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1972;49;102PediatricsJohn J. Manning and Kedar K. Adour

FACIAL PARALYSIS IN CHILDREN

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ISSN: 0031-4005. Online ISSN: 1098-4275.

PrintIllinois, 60007. Copyright 1972 by the American Academy of Pediatrics. All rights reserved.by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarkedPEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,

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( R eceiv ed M ay 5 ; rev ision a ccep ted for p ub lica tio n A ugu st 2 , 197 1 .)This in ves tiga tio n w as su pported b G enera l R esearch Suppo rt G ran t R R 05521 , from th e N atio nal

In stitu te s o f H ea lth .A D D R E S S FO R R E P R I N T S : ( K.K .A . ) 280 W es t M acA rthu r Boulevard , O ak land , C a lifo rn ia 9 4611 .

P E D I A T R I C S , Vo l. 49 , N o . 1 , January 1972

D IA G N O S IS A N D T R E A T M E N T

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FAC IAL PARALYS IS IN CH ILDRENJ o h n J. M a n n in g , M .D ., an d K e d a r K . A d o u r, M .D .

From the D epa rtm en t o f O to la ryn go log y , K a iser Founda t ion Hosp i ta l , an d the D epar tm en t o fO to laryngo log y , T he P erm anen te M ed ica l G roup , K a iser Founda t ion Hosp i ta l ,

O aklan d, C alifo rn ia

ABSTRACT . In an y i n s t a n c e o f f a c i a l p a r a l y s i s i na ch ild , an effo rt shou ld be m ade to de te rm ine im -m edia tely w he ther it is caused by a spec ific , trea t-ab le en tity . O f 61 cases o f fac ia l pa ra lysis in ch il-d ren seen in a F ac ial P ara lysis C lin ic , 38% w eren o t B e lls pa lsy . E ig h t o f the 61 ch ild ren had d is-ease am en ab le to spec if ic th erap y ava ilab le today .

E xperience w ith 50 4 p atien ts o f a ll ag e g roupsse en w ith in 4 years ha s led th e au thors to abandonfac ia l ne rve decom pression in the treatm en t o fB ells p als y.

Ped ia trics, 49 :10 2 , 1972 , F A C IA L P A R A L Y S IS ,BELL S P A L S Y , F A C IA L N E R V E D E C O M P R E S -S I O N .

B E TWEEN 1966 , w hen th e F ac ia l P a ra lys isC lin ic w as estab lish ed at the K a ise r-

P e rn ianen te m ed ica l cen te r in O ak land , andN ovem ber 1970 , 50 4 pa tien ts w ith fac ia l pa -ra lys is w ere refer red to th is c lin ic by phy si-c ians of T he Perm an en te M edica l G roupth ro ughou t N orthe rn C alifo rn ia . Am ongthem w ere 61 ch ild ren younger than 14years. P resen ted here is an ana lys is o f thecauses, na tu ra l course , p ro b lem s in ev a lu a-tio n , and re su lts o f trea tm en t fo r facia l p a-ralys is in these ch ild ren .

S U B J E C T SA ll o f the 61 ch ild ren w ere dependen ts o f

rnem l)e rs o f the K aise r F ounda tion H ea lthP lan , w h ich h as app ro x in ia te ly 9 00 ,0 00 sub-sc rib ers in N o rthe rn C alifo rn ia , ch ie f ly em -p loy ed pe rsons and th eir fam ilie s from a llso cioecon om ic leve ls excep t th e ve ryw ea lth y . T he gene ra l cha rac ter is tic s o f theH ea lth P lan popu la tion , in clu d ing its aged istr ibu tio n , a re a lm o st iden tical w ith thoseo f the popu la tion of the S ta te o f C a lifo rn iaas a w hole ; s ta tistic s derived from stud iesO f the H ea lth P lan popu la tio n re flec tp ro bab ilitie s fo r the en tire sta te . T he ageso f th e ch ild ren rang ed from new born to 14years. F if ty -seven percen t o f the ch ild renw ere g irls; 43% w ere b oys .

