GUIDELINE FOR THE MANAGEMENT OF IDIOPATHIC FACIAL PALSY. All children under 16 presenting to UHW or CHfW with IFP. Dr P Jeffrey Morgan ST8

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1 GUIDELINE FOR THE MANAGEMENT OF IDIOPATHIC FACIAL PALSY Reference: IFP Version No: 1 Applicable to All children under 16 presenting to UHW or CHfW with IFP Classification of document: Area for Circulation: Author: Group Consulted: Ratified by: Guideline Children s Hospital for Wales Dr P Jeffrey Morgan ST8 Practitioners within the Children s Hospital for Wales, UHW Current literature Child Health Guideline Meeting June 2013 Date Published: August 2013 Version Number Date of Review Reviewer Name Completed Action Approved By Date Approved New Review Date Disclaimer These have been ratified at the Child Health Guideline Meeting, however clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of theindividual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

2 IDIOPATHIC FACIAL PALSY GUIDELINE Idiopathic Facial Palsy (IFP) is not an uncommon presentation to Children s Assessment Units and emergency departments. Estimates of incidence in childhood vary between 1 3/100,000 depending on age, being lower in those under 10y. IFP is generally characterised by acute onset of unilateral facial weakness and inability to close the eye on the affected side. The striking clinical appearance may cause considerable anguish to both the child and parents. Common causes of facial weakness in children include infection, trauma, congenital or a neoplastic cause. However, for the majority of patients, the cause remains unknown and it is these cases we refer to as idiopathic or Bell s Palsy (40 70%). The aim should be to exclude other causes of facial weakness before initiating an appropriate management strategy for IFP. Unfortunately, the relative paucity of paediatric trials means there is currently no consensus for the diagnostic approach and management for IFP in children. Management with corticosteroids is still controversial. Several adult studies demonstrate an improved rate of recovery following the use of steroids. IFP is generally a self limiting benign condition showing signs of recovery between 3 weeks and 3 months. The vast majority of children achieve remission, with resolution of clinical signs in up to 80 90% children by 6 months, approaching 100% at 12 months. This represents a better prognosis when compared to adult studies. However, paediatric studies are sparse and three trials presented no added benefit when corticosteroids were used. The risk of recurrence of IFP in children has been estimated at 7 10%, reoccurring at a median of 9.8years.

3 FEATURES OF IDIOPATHIC FACIAL PALSY: Acute onset Unilateral lower motor neurone weakness Preceding posterior auricular pain Distortion of taste sensation Hyperacusis Loss of hearing Excessive lacrimation Eye discomfort/visual disturbance HISTORY SHOULD INCLUDE: Age of onset Evolution of symptoms Previous episodes Recent viral illness /ear infections Preceding trauma Easy bruising/lethargy Recent immunisations Tick bites/travel to areas endemic for Lyme Disease EXAMINATION & INVESTIGATIONS: IFP is a diagnosis of exclusion, therefore it is imperative to perform a full system examination to eliminate possible secondary causes or misdiagnoses 1. Document severity of facial weakness on admission if possible use House Brackmann score (see appendix 1) or ask parents to use phone s camera Confirmation of Facial Palsy: 1. Record Blood Pressure 2. FBC Keep initial investigations to a minimum Refer to General Paediatrics Consider alternative diagnosis if: Pallor or bruising Lymphadenopathy Hepatosplenomegaly Rash/vesicles Arthalgia Discuss with Neurology if: Abnormal neurological signs Recurrence of IFP Consider neuroimaging Discuss with ENT if: Otoscopy vesicles/discharge Hearing loss Whisper test Parotid Swelling Mastoiditis Add CRP & cultures Consider aciclovir/antibiotics Consider neuroimaging Further investigations should be discussed with middle grade or Consultant based on clinical history and examination findings

4 TREATMENT: Eye Care: Steroids: For all patients A. Hypomellose drops or Viscotears QDS B. Lacrilube ointment and covering of affected eye at night If within 72h of onset: Prednisolone (1mg/kg/day) 7day course Consider use of PPI, eg, Omeprazole, if long term use of steroid required Steroids: Beyond 72h of onset: Discuss individual case with Consultant Aciclovir: Treat all patients who present with vesicles see BNF for children for dose Literature supports the administration of corticosteroids within 72 hours of initial symptom presentation. The dose and duration of 1mg/kg/day in a 7 day tapering course is supported by adult and paediatric studies. FOLLOW UP: Review 5days from starting Prednisolone Paediatric Nurse Practioner Clinic Assess for signs of clinical improvement Reassess affected eye Review 3 4w General Paediatric Outpatients Clinic Reassess neurological examination and affected eye If resolution of symptoms or evidence of clinical improvement: Discharge with advice regarding: 1. Recurrence 2. Onset new symptoms If IFP persists or recurrence within 4m: Consider alternative diagnosis Neuroimaging (MRI) Consider serological investigations HSV, EBV, B. burgdorferi Discuss with neurology/ent/microbiology

5 EDUCATION: Provide written parent information sheet Advise simple analgesia for pain relief Explain potential adverse effects of Prednisolone Explain may experience some noise hypersensitivity Re iterate importance of eye care and attending follow up Offer reassurance that prognosis is generally excellent with almost all patients exhibiting signs of recovery for 3w 3m. More than 95% children make full recovery by 12m Advise to seek medical attention should facial weakness continue to evolve or onset of new signs in particular visual disturbance KEY REFERENCES: Malik V, Joshi V, Green KMJ, Bruce, IA. 15 minute consultation: A structured approach to the management of facial paralysis in a child. British Medical Journal. 2012;97:82 85 Salinas RA, Alvarez G, Daly F and Ferreira J. Corticosteroids for Bells Palsy (idiopatic facial paralysis). The Cochrane Collaboration Sullivan FM, Swan IRC, Donnan PT, Morrison JM, Smith BH, McKinstry B et al. Early treatment with prednisolone or acyclovir in Bell's palsy. The New England Journal of Medicine. 2007; 357(16) pp Drack FD, Weissert M. Outcome of peripheral facial palsy in children A catamnestic study. European journal of Paediatric Neurolgy 17 (2013):

6 Appendix 1. House Brackmann Facial Nerve Grading System Grade I Grade II Grade III Grade IV Grade V Grade VI Normal Normal facial function in all areas Slight Dysfunction Slight weakness noticeable on close inspection; may have very slight synkinesis Normal symmetry and tone Forehead moderate to good function Eye complete closure with minimum effort Mouth slight asymmetry Moderate Dysfunction Obvious but not disfiguring difference between two sides; noticeable but not severe synkinesis,contracture, and/or hemi facial spasm Normal symmetry and tone Forehead: slight to moderate movement Eye: complete closure with rffort Mouth slightly weak with maximum effort Moderate Severe Dysfunction Obvious weakness and/or disfiguring asymmetry Normal symmetry and tone Forehead: none Eye: incomplete closure Mouth: asymmetric with maximum effort Severe Dysfunction Only barely perceptible motion Asymmetry Forehead: none Eye: incomplete closure Mouth: slight movement Total Paralysis No movement House JW and Brackmann DE. Facial nerve grading system. American Academy of Otolaryngology Head and Neck Surgery. 1985;93: