• Understanding what Facial Nerve Palsy is

• To streamline investigation and management of children presenting to Emergency Department with Facial Nerve Palsy

• To ensure appropriate follow up for children presenting with Facial Nerve Palsy to Emergency Department

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• Bell’s Palsy (idiopathic lower motor neurone Facial Nerve Palsy) occurs in about 1 in 60 people in their lifetime.

• Various drug treatments have been tried and there is no current evidence that any particular therapy is of benefit. There is some evidence from 20 years ago that prednisolone may be a little more effective than no treatment but a recent study has shown no benefit, although it was underpowered.

• According to recent review of the incidence of Lyme disease nationwide, 13.7% of confirmed cases were in young people 19 years old and under.

• Even though our Trust does not sit in a Lyme disease endemic area, there is a significant nationwide increase in Lyme disease cases since 2001. Frimley Health looks after patients across Surrey, Hampshire and Berkshire, with Lyme disease incidence of 23.4 cases per 100,000 in Surrey, and 37.3 cases per 100,000 in Hampshire and Berkshire.

At Frimley Park Hospital, between October 2019 and October 2020, eight patients under the age of 18 years presented to paediatric ED with facial palsy and have subsequently been diagnosed as Bell’s Palsy. There was significant variation in investigation and treatment. None of the children re-presented to ED within 2 weeks of diagnosis.

Bell's Palsy

• Acute peripheral usually one-sided facial palsy

• Often idiopathic, occurring on ipsilateral side of the face to the affected nerve

• Diagnosis of exclusion

• Aetiology remains unclear despite many speculations

• If associated with herpes simplex infection then possibly due to reactivation of the infection in the geniculate ganglion rather than acute infection

• Make sure it is thorough!

• Onset of symptoms and progression

  • Often unilateral short onset (<72h) weakness of facial muscles

  • In lower motor neurone palsy the forehead is NOT spared

• Less common features: ear pain, pain behind the ear, hearing impairment or hyperacusis, facial numbness, dry eye, altered taste

• Recent infections, particularly any history of tick bites or travel in tick-prone areas, and insect bites

• Trauma

• Systemic symptoms, including pain and weight loss

• Chest, abdomen, cranial nerves, ENT, eyes, peripheral nervous system, joints and skin

• Include gross tests of hearing in the ENT exam with Rinne and Weber’s tuning fork tests

• Cervical, supraclavicular and axillary areas for any lymphadenopathy

• Assess the function of the facial nerve using the House-Brackmann classification

• Full blood count and blood film to rule out Acute Lymphoblastic Leukaemia

• Lyme disease serology

• If any red flags or otherwise suspicious features, consider other appropriate imaging

• Eye care

  • Hypermellose drops up to 1hourly if needed

  • Hypermellose ointment at night if inadequate eye closure

  • Discuss with ophthalmology for local follow up if inadequate eye closure

• If any suspicion of tick bite and Lyme disease then consider treatment with antibiotics

  • Under 9 years

    • Oral amoxicillin

    • 33kg and over 1g three times a day for 21 days

    • Under 33kg 30mg/kg three times a day for 21 days

  • Under 9 years if penicillin allergic

    • Azithromycin 10mg/kg up to max of 500mg once a day for 17 days

  • 9 to 12 years

    • Oral doxycycline:

    • 45kg and over 100mg twice a day for 21 days

    • Under 45kg oral doxycycline 5mg/kg in 2 divided doses on day one, followed by 2.5mg/kg in 1 or 2 divided doses for total of 21 days

  • Over 12 years

    • Oral doxycycline 100mg bd orally for 21 days or 200mg od for 21 days

    • First alternative: Amoxicillin 1g tds for 21 days

• If any concerns regarding HSV or VZV infection start acyclovir

  • If history in patient or immediate family

• ED will review point of care FBC and blood film whilst the child is still in ED

• Contact ENT to arrange follow up in ENT clinic in 5-7 days – ENT will review the Lyme serology results. At FPH please email Miss Patmore with patient details. At WPH contact the generic ENT SHO email.

• If persistent symptoms for more than 3 weeks, consider alternative diagnosis and referral to paediatrics

• Ophthalmology if eye not closing

• ENT for follow up as above

• Consider paediatric referral if signs not consistent with Bell’s Palsy

• Symptoms should improve by 3 weeks from onset

• Most children have good prognosis with resolution within 2 to 6 months.