Acta Oto-Laryngologica, 2009; 129: 915
920

ORIGINAL ARTICLE

Outcomes of facial palsy in children

WEI-HSUN SHIH2, FEN-YU TSENG3, TE-HUEI YEH1, CHUAN-JEN HSU1 &

YUH-SHYANG CHEN1
1
Department of Otolaryngology, 3Department of Internal Medicine, National Taiwan University Hospital and National
Taiwan University College of Medicine, Taipei and 2Department of Otolaryngology, St Paul’s Hospital Taoyuan, Taiwan

Abstract
Conclusions. Facial palsy in children might be an alarming sign of serious underlying disease such as tumor, systemic disease
or congenital anomalies and the recovery is poor in those cases. Therefore, careful investigation and differential diagnosis
are essential in children. Prednisolone does not make a significant difference in the outcome in the treatment of children
with Bell’s palsy. The prognosis of Bell’s palsy in the pediatric group is good; patients usually recover within 3 months.
Objectives. To review and analyze the etiology, management, and outcome of facial palsy in children. Patients and methods.
Using a retrospective chart review, patients under the age of 15 years with a diagnosis of facial palsy were collected from
1996 to 2002. Results. A total of 56 cases (29 male, 27 female) with a mean age of 6.994.5 years were included in this
analysis. Causes of facial palsy were Bell’s palsy (44 patients, 78.6%), neoplastic (4 patients, 7.1%), head injury (3 patients,
5.4%), congenital (3 patients, 5.4%), or infectious (2 patients, 3.6%). In Bell’s palsy there was no significant difference in
the recovery rate between the groups with or without prednisolone treatment and between the groups that received
medication within 1 week of syndrome onset or after more than 1 week.

Keywords: Facial palsy, children, prednisolone, etiology, outcome

Introduction The prognosis and outcomes for facial palsy are

Facial palsy, although not life-threatening, remains
relatively common and can have severe effects on a
patient’s quality of life. The incidence of facial palsy
is 15
40 per 100 000 inhabitants [1]. However, the
incidence of facial palsy in children is relatively low.
From Falco and Erisksson’s report [2], 0.2% of
44 292 newborn babies have facial palsy. The etiol-
ogy of facial palsy may be classified into: (1)
infectious causes such as otitis media, chickenpox,
herpes zoster oticus, mumps, and mononucleosis; (2)
non-infectious causes such as congenital disorders,
traumas, neoplasms, metabolic diseases, and auto-
immune diseases; and (3) idiopathic (Bell’s) palsy.
Facial palsy in children is a complex condition that
may involve facial functions, and may include
cosmetic and psychological problems. The etiology,
management, and outcomes often cause a significant
amount of concern and confusion for clinicians and
children’s parents.
highly dependent on the etiologic nature as well as
the management offered to the patient. It is im-
portant for any practitioner who assists this popula-
tion to have an understanding of the common
etiologies and initial management of facial palsy. A
review of related articles reveals that numerous
papers have studied adult facial palsy, but only a
few have focused on facial palsy in children. Because
of the rarity of facial palsy in children, there is no
definite conclusion about the prevalence, treatment,
and outcome of facial palsy in pediatric patients.
Therefore, the aim of the present study was to report
our experience of the clinical course, etiology,
treatment, and outcome of facial palsy in children.
Patients and methods
This was a retrospective study based on chart review
and telephone interviews. There were 56 patients

Correspondence: Dr Yuh-Shyang Chen, Department of Otolaryngology, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei 100,
Taiwan. Tel: 886 2 2312 3456 ext. 65216. Fax: 886 2 2341 0905. E-mail: yschen@ntu.edu.tw

(Received 11 August 2008; accepted 10 September 2008)

ISSN 0001-6489 print/ISSN 1651-2251 online # 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As)
DOI: 10.1080/00016480802468179
916 W.-H. Shih et al.

