CASE REPORT


https://doi.org/10.5005/jp-journals-10077-3270
Journal of South Asian Association of Pediatric Dentistry
Volume 6 | Issue 2 | Year 2023

Management of Idiopathic Facial Palsy in Pediatric Patients: A Case Series


Parayash Dallakoti1https://orcid.org/0000-0002-4397-4521, Sunanda Sundas2https://orcid.org/0000-0002-3056-1365, Sagar Adhikari3https://orcid.org/0000-0002-3499-0028, Sumana Sulu4https://orcid.org/0000-0003-4716-9703, Amita Rai5https://orcid.org/0000-0003-2195-6389

1Department of Pediatric and Preventive Dentistry, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal

2,5Department of Pediatric and Preventive Dentistry, People’s Dental College & Hospital, Kathmandu, Nepal

3Department of Oral Medicine and Radiology, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal

4Department of Oral Medicine & Radiology, BP Koirala Institute of Health Sciences, Dharan, Nepal

Corresponding Author: Sunanda Sundas, Department of Pediatric and Preventive Dentistry, People’s Dental College & Hospital, Kathmandu, Nepal, Phone: +977 9849247117, e-mail: sunandapedo@yahoo.com

Received on: 31 May 2023; Accepted on: 20 July 2023; Published on: 23 August 2023

ABSTRACT

Background: Bell’s palsy, presently recognized as lower motor neuron palsy, is a diagnosis of elimination after careful exclusion of other etiologies. It tends to be the result of events that are compressive, infected, inflammatory, or traumatic to the nerve. The patient may present with signs of acute, idiopathic facial paralysis, sagging corners of the mouth, and an absence of the nasolabial fold on the impacted side.

Case Description: This case series presents three different cases of Bell’s palsy treated with different treatment modalities such as systemic steroids and antiviral medications, methylcobalamin, home exercises, physiotherapy, and transcutaneous electrical nerve stimulation (TENS) therapy.

Conclusion: Herpes simplex virus is the most frequent cause of Bell’s palsy; however, there are several additional etiologies for facial palsy that should be thoroughly ruled out. Bell’s palsy is less frequent in children as compared to adults; hence, early diagnosis and proper management are important.

How to cite this article: Dallakoti P, Sundas S, Adhikari S, et al. Management of Idiopathic Facial Palsy in Pediatric Patients: A Case Series. J South Asian Assoc Pediatr Dent 2023;6(1):95-98.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.

Keywords: Bell’s palsy, Case report, Idiopathic facial paralysis, Management.

INTRODUCTION

Facial palsy is a neuropathy involving the seventh cranial nerve characterized by facial muscular paralysis. It is of two types—upper motor neurons (UMNS) and lower motor neurons (LMNS) palsy. UMNs palsy is presented with unilateral facial palsy without the involvement of the frontalis and orbicularis oculi muscles.1 It may be associated with monoparesis, hemiparesis, and dysphasia. The hallmark of LMNs palsy is unilateral paralysis of all facial expression muscles, including those used for emotion and voluntary movements. Bell’s palsy is presently recognized as LMNs palsy with no known local or systemic cause.1

The patient may present with acute, idiopathic facial paralysis with signs of widening palpebral fissure, absence of nasolabial fold, and dropping of one of the corners of the mouth. The patient might not be able to purse their lips, totally close one eye, or wrinkle half of their forehead.2 Sometimes, classic Bell’s palsy sign may be present where the eye cannot close without a simultaneous movement of the eyeball upward and outward. The affected side of the face experiences discomfort and numbness as well as decreased salivation, taste loss, and hyperacusis as symptoms.2 The present case series highlights the management of Bell’s palsy in children with different treatment modalities.

CASE DESCRIPTION

Case One

A 14-year-old male visited the Department of Pediatric and Preventive Dentistry in one of the dental colleges of Kathmandu with the main complaint of “deviation of the mouth towards the right while smiling.” Examination revealed incomplete closure of the left eye, absence of nasolabial fold on the left side, and inability to blow mouth (Fig. 1). The intraoral and extraoral examination revealed no known cause for the complaint. A diagnosis of Bell’s palsy on the left side of the face was made (House–Brackamann grade IV).

Figs 1A to F: Clinical presentation showing; (A) Jaw deviation; (B) Lips deviation; (C) Incomplete closure of left eye; (D) 1-month follow-up showing complete eye closure; (E) 1-month follow-up showing a nearly normal smile; (F) 1-month follow-up showing nearly normal jaw opening

He was born full-term by cesarean section with an uneventful neonatal and natal period. He was prescribed a course of prednisolone and artificial tears. For 6 days, a daily dose of 40 mg of prednisolone was advised, decreased by 10 mg every 3 days. He was also advised for physiotherapy of facial muscles.