T he d iagno ses a re lis ted in the o rd er o f

frequ ency in Tab le I. T h e d ia gn oses oth erthan B e lls pa lsy w ere m ad e on the b as is o fthe o nse t o f th e fac ia l pa ra lysis in co n jun c-tion w ith ev id en ce of th e o the r illne sse sno ted . Th ese d iag noses rep re sen t ou r pe r-so na l exp erience. O ur crite ria fo r d iag nos isa re in ag reem en t w ith th ose p resen ted byD r. P ain & in h is exce llen t rev iew article inth e Journa l o f P ed ia tr ic s, w hich con tain s acom p lete d iscussio n of the d ifferen tia l d iag -no sis o f fac ia l pa ra ly sis , and of the ana tom yand phy sio log y o f the fac ia l ne rv e . B ir thtraum a w as assum ed to be the cause o f fa -c ial pa ra lys is in fiv e in fan ts w ho h ad no ev i-d en ce of co ngen ita l d isea se , an d w hoseroen tg en ogram s of th e o tic cap su le show edn o a bn or m al it y.

S ix ty - tw o p ercen t o f the ch ild ren h adB e lls pa lsy . In 10% the cause o f the facia lp a ra lysis w as o titis m ed ia ; in 8% it w asb irth traum a . E ach o the r cause acco un tedfo r few er than 4% o f the cases o f facia l pa -ra lysis . D e ta ils respectin g d iagn osis andm anagem en t a re g rou ped w ith R esu lts ino rde r to pe rm it con tinu ity in p re sen ta tiono f each d isea se .

ClinicalM E T H O D S

W e stre ssed the im portance o f see ing thepa tien t as soo n as poss ib le af ter the onset o f

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T A BL E II ) IAGNOSES IN 61 C H I L D R E N W I T h F A C I A L P A R A L Y S I S *

3765

a

III1I

D I A GN O SIS A N D T REA T M EN T 103facial paralysis. A rrangements f or pati entsto be seen in the Facial Paralysis Clinicw ere made by a single telephone call to ourreceptionist or nurse. A s a result, 72% ofthe children w ere seen within 72 hours ofthe onset of facial paralysis. V isits subse-quent to the initial evaluation were madeat the patients convenience so that maxi-mal follow-up data might be obtained.Pro toco l

T he protocol for initial examination ofan y patient entering the Facial ParalysisClinic typically includes the following stud-ies, some of w hich cannot, how ever, be per-formed accurately in a child. I nitially, theP1IP05( of this evaluation w as to determineat w hat level the nerve w as involved, andwhether the patient should be treated sur-gically. T he operation usually consideredw as facial nerve decompression as advo-cated l)y Caw thorne,2 by K ettel, and byJongkees.

1. N eurological examination2. Ear, nose, and throat examination3. Roentgenologic study of the mastoid

area4. Complete blood count; erythrocyte

sedimentation rate5. 2-hour postprandial blood sugar6 . Roentgenogranl of the chest7. A udiogram, w ith special testing as

indicated.8 . S ch ir m er t ea r t e st9. T aste test, by history10. Serial 4-point nerve excitability test1 1 . Electromyography and nerve conduc-

tion stu(lies as indicated.Other studies are being added to the pro-

tocol, including serology, tuberculin skint est , el ec tr onyst agmology , acoustical impe-dance testing of the middle ear, and others.

D etails of certain of these tests are worthnoting.N euro log ica l E xam in a tio n

T he completeness of the paralysis is deter-mined in older children by asking themto raise the eyebrow, wrinkle the fore-

Patien tsD ia g n o a s ( N o )

B ell s pal syO t it is m ed iaB irth traumaIlistiocytosis-XS ku ll f racture

KnownProbable (traumatic neuroma)

C o n g e n t i a lH y p o g e n e s i s o f f a c i a l nerveO ti c capsul e abno rm al iti es

H erpes zoster cephalicusV ericellaM umpsP o s t i m m u n i z a t i o nM y x o m a t o s i s (probable)Etiologic factor unknown

* O ne patient, age 154 years, not included in thisseries, presented w ith unilateral facial paralysis and aneventual diagnosis of leukemia. X -ray revealed a de-structive lesion in the affected petrous apex.

