NottinghamNeonatalServiceClinicalGuidelines

GuidelineNo.F16

Title:

Management of facial nerve palsy in newborn period

Version:
Ratification Date:
Review Date:
Approval:
Authors:
Job Title:
Consultation:

1 (May 2013)
26.3.13.
April 2016
Nottingham Neonatal Service Clinical Guideline Meeting
Dr Dushyant Batra
Consultant Neonatologist
Nottingham Neonatal Service Staff, Clinical Guideline Meeting
Mr Ciaran OBoyle (Consultant Plastic Surgery) and Ms Katya Tambe
(Consultant Ophthalmology)
Guideline Contact: Dr Stephen Wardle, Guideline Coordinator and Consultant
Neonatologist, C/O Stephanie Tyrell, Nottingham Neonatal Service
stephanie.tyrrell@nuh.nhs.uk
Distribution:
Nottingham Neonatal Service, Neonatal Intensive Care Units
Target Audience:
Staff of the Nottingham Neonatal Service
Patients to whom
Patients of the Nottingham Neonatal Service who fit the
this applies:
inclusion criteria of the guideline below
Key Words:
facial nerve palsy
Risk Managed:
Morbidity from facial nerve palsy
Evidence used:
The contemporary evidence bas has been used to develop this
guideline. References to studies utilised in the preparation of this
guideline are given at its end.
Clinical guidelines are guidelines only. The interpretation and application of clinical
guidelines remain the responsibility of the individual clinician. If in doubt, contact a senior
colleague. Caution is advised when using guidelines after the review date. This guideline has
been registered with the Nottingham University Hospitals NHS Trust.

KEY POINTS
Facial nerve palsy in the newborn period may be congenital, caused by
events around the time of birth, or developmental, resulting from anomalies
or mishaps in development of facial pathway
More than 90% of infants with congenital facial palsy will recover by 3-6
months
Eye care may be paramount in infants with incomplete eye closure
Persistent residual weakness at 3 months should warrant referral to plastic
surgery clinic

1. Introduction/Background
Facial nerve palsy in the newborn period may be congenital, caused by conditions acquired during
or at birth (e.g. birth trauma) or developmental, a result of developmental abnormalities of facial
pathway (isolated or as part of syndromes like Mbius syndrome). The congenital form is most
common and carries a good prognosis. More than 90% of infants with congenital form will have full
recovery; the process may take hours to 6 months1, 2. The majority, although not all of these cases,
have been associated with instrumental deliveries especially forceps use. Pressure of the posterior
blade compressing the bone overlying the vertical segment of the facial canal is implicated3. For
non-instrumental deliveries, intrauterine trauma from pressure on the infant's face by the sacral
prominence during labor has been suggested as possible cause in such cases4.

NottinghamNeonatalServiceClinicalGuidelines

GuidelineNo.F16

Developmental facial nerve palsy results from developmental mishaps during embryogenesis. This
may result from aplasia/ hypoplasia of cranial nerve nuclei or abnormal differentiation and neuronal
connections of cranial neuronal pools, or from abnormal axonal transport of molecules necessary
for muscle function and development5. Genetic factors, vascular events, or teratogenic insults have
been implicated6. Please see Appendix 2 for common causes, their presenting features and
management.
2. Patient group
Newborn infants noted to have facial nerve palsy at birth or on postnatal examination.
3. Patient Assessment:
All infants suspected to have facial nerve palsy should be reviewed by a tier 2 Speciality Trainee
(registrar). The details of pregnancy, labour and delivery, maternal medical history and family
history should be documented.
Facial nerve palsy is usually unilateral and evident by
Absence of forehead wrinkling
Shallow or absent nasolabial fold on affected side
Impaired movement of lips
Asymmetry of the face especially on crying with deviation of angle of mouth
In severe cases:
Impaired eye closure
Complete absence of facial movements on affected side
Facial asymmetry at rest
Difficulty in feeding because of impairment of sucking
Bilateral facial palsy can be easily missed as the facial symmetry is often maintained. Face
examination should evaluate upper and lower half of face on both sides for movements, nasolabial
folds as well as assessment of sucking. In addition, a detailed clinical examination including full
neurological assessment, evidence of other features associated with difficult deliveries like bruising
of scalp, haemotympanum, severe sutural moulding, Erbs palsy should be looked for. Difficult
delivery, prolonged labour, instrumentation especially forceps and evidence of other birth injuries
suggest congenital aetiology. On the other hand, dysmorphic features, other cranial nerve palsies,
other coexisting anomalies and family history of facial nerve palsy favour developmental cause.

4. Management in Postnatal wards (Appendix 1):

Majority of infants with congenital facial nerve palsy will recover with time. Attention to eye care to
prevent corneal damage is paramount in infants unable to close their eyes(s). Eye lubrication with
artificial tears or OC Lacrilube ointment 4-6hrly should be commenced as early as possible in
these infants.
Infants with facial nerve palsies associated with facial laceration should be urgently referred to oncall Plastic Surgery Registrar. These infants may require surgical exploration on an urgent basis.
Medical photography should be contacted after parental consent to take photographs of the wound.
Some infants with facial nerve palsy may have difficulty in feeding and may need additional support
for establishment of the feeding. Other infants should be reassessed within 24hours time. In
absence of full recovery at this time, a follow up in admitting consultants outpatient clinic should be
arranged. All infants with facial nerve palsy should be discussed with the admitting consultant.
Infants with persistent severe palsy i.e. unable to close eye(s), complete absence of movement on
the affected side, facial asymmetry at rest and difficulty in feeding, will need follow up in two weeks
time. Infants unable to achieve spontaneous eye closure at discharge should be prescribed artificial
tears or OC Lacrilube ointment 4-6 hourly until the review in the clinic. Other infants should be
booked in consultant clinic in six weeks time.