Case Two

This case involves a 14-year-old female who presented to the Department of Pediatric and Preventive Dentistry in one of the dental colleges of Kathmandu with a chief complaint of a “twisted smile for 1 week.” She also noticed difficulties in drinking water without spilling and drooling from the right corner of her mouth. She was anxious about the condition because she works as a model. Examination revealed loss of right nasolabial fold, absence of wrinkle on the right forehead while raising an eyebrow, incomplete closure of the right eye, and deviation of the mouth towards the left while opening and smiling (Fig. 2). The child was identified as having right hemifacial Bell’s palsy (grade IV House–Brackmann).

Figs 2A to F: Clinical presentation showing; (A) Lips deviation; (B) Jaw deviation; (C) Incomplete closure of right eye; (D) 1-month follow-up showing complete eye closure; (E) 1-month follow-up showing nearly normal jaw opening; (F) 1-month follow-up showing nearly normal smile

She was born full-term through normal delivery. Her mother denied any complications in the prenatal and postnatal period. She was prescribed a course of prednisolone and artificial tears. For 6 days, a daily dose of 40 mg of prednisolone was advised, decreased by 10 mg every 3 days. And tablet of methylcobalamin 1500 mcg was given once daily for 15 days. She was referred to a physiotherapist, where physiotherapy was performed for 3 months until all function was restored.

Case Three

A 15-year-old boy presented to the Department of Oral Medicine and Radiology at one of the tertiary medical centers of Nepal with the chief complaint of deviation of the lower lip to the right side in the last 4 days. His mother also reported that he had a fever 28 days back for 1 week. There was no history of pain or facial trauma. The patient denied having recently experienced any systemic symptoms, such as nausea, vomiting, or fever. Physical examination revealed restricted motion of the left upper and lower lips. Facial asymmetry was noticed involving the left eye and eyebrow. There was a deviation of the lower lip on the right side while opening the mouth, absence of crease on the left side of the forehead while raising the eyebrow, unable to close the left eyelid completely, and deviation of lip toward the right side while smiling (Fig. 3). The child was identified as having left hemifacial Bell’s palsy (House–Brackmann grade IV). Acyclovir, methylcobalamin, prednisolone, and artificial tears were prescribed for him. For 6 days, a daily dose of 40 mg of prednisolone was advised, decreased by 10 mg every 3 days. Other drugs prescribed were tablet acyclovir 400 mg five times daily for 7 days and tablet methylcobalamin 1500 µg once daily for 15 days. Transcutaneous electrical nerve stimulation (TENS) therapy was given for 1 week in the bilateral parotid region in continuous mode. Self-performance physiotherapy for facial muscles was also advised. Follow-up was planned after 1 month, and a substantial recovery was seen.

Figs 3A to D: (A) Initial presentation; (B) During TENS therapy; (C) Clinical presentation after 1-week; (D) Clinical presentation after 1 month

All the patients had acute onset, and they denied a history of headache, pain in or around the ear, recent surgery, altered taste sensation, similar illness in the past, fluid-filled blister formation or ulceration in the face, weakness of extremities, joint pain, rashes, eye irritation, and tick bite. The oral mucosa was found to be free of lesions. There is no history of recurrence, high blood pressure, neck stiffness, recent trauma, and tick bite. There was not any relevant medical history reported on all three patients. No lymphadenopathy was observed. A year’s worth of additional follow-ups was scheduled every 6 weeks.

DISCUSSION

Bell’s palsy, which was explained by Sir Charles Bell in 1821, is associated with rapid onset facial nerve paralysis (<72 hours).3 The incidence of Bell’s palsy in the pediatric population ages 0–14 is approximately 6.6/100000 person-years.4 Though viral infection is supposed to be the most common cause, the exact mechanism is still unknown. Bell’s palsy is diagnosed by rigorous exclusion of all other potential causes. Bell’s palsy isn’t the only cause of facial paralysis; other possible etiologies include hypertension (2.5% of pediatric presentations), cholesteatoma, infectious mononucleosis, leukemia, stroke, and acute disseminated encephalomyelitis.5 The diagnostic tests for patients with Bell’s palsy include computed tomography or magnetic resonance imaging, electrodiagnostic test, serological test, hearing test, and Schirmer test. But individuals with newly diagnosed Bell’s palsy are not advised to undergo routine laboratory tests.6 Hence, the patients were diagnosed with Bell’s palsy based on history and clinical examination without any diagnostic tests. However, a thorough evaluation is needed if there is no clinical improvement after 4 months or if the symptoms return.7 As early diagnosis is important for a good prognosis, the patient should be referred to a neurologist, ophthalmologist, and otolaryngologist and should rule out other uncommon causes if there are no signs of recovery.