head, close the eyes tightly, and to grin,show ing the teeth. I n infants the most con-venient way to examine the facial muscula-hire is to have the baby cry. I f there is theslightest bit of volitional movement of anyof the facial muscles on the affected sidethe paralysis is said to be incomplete.Sch irm er Tea r T es t

T he secretory fibers for lacrimation leavethe facial nerve at the geniculate ganglionw hich is anterior and medial to the horizon-tal ( middle ear ) portion of tile nerve.W hether or not lacrimation is occurring inan infant is established by the presence orabsence of tears during crying. L acriniationi s qua nt it at ed by the Schirmer test. A stripof filter paper 0. 5 cm w ide and 2 cm long ishooked into the lower eyelid. A normalquantity of tears fully moistens each stripwithin 5 minutes. W e modify this methodby having the patient inhale ammoniafumes, which stimulate a rapid flow oftears, reducing w etting time to less than 2minutes. A decrease in the quantity of tears



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xJ

F ic . 1 . F ou r-po in t facia l n erve testing site s.

B lo o d Su g a r

10 4 FA C IAL PA RALYS IS IN CH ILD REN

iIl(liC a tes invo lvem en t o f the fac ia l n erve a to r m ed ia l ( prox imal ) to th e gen icu la tegang l ion .

Tas te Tes tC lassic testitig fo r taste inv o lves b ila te ra l

te sting of the an te rio r tw o -th irds o f thetong ue . W e have no ted in ou r adu lt pa -tien ts a very h ig h corre la tion be tw een testresu lts an d a h is to ry of onset o f aberran ttaste. W e no lon ge r te st fo r taste b u t ra the rask th e pa tien t w he ther food tas tes havechang ed . C h ild ren w ith ageusia re la te th atice c ream or candy h as a funn y ta ste .A u d i o g r a m

T ile p re sen ce o r ab sen ce o f h ype racusis(ab norm al sensitiv ity to lou d no ises) is a lsoe lic ited by h is to ry . E lec tro acou stical im pe -d ance te sting of the s tap ed ius re flex has no tye t b een in clu ded in our stud y .

It has b een sug gested th at B e lls pa lsym ay be a p rim ary ischem ic d isease , andm ay rep re sen t th e f irs t s ign o f d iab ete s . F o rth is rea son eve ry pa tien t is sc reened fo r d i-abe te s w ith a 2 -ho ur postp rand ial b lo odsug ar . N o ch ild in ou r ser ie s h ad d iabe te s .In d i c a t i o n s f o r Dec o m pres s io n

The ind ica tio ns fo r su rg ica l d ecom pres-sion o f the facia l n erve w ere based on th ere su lts o f p ercu taneous ne rv e exc itab ilityte sting , w h ich is w e ll to lera ted by adu lts ,and w hich had b een repo rted by L aum ans,5C am pbe ll,6 and A lfo rd 7 to a ffo rd accu ra teapp ra isa l o f ne rve fun ctio n . O u r m e thod o fd ete rm in in g the p re sen ce or absence o fd en erva tion w as o rig ina ted du rin g th ecou rse o f th is stu dy . M o st c lin ic ians stim u -la te th e ne rv e a t th e trun k an d d efine actu alo r im p end in g dene rv atio n as a d ifference



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D IA G N O SIS A N D T R EA T M EN T 105bet eeI l tile affcctN i and the unaffectedside of 3.5 iiia or more in the current re-quired to elicit muscle motion. But thereare sources of serious error in the test asusually performed. I n order to reduce test-retest error, and to derive an indication ofprognosis, w e tested nerve excitability atfour points ( Fig. 1 ) : the frontalis, orbicu-laris oculi, orbicularis oris, and nerve trunk.I f the peripheral nerves w ere found to beequally excitable bilaterally, w hile thetrunk displayed a difference greater than3.5 ma, a test error had obviously beenmade. T est-retest reliability for nerve excit-ability determination w as least at the nervetrunk, and greatest at the frontalis.

