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PEDIATRIC DENTISTRY/Copyright 1987 byThe American Academy of Pediatric DentistryVolume 9 Number 1

Facial nerve paralysis: report of two cases of Bells palsyMartha Ann Keels, DDS Linwood M. Long, Jr., DDS, MSWilliam F. Vann, Jr., DMD, MS, PhD

AbstractThecases of an ll-year-old white male andan 8-year-oldblack malewith facial paralysis are presented. ncludedare de-scriptionsof diagnosis, linical course, reatment,prognosis, ndrecommendationsor future cases.

Facial nerve paralysis is an important cause ofmorbidity in children. Its presentation can be fright-ening for both the child and parents. The most com-mon cause of facial nerve paralysis in children isBells palsy2 Bells palsy is the accepted term to de-scribe unilateral, peripheral facial nerve paralysiswhich is idiopathic with acute onset.

Sometimes facial nerve paralysis is a sign of anunderlying disease process. Because the facial nervecourses through intracranial, intratemporal, and ex-tracranial regions, determination of the etiology offacial nerve paralysis is complicated (Olsen 1984). Mayet al. (1981) evaluated 170 children over a 17-year-period (1963-80) and found that Bells palsy account-ed for 42%of the facial nerve paralyses. The remain-ing causes in children were trauma (21%), otitis media(13%), syndromes (13%), congenital (8%), and(2%) (May et al. 1981). Depending on the cause,prognosis of facial nerve paralysis may be sponta-neous regression or rapid morbidity and fatality. Itshould not be assumed that a child presenting withfacial nerve paralysis has Bells palsy because moreserious disorders can cause similar signs and symp-toms (May et al. 1981).The purpose of this case report is to present 2children with facial nerve paralysis. The diagnosisand course of each were very different and these casesunderscore the important role of the pediatric dentistin recognition and referral of such cases.1 Adour 982;May t al. 1981;Olsen1984.~Olsen1984; Blattner 1969; McGovernnd Estevez1983;Peitersen1982.

Review of Facial Nerve AnatomyThe facial (7th cranial) nerve has parasympa-thetic, motor, and sensory nuclei in the pons, a partof the brain stem located in the posterior cranial fossa.The fibers from the motor nucleus pass below thefloor of the 4th ventricle and continue around thenucleus of the abducens (6th cranial) nerve to com-bine with parasympathetic and sensory fibers to forma common nerve trunk. The nerve trunk exits thebrain and continues its lateral course through thefacial canal. Where the canal makes an acute bendtoward the middle ear cavity, the geniculate ganglionis located. At the level of the geniculate ganglion, the

greater superficial petrosal nerve arises and suppliesparasympathetic fibers to the lacrimal gland and mu-cous membrane of the nose and mouth (Fig 1).Distal to the geniculate ganglion, the facial nervegives rise to 2 branches. The first contains the motornerve to the stapedius muscle, which serves to damp-en the oscillations of the ear ossicles. The second isthe chorda tympani nerve, which contains sensoryfibers for taste from the anterior 2,4 of the tongue. Thechorda tympani nerve also joins with the lingual nerveand provides parasympathetic innervation to the sub-mandibular and sublingual glands.The facial nerve exits the temporal bone throughthe stylomastoid foramen and subdivides into its ter-minal branches, which supply the motor innervationto the muscles of facial expression.

Central Versus Peripheral Lesionsof the Facial NerveThe facial nerve primarily innervates the musclesof facial expression. There are 2 types of paralysisaffecting the motor function of the facial nerve and

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Sup. sa~ivatoryMotor nucleusVII ganglion

Nucleus fasc. 3es

Lacrimal gland

superficial petrosal nerveNasal and palatine glands

ganglion muscle

Chordatympani nerve

ganglionSublingual glandSubmandibular gland

StyMuscles of=acial expression

FIG1. Anatomy f the facial nerve (Olsen 1984; Alford et al.they maybe classified as a central type or a peripheraltype (Fig 2--Carpenter 1978; Montgomery 1981).The central type involves the corticobulbar fiberswhich convey impulses from the cerebral cortex tothe cells of the motor nucleus of the facial nerve. Acentral lesion interrupting the corticobulbar path-ways results in paralysis only of the lower facial mus-cles on the opposite side of the lesion. This is explained