NottinghamNeonatalServiceClinicalGuidelines

GuidelineNo.F16

Additional management of infants with suspected developmental facial nerve palsy (see Appendix
2) will depend upon other abnormalities and may include involvement of multidisciplinary team like
Genetics, Paediatric Neurology, family care team and physiotherapy.

5. Management in the clinic:

Absence of any recovery signs at 6 week follow up visit should warrant referral to Mr Ciaran
OBoyle (Consultant Plastic Surgery with special interest in Facial nerve palsy) and Ms Tambe
(Consultant Ophthalmology). Infants with partial recovery at this visit will need additional outpatient
assessment at 3 months. Persistent residual palsy at this stage will also need plastic surgery and
ophthalmology referral. MRI Head including temporal bone (to include facial canal and inner ear)/
Neurophysiological investigations may be considered in consultation with Plastic surgery/ Paediatric
Neurology team.
In infants with other cranial nerve involvement e.g. Mbius syndrome (See Appendix 2), referral to
Paediatric Neurology should be considered.

REFERENCES
1.
Hughes CA, Harley EH, Milmoe G, Bala R, Martorella A. Birth trauma in the head and neck.
Archives of otolaryngology--head & neck surgery. 1999 Feb;125(2):193-9.
2.
Falco NA, Eriksson E. Facial nerve palsy in the newborn: incidence and outcome. Plastic
and reconstructive surgery. 1990 Jan;85(1):1-4.
3.
McHugh HE. Facial Paralysis in Birth Injury and Skull Fractures. Arch Otolaryngol. 1963
Oct;78:443-55.
4.
Shapiro NL, Cunningham MJ, Parikh SR, Eavey RD, Cheney ML. Congenital unilateral facial
paralysis. Pediatrics. 1996 Feb;97(2):261-4.
5.
Song MR. Moving cell bodies: understanding the migratory mechanism of facial motor
neurons. Archives of pharmacal research. 2007 Oct;30(10):1273-82.
6.
Terzis JK, Anesti K. Developmental facial paralysis: a review. J Plast Reconstr Aesthet Surg.
2011 Oct;64(10):1318-33.

NottinghamNeonatalServiceClinicalGuidelines

GuidelineNo.F16

Appendix 1: Facial Nerve Palsy Guideline Summary

Neonatewithfacialnervepalsynotedatbirth
oratnewborncheck

Antenatalhistory,birthhistory;detailedclinicalexaminationincludingallcranial
nervesandneurologicalassessmentbyTier2traineeorSeniorANNP

Presenceoffaciallaceration
shouldwarrantreferraltoon
callplasticsurgeryregistrar

Ifinfantcantcloseeye:Starteye
lubricationwithartificialtears

Reassesswithin24hours

FullRecovery
Anyofthefollowingfeatures:
Completeabsenceoffacial
movementonaffectedside
Noeyeclosure
Difficultfeedingbecauseof
facialnervepalsy

Discharge

NO

YES

OPDAssessmentat6weeks

OPDAssessmentat2weeks
Reviewfeeding,eyeclosure
andfacialnervefunction
Ophthalmologyreferralto
MsKTambeifnotclosingeyes
spontaneously

FullRecovery

Yes

NO

Ifnosignofimprovement
considerplasticsurgeryreferral
Outpatientreviewat3months
ifsomeimprovement

FullRecovery

ReferraltoMrCiaranOBoyle,Consultant
PlasticSurgeryandMsKatyaTambe,
ConsultantOphthalmology
ConsiderMRIscanHeadwithtemporalbone
andNeurophysiologyoffacialnerve

No
Yes

Discharge

NottinghamNeonatalServiceClinicalGuidelines

GuidelineNo.F16

Appendix 2:
Developmental facial nerve palsy: common causes, clinical features and management

S
No

Clinical
Condition

Clinical Features

Management

1.

Mbeus
Syndrome

-Karyotype and FISH to exclude

22q deletion and chromosomal
abnormalities
-Paediatric Neurology referral
-Consider Genetics review

2.

Asymmetrical
crying faces
(ACF)

-Facial nerve palsy (usually

bilateral)
-Other cranial nerve palsies (6th,
12th, 9th)
-Limb abnormalities
-Usually sporadic
-significant ulinateral depression
of the lower lip with crying
-10% risk of associated major
abnormalities including cardiac
defects

3.

Hemifacial
microsomia
(includes
Goldenhar
Syndrome)

-As above

4.

22q deletion
(DiGeorge
Syndrome)

5.

CHARGE
syndrome

-1st and 2nd branchial arch

abnormalities with variable
phenotype
- Ear abnormalities
- mandibular, maxillary, orbital
hypoplasia
- facial nerve palsy or facial
muscle hypoplasia
- verterbral and eye
abnormalities, hearing loss,
cardiac abnormalities
- dysmorphic features
(almond shaped eyes,
prominent nasal bridge,
micrognathia)
- heart defects
- cleft palate
- a subset associated with
facial nerve palsy
C: Coloboma of iris/ retina
H: heart defects
A: Atresia choanae
R: Retardation of growth and/ or
development
G: Genital anomalies
E: Ear anomalies with associated
facial nerve palsy and
swallowing difficulty
-caused by defect in CHD7 gene

-As above +
-Echocardiogram

As above

All of above +
-Specific genetic test
-Speech and language therapy
(SALT) involvement if problems
with sucking and swallowing