1. Sunrise teaching
Elaine McKinley

2. 7 year old with unilateral lower motor neurone facial paralysis
Problem:
7 year old with unilateral lower motor neurone facial paralysis

3. Facial Nerve Cranial Nerve VII Efferent and afferent fibres
Motor: Controls muscles of facial expression and innervates Stapedius muscle
Sensory: conveys taste of the anterior two-thirds of the tongue
Parasympathetic: Salivary and lacrimal glands

4. Muscles of facial expression
Function
Occipitofrontalis
Raises eyebrows, wrinkles forehead horizontally
Corrugator Supercilii
Wrinkles forehead vertically
Orbicularis Oculi
Closes eye
Orbicularis Oris
Draws lips together
Zygomaticus Major
Elevates angle of the mouth (laughing)
Buccinator
Permits smiling; blowing / pursing of the lips

5. History Onset Progression Duration Unilateral/Bilateral
Associated symptoms
Any hx of head trauma / surgery
Immunisation hx (polio, rabies, tetanus & influenza)
Recurrence
PMHx

6. Symptoms Change in the appearance of the face
Difficulty closing one eye
Difficulty making expressions, grimacing
Difficulty with fine movements of the face
Facial droop
Difficulty eating (items fall out of the weak corner of the mouth)
Face feels pulled to one side
Face feels stiff
Headache
Impairment of taste
Pain behind the ear
Increased loudness of sound in one ear / Sensitivity to sound (hyperacusis)

7. Examination General systematic clinical examination
Full neurological examination, including focused cranial nerve examination
Examination of the neck must be performed to illicit a parotid neoplasm or cervical lymphadenopathy

8. Cranial Nerves I - VI

9. Cranial Nerves VII - XII

10. Signs of Facial Nerve Paralysis
Facial asymmetry
Eyebrow droop
Inability to wrinkle forehead
Drooping of corner of mouth
Inability to close eye and uncontrolled tearing
Unable to put hold lips tightly together

11. House-Brackmann scoring of facial function

12. Causes of Facial Nerve Palsy
Idiopathic
Bell’s palsy (40-70%)
Melkersson–Rosenthal syndrome (recurrent alternating facial palsy, furrowed tongue, faciolabial oedema)

13. Causes of Facial Nerve Palsy
2. Infection (13-36%)
Otitis media
Mumps
Mastoiditis
Infectious mononucleosis (glandular fever)
Herpes zoster cephalicus (Ramsay–Hunt syndrome)
Malaria
Chickenpox
Tuberculosis
Encephalitis
Lyme disease
HIV
Meningitis
Poliomyelitis (type I)

14. Causes of Facial Nerve Palsy
3. Trauma (19-21%)
Skull base fractures
Facial injuries
Penetrating trauma to middle ear
Barotrauma (altitude paralysis/scuba diving)

15. Causes of Facial Nerve Palsy
4. Metabolic
Diabetes mellitus
Hypertension
Acute porphyria

16. Causes of Facial Nerve Palsy
5. Neoplastic (2-3%)
Cholesteatoma
Leukaemia
Haemophilia
Fibrous dysplasia
Parotid tumours
Facial nerve tumour
Cerebello-pontine angle tumours

17. Causes of Facial Nerve Palsy
6. Toxic
Tetanus
Diphtheria
Thalidomide
Carbon monoxide

18. Causes of Facial Nerve Palsy
7. Iatrogenic
Postimmunisation
Antitetanus serum
Vaccine for rabies
Parotid surgery
Mastoid surgery
Forceps delivery

19. Causes of Facial Nerve Palsy
8. Autoimmune syndrome
Thrombotic thrombocytopaenic purpura
Kawasaki disease
Guillian barre/Miller–Fisher syndrome

20. Causes of Facial Nerve Palsy
9. Neurological
Millard-Gubler syndrome (abducens palsy with contralateral haemiplegia due to lesion in the base of pons involving corticospinal tract)
Opercular syndrome (cortical lesion in facial motor area)

21. Causes of Facial Nerve Palsy
10. Congenital (8-14%)
Dystrophia myotonica
Moebius syndrome (facial diplegia associated with other cranial nerve deficits)

22. Investigations Hearing test Consider MRI progressing > 3 weeks
lack of improvement after 6 months
recurrent facial palsy
single facial segment involvement
high suspicion of an underlying neurological disorder

23. In the absence of other causes in the history or examination – presumed diagnosis is
Bell’s Palsy

24. Treatment Eye care Steroid +/- antiviral Surgical intervention
Artificial tears
Moisturising eye ointment at night
Protective eye wear
Steroid +/- antiviral
Surgical intervention

25. Prognosis of Bell’s Palsy
Good prognosis
Most have recovery between 3 wks – 3mths
If not recovering/progressively worse ? Underlying cause