Cortex--~~~~ Motor area, faceCorticobulbar~~~ Central lesiontract ~

\/2~ YY,,~L~- Nucleus of~ons ..--~--~//~ ~ facial nerveFacial nerve~~ Peripheral lesion

PartialFacial Total FacialMuscle aralysis Muscle aralysisF[6 2. Muscleparalysis difference betweena central lesionand a peripheral lesion of the facial nerve (Carpenter 1978;Montgomery1981).

1973; Carpenter 1978; Montgomery 981).by the fact that the corticobulbar fibers to the fore-head and the upper half of the face are distributedbilaterally; however, the fibers to the lower half ofthe face are predominantly crossed.The peripheral type lesion of the facial nerveoccurs at the level of the pons or anywhere along thedistal course of the nerve. This lesion produces totalfacial paralysis on the sameside as the lesion.A central lesion produces a less severe type offacial paralysis compared o the peripheral lesion, butits origin may represent a serious problem in thebrain. A simple neurological test to differentiate acentral from a peripheral lesion in a patient withfacial nerve paralysis is to ask the patient to wrinklethe forehead; if the patient can wrinkle the entireforehead, the lesion is centrally located. If the patientcan wrinkle only half the forehead, the lesion is pe-ripherally located.Bells Palsy

Sir Charles Bell originally described this condi-tion in 1821. The term Bells palsy is used to describean acute-onset, idiopathic facial paralysis resultingfrom a dysfunction anywhere along the peripheralpart of the facial nerve from the level of the ponsdistally.40lsen 1984; Blattner 1969; McGovern nd Estevez 1983; Peitersen

1982.

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There are many theories about the cause of Bell'spalsy but the etiology is unknown (Shafer et al. 1983).The most popular hypothesis is that it is caused by avirus similar to Herpes simplex or zoster.5 Other pro-posed etiologies include physiologic compression ofthe nerve due to arteriospasm, venous congestion orischemia, and narrowing of the bony canal (Olsen1984; Shafer et al. 1983). Several case reports supporta fami l ia l tendency suggesting the inheritance of anaberrant facial canal.6

Bell's palsy is rare in children under the age of2 years (Blattner 1969). Its occurrence is slightly great-er in females at a 1.5 to 1 ratio (Olsen 1984; Shafer etal. 1983). There is no race predilection for Bell's palsy(Olsen 1984). The incidence is 1 in 5000 persons peryear (Olsen 1984).

The signs of Bell's palsy include widening of thepalpebral fissure, flatteningof the nasolabial fold, anddrooping of one corner of the mouth when smiling(Shafer et al. 1983; Abbas and Prabhu 1981). Thesesigns occur on the same side of the face as the lesion.There may be an inability to wrinkle half of the fore-head, to close one eye completely, and to purse thelips (Shafer et al. 1983; Abbas and Prabhu 1981). Bell'sphenomenon is a classic condition wherein the eyecannot close without a simultaneous movement ofthe eyeball upward and outward (Abbas and Prabhu1981).

The symptoms of Bell's palsy include pain andnumbness on the affected side of the face, especiallyin the temple, mastoid area, and along the angle ofthe mandible (Shafer et al. 1983). The mouth may bedry due to decreased salivary secretion and there maybe loss of taste on the anterior % of the tongue as wellas hyperacusis on the affected side (Abbas and Prabhu1981).

The most important treatment measure is sup-portive care for the eye (Adour 1982; Hughes 1983).Daytime artificial tears and a nighttime eye patch arerecommended to prevent corneal abrasion (Olsen1984). For persons with persistent paralysis of thefacial nerve, treatment modalities such as steroidtherapy and surgical nerve decompression have beenprescribed.7

Most authors agree that 75% of Bell's palsy casesregress spontaneously with complete recovery. Ap-proximately 15% of the cases have satisfactory recov-ery with a slightly detectable neurologicaldefici t and10 % of the cases have permanent paralysis (Olsen1984). A favorable prognosis is associated with Bell'spalsy which occurs in a single episode, is painless,involves only a partial paralysis of the peripheral part5 Adour 1982; Olsen 1984;Mc Go v e rn an d Estevez 1983.' Shafer et al. 1983; Bu r zynsk i and Weisskopf 1973; Samuel 1984.7 Adour 1982; Olsen 1984; Hughes 1983.

