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1 CASE REPORT

A 12-year-old male was seen with a three-day history of right sided facial weakness. He was unable to close his right eye. He denied pain, headache, nausea, vomiting, dizziness, verti-go, visual problems, altered sensation, altered taste or weak-ness. There was no history of a recent viral infection, trauma or dental procedure and no recent history of travel or outdoor recreational activities. On physical examination he was unable to lift his right eyebrow or close his right eye and when asked to puff out his cheeks, the corner of his left mouth drooped downward (Figure 1).

2 DISCUSSION

Bell’s palsy was first described by Sir Charles Bell, a Scot-tish surgeon, in 1821. It affects the muscles innervated by the facial nerve, the frontalis, orbicularis oculi, nasalis, and or-

bicularis oris. The prevalence varies between 11 and 40 cases per 100,000 individuals [1]. Males and females are affected equally [2]. While usually idiopathic, other causes include congenital, genetic, infectious, inflammatory, neoplastic, and vascular processes [3]. (Table 1) One case series explored the autosomal dominant mode of inheritance in three generations of a Dutch family [4] while a case report in a 26-year-old male noted that his mother and maternal grandmother had similar histories of facial paralysis [5]. When determining the need for imaging or testing (MRI, lumbar puncture, CT or EMG), risk factors for cranial tumors, ischemic or hemorrhagic cere-brovascular events, or life threatening infections such as HSV encephalitis need to be determined. In isolated Bell’s palsy, MRI is usually normal. This allows the diagnosis of idiopathic unilateral facial paralysis to be made as a diagnosis of exclu-sion [7].While most idiopathic cases resolve spontaneously without treatment, steroids and/or acyclovir may be used. One ran-domized controlled trial compared outcomes with predniso-lone and acyclovir [6]. Results showed that at three months the absolute risk reduction associated with prednisolone was 19% and at nine months the equivalent numbers showed a risk reduction of 12% [6]. One double-blind randomized con-trolled study compared acyclovir-prednisone to placebo-pred-nisone and found that acyclovir and prednisone were signifi-cantly better than prednisone. The study suggested that herpes infection may be a common underlying cause [8]. Although most cases are self-limited, 30 percent of patients may have persistent facial paralysis, disfigurement, and neuropathic fa-cial pain [6]. If symptoms do not resolve within 6 to 8 weeks, MRI with contrast may be useful [7]. While there is signifi-cant variation in positive findings associated with a diagnosis of Bell’s palsy on MRI, one cohort study showed that most cases involved the facial nerve at the location of the fallop-ian canal segment where it reaches the internal auditory canal, medial to the geniculate ganglion [7]. The same study linked the suspected facial nerve dysfunction as secondary to either diffuse cellular inflammation, potential neural degeneration or hyper-vascularity and subsequent entrapment neuropathy sec-ondary to neural edema as it travels through the osseous fal-lopian canal [7]. Additionally, between 7 and 15% of patients may developed recurrent symptoms. If this occurs, prompt imaging and testing for other causes is important.

CASE REPORT

Received: 14 July 2020 Accepted: 08 August 2020 Published: 17 August 2020

A Case Report on Bell’s Palsy in a Pediatric Patient

Nandita Singh1 | Joel Matthews2 | Fatima Aly1 | Lynnette J Mazur*

1McGovern Medical School, United States

2University of Lancashire, Lancashire, United Kingdom

Journal of Medical & Advanced Clinical Case Reports

CorrespondenceDr. Lynnette MazurMcGovern Medical SchoolUnited StatesE-mail: Lynnette.J.Mazur@uth.tmc.eduTel: +1-713-500-5668

Figure 1: Right sided facial weakness, Lagophthalmos, and asymmetric wrinkling of forehead.

2

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4. Hageman G, Ippel PF, Jansen ENH, Rozeboom AR (1990). Familial, alternating Bell’s palsy with dominant inheri-tance. European neurology 30: 310-313.

5. Clement WA and White A (2000) Idiopathic familial facial nerve paralysis. The Journal of Laryngology & Otology 114: 132-134.

6. Sullivan, Frank M, Iain RC, Peter T, Donnan, et al. (2007) “Early treatment with prednisolone or acyclovir in Bell’s palsy.” New England Journal of Medicine 16: 1598-1607.

7. Tien R, Dillon WP, Jackler RK (1990) Contrast-enhanced MR imaging of the facial nerve in 11 patients with Bell’s palsy. AJR. American journal of roentgenology 155: 573-579.

8. Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, et al. (2007) Early treatment with prednisolone or acy-clovir in Bell’s palsy. New England Journal of Medicine 357: 1598-1607.

In conclusion, Bell’s palsy is usually idiopathic in children and resolves spontaneously over the course of a few months. Our patient was treated with a five-day course of prednisone and in order to prevent exposure keratitis was advised to use methyl-cellulose eye drops and an eye patch while sleeping. His symp-toms gradually improved over the course of six weeks and he was advised to return if they recurred.

Congenital

Moebius syndrome (unilateral or bilateral hypoplasia of facial nucleus with other cranial nerve abnormalities such as abducens nucleus malformationCongenital cranial nerve paresis 1 and 2(Chromosomal abnormalities)Branchial arch malformation and perinatal trauma

Infectious

Otitis mediaHerpes simplexVaricella Zoster: Ramsay Hunt syndrome with painful vesicular lesions in the external auditory canal with VIII nerve dysfunctionLyme disease (Borrelia Burgdorfi)Other virus infections: mumps, EBV, CMV, rubella, HIV, polioBacterial: Syphilis, Bartonellosis, Tuberculosis, botulism, diphtheriaFungal: Mucomycosis

Vascular

Ischemic or hemorrhagic strokesCrossed syndromes of Millard-Gubler (facial palsy and contralateral hemiparesis), Foville (facial palsy, conjugate gaze paralysis, and contralateral hemiparesis), Microvascular causes from diabetes and hypertension.

InflammatorySarcoidosis, Miller Fisher syndrome of GBS, Multiple sclerosis, Vasculitis (Giant cell arteritis in elderly), amyloidosis

NeoplasticCP angle tumors, meningioma, parotid tumors, metastatic lesions, neurofibromatosis

Miscellaneous

Melkersson-Rosenthal syndrome, characterized by recurrent facial paralysis, episodic facial swelling, and a fissured tongue, seen in adolescence with unclear etiology

Iatrogenic Botulinum toxin

Table 1: Differential Diagnosis of Facial Paralysis.

3 REFERENCES

1. De Diego-Sastre, Prim-Espada, Fernández-García (2005) The epidemiology of Bell’s palsy. Revista de neurologia 41: 287.

2. Gilden DH (2004) Bell’s palsy. New England Journal of Medicine 351: 1323-1331.

3. Ronthal M (2012) Bell’s palsy: pathogenesis, clinical fea-tures, and diagnosis in adults. In UpToDate. Wolters Klu-wer Health, New York.