herpes Simplex Virus
(HSV)4. Consequently, common treatment approaches
include steroids to reduce facial nerve inflammation,
acyclovir to treat the inciting infection.
29

Vol.-9, Issue-II, July-Dec. - 2015

DISCUSSION

An other vital aspect of treatment is eye

care.However, due to a paucity of properly randomized
studies in children with Bells palsy, the efficacy of
steroids as well as of other therapies can only be
extrapolated from studies done in adults. Whether
corticosteroids are necessary or even more effective
than in adults remains controversial.Most pediatric
trials did not provide conclusive evidence of any benefit
in using steroid or acyclovir as treatment1.

trial of oral steroids may be offered to all patients

presenting within the first 2 to 3 weeks of onset of
facial paresis, even though there is no conclusive
evidence of their benefit.

However, steroids are generally safe and probably

effective in improving facial function outcomes. In this
infant, we commenced syrup prednisolone 1mg/kg/
day with tapering dose.

(d) No financial disclosures

Hence, early treatment with oral steroids is

probably effective to improve facial function.Use of
acyclovir either in combination with steroid or alone
are still controversial and that acyclovir is only possibly
effective in improving facial functional outcome1.

DISCLOSURES
(a)

(b) Sponsorships - None

(c)

Vol.-9, Issue-II, July-Dec. - 2015

30

Funding - None

REFERRENCES
1.

Pratibha Singhi, Vivek Jain, Bells Palsy in

Children, Seminars in Pediatric Neurology, Vol
10, No 4 (December), 2003: 289-297.

2.

Josef Finsterer,Management of peripheral facial

nerve palsy, European Arch Otorhinolaryngol.
2008 July; 265(7): 743752.

3.

Evans AK, LicameliG, BrietzkS, Pediatric facial

nerve paralysis: Patients,management and
outcomes International Journal of Pediatric
Otorhinolaryngology 2005;69 : 15211528.

4.

Virginia Wong,Outcome of facial nerve palsy

in 24 children, Brain & Development 1995;
17:294-6.

5.

Han-sheng Tsai et al, Epidemiology and treatment

of Bells Palsyinchildren in northern Taiwan,
MicrobiolImmunolInfec. 2009, 42:351-356.

CONCLUSION
While this is a relatively rare event in the pediatric
population, Bells palsy does occur. Fortunately it is a
self-limiting condition with a favourable prognosis.
However we should not disregard other probable
diagnosis of children presenting with facial nerve palsy
as Bells palsy is still a diagnosis of exclusion. Further
investigation may not be needed but it is recommended
if the disease do not show any sign of improvement. A

Competing interests/Interests of Conflict- None