F IG 3. Case 1: Left-side facial nerve paralysis secondary toBell 's palsy.

of the facial nerve, and has early signs of recovery(Olsen 1984). A good prognosis is associated withBell's palsy seen in children (Olsen 1984; Peitersen1982).Case OneAn 11-year, 5-month-old white male presentedto the pediatric dentist with the chief complaint of"not being able to close his lef t eye or smile." Thefa the r first noted the signs the previous morning,including swelling along the left border of the man-dible and jumping of the left upper eyelid.

An extraoral exam revealed left-sided facial nerveparalysis. The lef t muscles of facial expression did notparticipate when the child smiled. No swelling wasapparent. The left eye would close only partially (Fig3).

Prior to the onset of paralysis, the child had beena regular dental patient for 2 years and received rou-tine treatment. An intraoral examination revealed noetiology to explain the facial paralysis.Past Medical History

The patient was an 8 pound, 14.5 ounce productof a full-term, spontaneous delivery. Gestation wasnormal and there were no complications at birth. Thepatient had experienced no previous serious illnessesor injuries. There were no known drug allergies norwere medications being taken. Upon recognition ofthe left-sided facial paralysis, the child's pediatrician

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F IG 4. Case 2: Left-side facial nerve paralysis secondary tobrain stem t umor .

was consulted. The pediatrician recommended thatthe patient be seen by an ophthalmologist.Ophthalmologist's Consultation

The ophthalmologist saw the child immediatelyand documented a negative history for headaches,nausea, vomiting, weakness, or paresthesia. The childhad experienced no change in taste, but had noticedan increase in noise through the left ear. The fa the rdenied any history of eye infection or trauma. Thefami ly history was negative for any ocular diseases.The ophthalmic examination revealed an eyelid lagwith flattening of the nasal labial fold on the lef t side.The child was able to abduct both eyes. The remainingexamination was within normal limits.

The clinical impression was Bell's palsy involv-ing the lef t side, but the ophthalmologist recom-mended the patient be evaluated by a neurologist torule out any f u r t h e r neurological problems.Neurologist's Consultation

The neurologist saw the patient on the same dayand confirmed the diagnosis of Bell's palsy. Symp-tomatic treatment was recommended for the eye, in-cluding daytime artificial tears and a night eye patchto prevent corneal abrasions.

One month after onset of the facial paralysis, thechild was seen in the pediatric dentist's office againand the symptoms of Bell's palsy were hardly no-ticeable. At a recall visit 3 months later, the child hadcomplete resolution of Bell's palsy.

FIG 5. Case 2: Bell's phenomenon or inabi l i ty to close th eleft ey e comple te ly .

Case TwoThis case involved an 8-year, 2-month-old black

male. On 12 January 1982, the mother called the pe-diatric dentist to report that her son's jaw "lookedswollen and twisted when he smiled." Examinationrevealed that when the child smiled, the mouth de-viated to the right side and the right eye closed (Fig4). The patient could not close his lef t eye completely(F ig 5).

The patient had been seen regularly by the pe-diatric dentist for 3 months for preventive and res-torative care and space maintenance. The intraoralexamination revealed no etiology for facial nerve pa-ralysis.Past Medical History

The child was a 6 pound, 12.5 ounce product ofa fu l l - term breach cesarean section, followed by anuneventful neonatal period. Developmental mile-stones had been reached within normal limits.Further Medical Work-UpAt the time of clinical observation of the facialdistortion, the pediatric dentist suspected Bell's palsyand referred the patient to a pediatrician. The pedia-trician supported the diagnosis of Bell's palsy andrecommended no treatment.