Corticosteroids are the most widely approved treatment for Bell’s palsy. Multiple randomized controlled trials show benefits with the use of corticosteroids.8,9 Corticosteroids were therefore administered since they have strong anti-inflammatory effects that reduce facial nerve irritation and hasten recuperation. The patients showed improvement in signs and symptoms in the follow-up visit. The medication was prescribed for a total of 6 days. Antiviral medications were not provided in cases one and two since the benefits of using them with steroids have not been convincingly demonstrated.10

For case three, an antiviral medication was administered in accordance with some signs and symptoms of viral infection. While there isn’t much data to back up the claim that exercise can improve face function,11 but also patients were instructed for home exercise as an adjunct therapy. The first case was completely treated in 15 days, but the second case recovered after 3 months. Since the second case’s recovery was taking long, methylcobalamin, home face muscle exercises, and physiotherapy were recommended in addition to corticosteroids. The groups treated with methylcobalamin had symptom alleviation more quickly than those treated with steroids alone.12

The psychological component is an additional crucial factor. For a child to continue with their regular routines and school is a highly difficult experience. Half of the patients with Bell’s palsy visiting the hospital are seen to demonstrate a substantial degree of psychological stress.13 Proper counseling must be done to both parents and children, as it was in our instance.

CONCLUSION

Bell’s palsy is a diagnosis of elimination that lacks a known explanation and isn’t always reversible. Systemic corticosteroids may be useful in recovery. Exercises, physiotherapy, and methylcobalamin may all be used as adjuncts for a quick recovery from the illness.

ORCID

Parayash Dallakoti https://orcid.org/0000-0002-4397-4521

Sunanda Sundas https://orcid.org/0000-0002-3056-1365

Sagar Adhikari https://orcid.org/0000-0002-3499-0028

Sumana Sulu https://orcid.org/0000-0003-4716-9703

Amita Rai https://orcid.org/0000-0003-2195-6389

REFERENCES

1. Scully C. Medical Problems in Dentistry E-Book: Elsevier Health Sciences; 2010.

2. Sivapathasundharam B. Shafer’s Textbook of Oral Pathology-E Book: Elsevier Health Sciences; 2016.

3. Ahmed A. When is facial paralysis Bell palsy? Current diagnosis and treatment. Cleve Clin J Med 2005;72(5):398–401. DOI: https://doi.org/10.3949/ccjm.72.5.398

4. Rowlands S, Hooper R, Hughes R, et al. The epidemiology and treatment of Bell’s palsy in the UK. Eur J Neurol 2002;9(1):63–67. DOI: https://doi.org/10.1046/j.1468-1331.2002.00343.x

5. Lunan R, Nagarajan L. Bell’s palsy: a guideline proposal following a review of practice. J Paediatr Child Health 2008;44(4):219–220. DOI: 10.1111/j.1440-1754.2007.01245.x

6. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell’s palsy. Otolaryngol Head Neck Surg 2013;149(3_suppl):S1–S27. DOI: 10.1177/0194599813505967

7. Chweya CM, Anzalone CL, Driscoll CLW, et al. For whom the Bell’s toll: recurrent facial nerve paralysis, a retrospective study and systematic review of the literature. Otol Neurotol 2019;40(4):517–528. DOI: 10.1097/MAO.0000000000002167

8. Grogan PM, Gronseth GS. Practice parameter: steroids, acyclovir, and surgery for Bell’s palsy (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology. Neurology 2001;56(7):830–836. DOI: 10.1212/wnl.56.7.830

9. Madhok VB, Gagyor I, Daly F, et al. Corticosteroids for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2016;7(7):CD001942. DOI: 10.1002/14651858.CD001942.pub5

10. Gagyor I, Madhok VB, Daly F, et al. Antiviral treatment for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2019;9(9):CD001869. DOI: 10.1002/14651858.CD001869.pub9

11. Teixeira LJ, Valbuza JS, Prado GF. Physical therapy for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2011;(12):CD006283. DOI: 10.1002/14651858.CD006283.pub3

12. Jalaludin MA. Methylcobalamin treatment of Bell’s palsy. Methods Find Exp Clin Pharmacol 1995;17(8):539–544. PMID: 8749227.

13. Bradford Jones K, Singh N, Galli V, et al. Clinical case management for adults with a developmental disability in a medical home. Prof Case Manag 2019;24(1):56–62. DOI: 10.1097/NCM.0000000000000343

________________________
© The Author(s). 2023 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.