A lthough the procedure is simple, a cer-tam degree of sophistication, gained w ithexperience, is required for determining thelocation of tile nerve branches. A t the startof testing, the milliampere setting is placedat higher than the expected threshold level.A dults typically tolerate decreasing stimuli,but sometimes become uncooperative w ithincreasing stimuli. U nfortunately, mostchildren do not cooperate w ith either nerveconduction or electroniyographic studies:46 ( 75% ) of the 61 children of this seriescould no t be adequately tested for this rea-son.M eth o d o f E v a lu a t io n o f T h e r ap eu t i c R es u l t

A Facial Paralysis Recovery Profile( FPRP ) and a Facial Paralysis RecoveryIndex ( FPRI ) had been devised in the Fa-cia! Paralysis Clinic to determine the out-come of therapy. T ile FPRP w as designedas an additive arithmetical system ( TableI I ) . Return of facial function w as accu-rately measured in units of 25% ; pluspoints were assigned to each 25% of returnin each of three facial regions: forehead,mouth, and eyelid.Forehead motion w as determined by tak-ing a precise measurement of the distancethat the eyebrow could be moved upw ardvoluntarily by the patient on the affectedside, and comparing it w ith the appropriatedistance on the normal side. M outh motionwa s determined by measuring the distancethat the patient could move the mouth lat-

I \ l HE I IFA CIA L PA I IA LY SI & 4 II FA OV IRY Piioii LI

( ADOUR - SWANSON )

Dal i U 3( J,;_;;( #{149}5-;: ;;-is#;

Forehea 0 +1 -1-1 -f-2Eye 0 +1 + 4-3 4Mouth 0 +1 + +3 +4

erally, and comparing it with the appropri-ate distance on the normal side. Evaluationof the motion of the orbicularis oculi mus-cle is subject to error derived from notingthe upw ard and outw ard rotation of theeyeball or the dow nw ard movement of thelevator palpebrae superioris. T o obviatethis subjective error, each low er eyelid wasslightly everted by attaching to it one endof a butterfly adhesive bandage, and tapingthe distal end of tile bandage to the malarregion of the face. T he measured differencebetw een the voluntary upw ard excursion ofthe low er eyelid on the affected and normalsides was then the clear criterion for the de-gree of function, without subjective bias.

T he number of points assigned to a spe-cific degree of motion in a specific musclegroup w as calculated on the basis of the

T A BL E I I IM I N U S PO I NT S ASSI GNED TO Speiiic ( OMPLI(ATO)NSI N DET ERM IN I NG FAC IA L 1ARALY SI S I K eovF :I iv I N I flX

( A o o r R - S v A N s o N )

(a;,, pli(a t ion x I i7 itS

F requent, e a rly cor n p lic a lio ns:Pain -IEpiphora - 1Ageu.sia - II)eereased lacriniation - lIlyperacusis - I

F re que nt, la te com plica tion s:Contracture - ISynkinesis (mass f acial motion) - 1Crocodile (gustatory) tears - 1Facial spasiii - 1Ptisi5 of eyebrow - I

In fr equent, s er ious compl icat ions :C orneal ul cerati on - IFacial sl ing -4Tarsorrhapliy -4



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I 06 FA CI A L PA R A L Y SIS IN CH IL D R ENfunctional and cosmetic importance of thatgroup. Possible FPRP scores ranged from 0to + 10 (T able I I ).

A system of minus points was assigned tospecific complications (Table I I I ). T he to-tal number of minus points w as subtractedfrom the individual s Recovery Profile score.T he net figure so obtained w as designatedthe Facial Paralysis Recovery Index( FPRI ) . T he best possible FPRI , repre-senting full recovery of motion w ith nocomplication, w as +10.

T he complications of facial paralysis arepredictable, tiid can be divided, as in T ableII I, in to ea rly freq u en t, la te freq u ent, an dinfrequent serious categories. O ur FPRPand FPRI produce a changing figure, basedon these complications as they develop. T helate complications usually do not maketheir appearance before the tw elfth week,and are readily apparent at 6 months.

T his arithmetical system could be ap-plied accurately and reproduceably to olderchildren, but for younger children-w how ere the majority of our series-we had torevert to the less reliable subjective evalua-tion of the return of facial function. I t issaddening to discover that children w ith fa-cial paralysis learn not to smile; they be-come introverted and resist attempts at sub-jective evaluation. For this reason, no validcomparison of end results of treatmentcould be made in many of the subjects ofthi s ser ies.