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Sequelae and Hospital CourseTwo weeks after the child presented originallyto the dentist, he experienced a choking episode whileeating. The mother performed the Heimlich maneu-ver several times and the child vomited and becameunconscious. Cardiopulmonary resuscitation was ini-tiated by the mother and the rescue squad was calledand arrived within 20 rain. Food was suctioned fromthe nasopharynx, an airway placed, and oxygen ad-ministered. The child became arousable during trans-port to the local county hospital. He was transferredimmediately to a tertiary care medical center.Upon arrival at the medical center, the child waslethargic but verbally arousable. The mother reportedthat he had been experiencing left facial weaknessand nonspecific headaches for more than 2 weeks.The mother expressed also that his school perfor-mance had deteriorated over the last month.Physical exam in the emergency room revealedbilateral upgaze nystagmus and inability to abducteither eye. There was a decreased gag response bi-laterally. The palate rose symmetrically in the mid-line. There was no evidence of deviation of the tonguefrom the midline. The sensory examination was intactto all modalities. Deep tendon reflexes were greaterin the lower extremities than the upper. A chestradiograph revealed bilateral aspiration pneumoniaand a pneumomediastinumoThe child was admitted to the intensive care unitand placed on Dexamethasone to control intracra-nial pressure. He was treated for aspiration pneu-monia.The neurological assessment revealed a left facialnerve palsy, a left lateral rectus muscle palsy, a mildright hemiparesis with the upper extremities moreaffected than the lower, and positive bilateral Babin-ski signs. These signs were suggestive of a lesion inthe pons at the level of the 7th cranial nerve. Thedifferential diagnosis included pontine glioma, me-dulloblastoma, hemangioblastoma, and an arterio-venous malformation.A brain CT scan localized a low density, non-enhancing mass in the region of the pons with pos-terior displacement of the 4th ventricle. A presump-tive diagnosis of a pontine glioma was made.

The neurosurgeons recommended radiationtherapy in view of the morbidity associated with atumor biopsy. A second opinion obtained fromanother medical center corroborated the radiationtherapy treatment protocol. At the completion of ra-diation therapy, the left facial nerve palsy was lessconspicuous and the right hemiparesis was not de-tectable. There was no significant change in the brainCT scans during radiation therapy.Eight months from the original admission, thepatient presented to the emergency room with a

3-week history of intermittent frontal headaches, ab-dominal pain, nausea, and vomiting. The physicalexamination revealed a slurred, monotone speech. Anew brain CT scan displayed significant changes in-cluding compression of the lateral ventricles whichcreated obstructive hydrocephalus. Shunt placementand tumor biopsy were recommended but the motherelected noninvasive treatment due to morbidity as-sociated with surgery. Periodic clinic examinationswere recommended and 1 month later the brain CTscan revealed a significant increase in the size of thetumor and progressive metastasis into the lateral ven-tricles. Surgery was refused again.

Twelve months from the original diagnosis thechild died of a cardiopulmonary arrest believed to besecondary to the pontine tumor.Discussion and Conclusion

Though a small percentage of children present-ing with facial nerve paralysis have a brain stem tu-mor, a thorough medical evaluation is necessary toverify the absence of other neurological signs andsymptoms which may reflect intracranial pathology(May t al. 1981; Jackson et al. 1980). Bells palsy shouldbe a diagnosis of exclusion.As was the case with both of these young pa-tients, the dentist maybe the first to see such patientsbecause of the orofacial involvement with paralysisof the facial nerve. Proper assessment of a child withfacial nerve paralysis is needed to make an accuratediagnosis and give the correct prognosis. In summary,the most important thing the dentist can do is makea prompt and appropriate referral because early de-tection of intracranial pathology may improve thechilds prognosis.Dr. Keels is a fellow, Dr. Long s a clinical assistant professor, andDr. Vann is an associate professor and chairman, pediatric den-tistry, The University of North Carolina at Chapel Hill. Dr. Longalso is in private practice, pediatric dentistry and orthodontics inBurlington, North Carolina. Reprint requests should be sent to:Dr. Martha Ann Keels, Dept. of Pediatric Dentistry, The Universityof North Carolina at Chapel Hill, School of Dentistry 209H, ChapelHill, NC27514.