26. Reviewing the evidence for treating Bell’s Palsy
Michael McGowan

27. WARNING
Trying to read everything on these slides will cause your brain to melt.

28. Where to search?

30. No guideline but there is a CKS

31. Bell's palsy is an acute, unilateral, idiopathic, facial nerve paralysis. The paralysis also affects the eyelids, causing an impairment of blinking.
The cause of Bell's palsy remains unclear, but it has been associated with the herpes virus.
The annual incidence of Bell's palsy in the UK is 1 in 5000 people. It occurs most commonly between 15 and 60 years of age.
When making a diagnosis of Bell’s palsy:
It should be noted that maximum facial weakness develops within 2 days. Earache, pain behind the ear, aural fullness, or facial pain may precede the palsy. Severe pain might indicate Ramsay Hunt syndrome. This is caused by herpes zoster and is associated with a painful rash and herpetic vesicles.
Confirmation that the paralysis is caused by a unilateral, lower motor neuron lesion is required. The muscles controlling facial expression are affected on one side of the face only. This may result in drooping of the brow and corner of the mouth, weakness of the frontalis (forehead muscle), or inability to close the eye.
It should be confirmed that only the facial nerve is affected.
Other features such as loss of taste of the anterior two-thirds of the tongue (on the same side as the facial weakness) may occur.
Serious underlying pathology such as Lyme disease and parotid tumour should be excluded.

32. To manage Bell’s palsy:
The person should be reassured that the prognosis is good: most people with Bell's palsy make a full recovery within 9 months.
The person should be advised to keep the affected eye lubricated by using lubricating eye drops during the day and ointment at night. The eye should be taped closed at bedtime using microporous tape, if the ability to close the eye at night is impaired.
For people presenting within 72 hours of the onset of symptoms, prescription of prednisolone should be considered. There are no data supporting the use of prednisolone in people presenting after 72 hours.
Antiviral treatment is not recommended, either alone or in combination with prednisolone.
If there is doubt regarding the diagnosis, or there is recurrent or bilateral Bell's palsy, an urgent referral to neurology or to an ear, nose, and throat (ENT) specialist should be arranged.
If the cornea remains exposed after attempting to close the eyelid, an urgent referral to ophthalmology should be arranged.

33. If the paralysis shows no sign of improvement after one month, or there is suspicion of a serious underlying diagnosis (e.g. cholesteatoma, parotid tumour, malignant otitis externa), an urgent referral to ENT should be arranged.
If there is residual paralysis after 6–9 months, referral to a plastic surgeon with a special interest in facial reconstructive surgery should be considered.

34. So where do these recommendations come from?
To manage Bell’s palsy:
The person should be reassured that the prognosis is good: most people with Bell's palsy make a full recovery within 9 months.
The person should be advised to keep the affected eye lubricated by using lubricating eye drops during the day and ointment at night. The eye should be taped closed at bedtime using microporous tape, if the ability to close the eye at night is impaired.
For people presenting within 72 hours of the onset of symptoms, prescription of prednisolone should be considered. There are no data supporting the use of prednisolone in people presenting after 72 hours.
Antiviral treatment is not recommended, either alone or in combination with prednisolone.
If there is doubt regarding the diagnosis, or there is recurrent or bilateral Bell's palsy, an urgent referral to neurology or to an ear, nose, and throat (ENT) specialist should be arranged.
If the cornea remains exposed after attempting to close the eyelid, an urgent referral to ophthalmology should be arranged.
So where do these recommendations come from?

35. Steroids are well known to work.

36. But what about using antivirals?

37. Read the abstract of this SR and talk about your conclusion

39. Significant

40. Not significant (just)

41. Steroids work
Antivirals alone do not
Might help in combination but there isn’t evidence to support this

42. Applying this evidence to children?

43. Applying this evidence to children?
Open to all sorts of bias, no randomisation
Mirrors the adult recommendations
Small numbers
Outcome more or less the same

44. Probably alright to do so

45. Summary Outcome is good Supportive treatment a must
Improved by starting steroids within 72h
Might be improved by using antivirals in combination
Definitely not improved by using antivirals alone

46. And finally a point of interest…
If the paralysis shows no sign of improvement after one month, or there is suspicion of a serious underlying diagnosis (e.g. cholesteatoma, parotid tumour, malignant otitis externa), an urgent referral to ENT should be arranged.
If there is residual paralysis after 6–9 months, referral to a plastic surgeon with a special interest in facial reconstructive surgery should be considered.
And finally a point of interest…

47. …In this guidline…

48. …were the evidence is appraised…

49. …Acupuncturists do better trials than ENT surgeons?

50. The End
Questions for Elaine?