RESULTSO ne of the most important questions de-

termining treatment and prognosis isw hether the facial paralysis is clinicallycomplete or incomplete. I f it is clinically in-complete, the chance of recovery is excel-lent.

T w enty of the children in this series w hohad clinically incomplete paralysis fromany cause had a recovery index of + 10w ithin 3 to 6 w eeks after onset of paralysis.A n additional 17 had adequate return offunction but could not be accurately tested.

D enervation occurs only if facial paraly-sis is clinically complete. Because many of

our patients collid not be fully tested, theincidence of denervation could not be accu-ratel y determ ined.B e l l s P a ls y -37 Pa t ien ts

Early in this study, each patient w ithclinically complete Bells palsy w ho couldnot be tested in the outpatient departmentw as taken to the operating room at specif icintervals after onset of facial paralysis,where nerve excitability was tested underlight general anesthesia. I f a difference ofthe defined amplitude w as noted, a postau-ricular incision w as made, simple mastoid-ectomy was performed, and the facialnerve w as decompressed from the stylomas-toid foramen through its pyramidal portion.T his practice was discontinued in A pril1970 w hen w e determined that facial nervedecompression performed on the basis ofcritieria derived from nerve excitabilitytesting is not of benefit to patients w ithBells palsy.8 Before the inefficacy of de-compression w as determined, three chil-dren w ith Bells palsy underw ent this pro-cedure. Comparison of their postoperativecourses w ith those of patients treated non-surgically show ed that the rate and com-pleteness of recovery w as not altered by sur-gical decompression of the facial nerve.

Of the 16 children w ith clinically corn-plete Bell s palsy, 13 were old enough tocooperate sufficiently to permit accurateevaluation. A ctual or impending denerva-tion w as found in four. I n these four chil-dren, return of facial function w as delayed( it began at 6 w eeks) and w as maximal at 6months. C ontracture and synkinesis ( massfacial motion) developed in all of thesefour patients. In 21 of the Bells palsy pa-tients, paralysis was incomplete.O t i t i s M ed ia -S ix P a t ien t s

A ll o f th e six cases of fac ia l p ara lys is du eto otitis media were unilateral. In tw oinstances, facial paralysis was clinicallycomplete.

I n our clinic, w ith few exceptions, chil-dren w ith acute otitis media and facial pa-ralysis are treated in the following manner:



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D IA G N O SI S A N D T REA T M EN T 107If faCliul 1r1lysis is not cl ini cal ly coiiiplete,tI ltil)iOtiC therapy, decongestants, and myr-

ingotomy are suggested and the patient isfollow ed with careful observation. I f facialparalysis is clinically complete, surgicaltreatment is possibly indicated. Because ofthe infection, sflhlI ) le niastoidectomy with-otit decompression of the nerve is the pre-ferred surgical procedure.

T he tw o children w ith clinically corn-plete facial paralysis from otitis media weretreated by simple niastoidectomy withouticrve deconipressioii. A 2-year-old boy hada postauricular al)sccss and mucosal edemawithout evidence of destruction of the mas-toid air cells. N erve excitability levels ere C(lU al bilaterally. A t exploration thefacial nerve w as found to have no bonycovering iii its pyramidal portion. Fourw eeks after operation, recovery was corn-plete. I n a 3-year-old boy nerve excitabilitystudies indicated partial denervation. T hreeIllOnths af ter surgical exploration, the FPRPwas approximately + 8; the complicationsof sy nk il l si s and contracture reduced theFPRI to + 6.B i r t h T r au m a -F i v e Pa t i en t s

Four of the five cases of facial paralysistilought to result from birth trauma wereon the lef t; none w as bilateral. D elivery ofeach of the five infants had entailed the useof forceps or had been listed as diff iculti)y the obstetrician. N o treatment for the fa-cia! paralysis w as instituted in any of thef ive children. M ild contracture and synki-I lesi s d ev el oped OI l the affected side in tw o.H is t i o c y t o s i s -X ---Tw o Pa t i en t s

Tw o children, aged 10 months and 33years, with an eveiltual diagnosis of histio-cytosis-X ( eosinophilic granuloma ) pre-sented V it1l unilateral facial paralysis as theinitial evidence of disease. R oentgenogramsmade on admission to the hospital revealedbilateral lytic lesions in the mastoid pro-cesses. I n each patient, simple mastoidec-tomy w as performed on the side of thefacial paralysis 6 to 8 hours after onset,w ithout exploration of the facial nerve.