Abbas KED, Prabhu SR: Bells palsy among Sudanese children--report of 7 cases and review of literature. J Oral Med 36:111-13, 1981.

Adour KK: Current concepts in neurology--diagnosis and man-agement of facial paralysis. N Engl J Med307:348-51, 1982.

Afford BR, Jerger JF, Coats AC, Peterson CR, Weber SC: Neuro-physiology of facial nerve testing. Arch Otolaryngol 97:214-19, 1973.

Blattner RJ: Bells palsy in children. J Pediatr 74:835-37, 1969.Burzynski NJ, Weisskopf B: Familial occurrence of Bells palsy. Oral

Surg 36:504-6, 1973.Carpenter MB: Core Text of Neuroanatorny, 2nd ed. Baltimore;Williams and Wilkins Co, 1978 pp 126-28.

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Hughes GB: Current concepts in Bells palsy. Ear Nose Throat J 62:6-13, 1983.

Jackson CG, Glassock ME, Hughes G, Sismanis A: Facial paralysisof neoplastic origin: diagnosis and management. Laryngo-scope 90:1581-95, 1980.

May M, Fria TJ, Blumenthal F, Curtin H: Facial paralysis in chil-dren: differential diagnosis. Otolaryngol Head Neck Surg 89:841-48, 1981.

McGovern FH, Estevez J: Current concepts in the etiology andpathology of Bells palsy. Va Med 110:544-46, 1983.Montgomery RL: Head and Neck Anatomy with Clinical Correo

lation. NewYork; McGraw-Hill Book Co, 1981 pp 194-96, 309-13.

Olsen KD:Facial nerve paralysis 1. General evaluation, Bells palsy.Postgrad Med 75:219-25, 1984.Peitersen E: The natural history of Bells palsy. Am Otol 4:107-

11, 1982.Samuel J: Familial Bells palsy. J Laryngol Otol 98:977-79, 1984.Shafer WG, Hine MK, Levy BM: A Textbook of Oral Pathology,4th ed. Philadelphia; WB aunders Co, 1983 pp 859-60.

Pediatric Dentistry: ReviewersOn behalf of the American Academy of Pediatric Dentistry, the editorial staff wishes to thank those

individuals who have spent valuable time reviewing manuscripts for the Journal. Their professional expertisehas contributed greatly to the quality of this publication. Those listed were sent manuscripts from January 1through December 31, 1986.

A H RAlexander, Stanley A. Henderson, Hala Z. Ripa, Louis W.B Hennon, David K. Roberts, J. KeithBarenie, James T. Houpt, Milton I. Rovelstad, Gordon H.Bernick, Sheldon M. J SBinns, William H., Jr. Johnsen, David C. Saunders, William A.Bixler, David Jones, James E. Schneider, Paul E.Bugg, James L., Jr. Jorgenson, Ron Setcos, JamesBurzynski, Norbert J. K Shey, ZiaC Kennedy, David B. Shusterman, StephenCatalanotto, Frank A. Koerber, Leonard G. Silverstone, Leon M.Cisneros, George J. Kopel, Hugh Spedding, Robert H.Starkey, Paul E.Cooley, Robert Kracke, Roy R.Corcoran, John W. Krutchkoff, David Straffon, Lloyd H.Strange, Evelyn M.Creedon, Robert L. L Sullivan, Robert E.Croll, Theodore P~ Lewis, Thompson M.Currier, G. Fr~ins Loos, Paul J. TThomas, Joe P.D Luke, Larry S. Tinanoff, NormanDavis, Martin J. M Troutman, Kenneth C.Dummett, Clifton O., Jr. Miller, Chris VF Miller, Jerome B.Ferguson, Fred S. Mink, John R. Vann, William F., Jr.Fields, Henry W., Jr. Moore, Paul WFippinger, Terrance Musselman, Robert J. Weber, John D.Full, Clemens A. McDonald, John S. White, Stephen T.G N Wright, Gerald Z.Goldblatt, Lawrence I. Nelson, Linda P.Golnick, Arnold L.Good, David L. Porter, Donald R.Goodson, Max

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