Facial function returned w ithin 1 w eek an(1was complete w ithin 3 w eeks in each patient.X -ray therapy totaling 500 r of orthovoltagew as subsequently given to each mastoidarea. N erve excitability levels w ere alwaysequal bilaterally. T here has been no cvi-dence of systemic disease in either patient.Both are asymptomatic and had normalhearing 10 months and 3 years after the on-set of facial paralysis.Sk u l l F r ac t u r e -Tw o P at ien t s

One child had facial paralysis and ipsilat-era! complete hearing loss follow ing skullfracture. W hen the patient was first seen inour clinic, 3 months later, there w as mini-mal muscle motion in the affected side ande!ectrical studies indicated nerve degenera-tion. H e had the complications of epiphora,contracture, and synkinesis. Roentgeno-grams of the skull revealed a transverse andlongitudinal fracture through the mastoidbone. I n another child, the facial nerve wasexplored 2% years after the onset of facialparalysis. A neuroma of the vertical por-tion of the facial nerve, probably the re-suit of an old skull fracture, was found.Co n g en i t a l Fac ia l P a r a l y s i s -Tw o Pa t ien ts

Extratemporal exploration of the facialnerve in a 2-year-old boy revealed hypo-genesis of the facial nerve. T he other pa-tient w ith congenital facial paralysis hadabnormal roentgenographic findings in theotic capsule. Exploration w as not advised.H erp es Zo s t er Cep h a l i c u s -O n e Pa t ien t

A lthough herpes zoster cephalicus w asthe second most common cause of facial pa-ralysis in our adult population,8 it ac-counted for only one instance of facialparalysis among these 61 children. N erveexcitability levels remained equal bilater-ally. Six months after onset of paralysis,the FPRP was + 10; epiphora reduced theFPRI to +9.Va r i c e l l a -O n e P at ien t

A 3-year-old boy with chickenpox had in-complete facial paralysis follow ed by full



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108 F A C I A L P A R A L Y SI S I N C H I L D R E Nr( tllrn of facial motion within a l)eriocl of4 weeks.M um p s -O n e Pa t ien t

Clinically complete facial paralysis inconjunction w ith mumps w as followed bypartial denervation of the facial nerve. Re-covery was incomplete. FPRP and FPRIcould not be ascertained because of the pa-tient s lack of cooperation.Po s t im m u n iza t io n fo r D PT an dP o l io m y e l i t i s -O n e P at ien t *

I n a 1-year-old boy, nausea and low feverdeveloped one day after immunization forD PT and Sabin type I I poliomyelitis. Sevendays later there were complete right facialparalysis, loss of balance, and diminishedlacrimation. T esting under light general an-esthesia showed no nerve excitability on theright. Findings on spinal paracentesis w erenormal. U nder general anesthesia, the rightfacial nerve w as decompressed from its pyr-amidal portion through the stylomastoidforamen. T he nerve did not bulge from itsincised sheath. T hree months after decorn-pression the FPRP and FPRI were + 7. Sixmonths after operation, the FPRP w as +8;because of ptosis of the right eyebrow , theFPRI was +7. T he patient w as lost to fur-ther observ ati on.M y x om a to s is (P r o b ab le )-O n e Pa t ien t

Incomplete unilateral facial paralysis de-veloped after exposure to a pet rabbit w ithdiagnosed myxomatosis. I n the patient, re-sponse to cephalin flocculation test w asequivocal; the diagnosis of facial paralysiscaused by myxomatosis was probable butnot proved. T he administration of predni-sone, in diminishing doses, was follow ed bycomplete return of function w ithin 3 w eeksafter onset of paralysis.O th e r -Tw o Pa t ien t s

T w o patients were seen w ith facial paral-ysis w hich appeared to be of long standing.Possible relationship to other disease couldnot be determ ined.

#{176} his case has been reported previously.8

COMMENTO u r ex p er ien ce w it h sev e r a l o f t h ese en -

tities deserves comment.Tos#{176}oncluded that surgery plays no rolein the therapy of facial paralysis caused by

eosinophilic granuloma. I n view of our ob-servations, w e advise exploration and sim-p ie mastoide ctomy without facial nerve de-compression if facial paralysis compli-cates histiocytosis-X , and roentgenographicchanges suggest erosion in the mastoidprocesses.

I n t h e ligh t o f ou r ex p er ien ce w it h a d u lt streated in our clinic for facial paralysis af-ter skull fracture, we w ould explore the fa-cia! nerve in such a patient only if theparalysis w as present immediately upon in-jury. Facial paralysis of delayed onset afterskull fracture has been followed by excel-lent outcome if nerve excitability was notaffected. In those patients w ho show ed lossof nerve excitability, FPR P and FPR I wereunsatisfactory.

T he decision to decompress the facialnerve in the infant w ith postimrnunizationfacial paralysis was based on the normal ce-rebrospinal fluid and the possibility that thefacial paralysis might be Bells palsy. Facialnerve decompression is not indicated if thecause of the paralysis is thought to be at thebrain stem. In retrospect, it is seen that thedecreased tearing and loss of balanceshould have been considered contraindica-tions to surgical intervention.

Since w e have determined that facialnerve decompression is not of benefit inBells palsy, w e are now making a con-trolled study of orally administered steroids( prednisone) in this disorder. A lthoughmany articles have appeared in the litera-ture concerning the use of steroids in thetreatment of p a t ien t s w it h B ells p a lsy ,there has been no series affording statisticalproof that the steroid is or is not of benefit.Early analysis of the data indicates thatprednisone given w ithin the first 72 hoursafter onset of paralysis may decrease the in-cidence of facial denervation. For childrenolder than 10 years we recommend 40 mgdaily in divided doses for 4 days, tapering



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D I A G N OSI S A N D T REA T M EN T 109tilereafter to 5 mg daily to end at 8 days. T oyounger children w e have been giving 20mg daily for 4 days, tapering to 5 mg t o en dat 8 days. T he dosage, arbitrarily deter-mined, w as suggested by D r. G eorge W .Thorn.f1#{176}

Repeated observations over 4 years in ourFacial Paralysis Clinic have show n thatchildren are subject to the same causes offacial paralysis as is the adult population.T reatment must be based on complete eval-uation as outlined, with no special refer-ence to the age of the patient. I n any in-stance of facial paralysis in a child, an effortshould be made to determine immediatelywhether it is caused by a specif ic, treatableentity.

I H er se y P r o fe sso r o f the T heory and Practice ofPhysics, H arvard Me d i c a l S c h o o l , a n d P h y s i c i an i nChief , Peter B ent Brigham H ospital , B oston, M as-sachusetts.

REFERENCES1. Paine, R . S. : Facial paralysis in children. J.

Pediat., 19:303, 1957.2. C aw thorne, T . : T he role of surgery in the in-

vestigation and treatment of peripheral fa-cial palsy. L ancet, 1 : 1219, 1952.

3. K ettel, K . : Surgery of the facial nerve. A rch.Otolaryng., 81 :525, 1965.

4. Jongkees, L . B . S. : D ecompression of the facialnerve. A rch. O tolaryng., 85:29, 1967.

5. L aumans, E. P. J. : O n the prognosis of periph-eral f aci al paralysis of endotemporal origin.T hesis, A msterdam, 1962.

6. C ampbell, E . D . R . : A simple prognostic testin facial palsy. J. L a r y n g . , 77:462, 1963.

7. A lford, B . R. : Electrodiagnostic studies in fa-cial paralysis. A rch. Otolaryng., 85:259,1967.

8. A dour, K . K ., and Sw anson, P. J., Jr.: F acialparalysis: treatment response in 403 pa-tients. A ccepted for publication.

9. T os, M .: Facial palsy in H and-Sch#{ 252} ller-C hris-tian disease. A rch. Otolaryng., 90:563, 1969.

10. T horn, G. W .: Personal correspondence, N o-vember 26, 1969.



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1972;49;102PediatricsJohn J. Manning and Kedar K. Adour

FACIAL PARALYSIS IN CHILDREN

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