with facial palsy under 15 years of age from Etiology

December 1996 to December 2002. Their demo-
As regards the etiology of facial palsy in children
graphy, etiology, treatment, and outcomes were
(Table I), the most common cause was Bell’s palsy
reviewed. It is more difficult to perform electrodiag-
(44 patients, 78.6%), followed by tumor lesion (4
nostic testing on children, especially an infant or a
patients, 7.1%), head injuries (3 patients, 5.4%),
young child, than in adults because the child is often
congenital anomalies (3 patients, 5.4%), and infec-
uncooperative and not able to tolerate the electrical
tion (2 patients, 3.5%).
stimulation. Therefore, our estimation of whether
the paralysis was complete or incomplete was based
on observation of the patient’s facial movements Bell’s palsy
while at rest, during motion, crying or laughing. The
Of the 44 patients with Bell’s palsy, there were 36
recovery time was defined as the period between the (81.8%) with complete facial palsy and 8 (18.2%)
onset of facial palsy and complete recovery. with the incomplete type. Seven patients (15.9%)
We also compared the treatment modalities, the had preceding events 2
4 weeks before a Bell’s palsy
period before seeking medical attention, and the attack. Those events included acute rhinopharyngi-
outcome using Fisher’s exact statistical analysis
tis (four patients), herpangina (one patient), hand-
method. This study was undertaken with the
foot-mouth disease (one patient), and acute para-
approval of the Research Ethics Committee of the
nasal sinusitis (one patient).
National Taiwan University Hospital.
In these 44 patients with Bell’s palsy, 26 patients
(6 incomplete, 20 complete facial palsies) received
oral prednisolone (1 mg/kg/day) treatment for 7
10
Results
days. Normal function returned to all (26/26) within
Demography 3 months. Meanwhile, 18 patients (2 incomplete, 16
complete facial palsies) received no medication.
From 1996 through 2002, 56 patients with a mean
Among them, 94.4% of patients (17 of 18, including
age of 6.994.5 years suffering from facial palsy were
2 incomplete facial palsies) recovered completely
collected. There were 29 male and 27 female
within 3 months. There was no significant difference
patients, with ages ranging from birth to 15 years.
between the mode of treatment and recovery rate
Most patients were distributed in the 0
5 years age
using the Fisher’s exact test (p 0.4091) (Table II).
group (44.6%), with the peak incidence at 4 years
In the steroid medication group, we also analyzed
(eight patients, 14.3%). There were 36 left and 20
the relationship between the interval before seeking
right facial palsies. Forty patients (71.4%) had
medical attention and the outcome. The period from
complete facial palsy and 16 (28.6%) had the
onset of facial palsy to seeking medical help in our
incomplete type (Table I).
hospital was divided into two groups: (1) visiting our
Table I. Demography of facial palsy in 56 children. hospital within 1 week (18 cases), (2) and those
attending after more than 1 week (8 cases). We
Number Complete Incomplete Recovery found that except for one patient, no matter when
Parameter (%) palsy palsy (%) the patient was brought to our clinics, they all
recovered within 3 months. The exception was a 4-
Total 56 40 16 48 (86)
year-old boy who visited our clinic 4 weeks after the
Age distribution (years) onset of right complete facial palsy. No significant
0
5 25 15 10 19 (76)
difference was found between the period before
6
10 14 12 2 12 (86)
11
15 17 13 4 17 (100) seeking medical attention and recovery rate (Fisher’s
exact test, p 0.1364) (Table II). In summary, the
Gender
Male 29 21 8 24 (83)
facial nerve functional recovery rates in Bell’s palsy
Female 27 19 8 24 (89) were 38.6% (2 weeks), 77.3% (4 weeks), 86.4% (2
months), and 97.7% (3 months).
Sides
Right 20 14 6 17 (85)
Left 36 26 10 31 (86) Recurrence
Recurrence 3 3 0 3 (100)
Etiology Three of the 44 cases of Bell’s palsy had recurrent
Bell’s 44 (78.6) 36 8 43 (98) attacks; 2 girls had ipsilateral attacks and 1 boy
Tumor 4 (7.1) 0 4 1 (25) suffered a contralateral recurrence. The duration
Trauma 3 (5.4) 1 2 2 (67) between the recurrent episodes was 4 months, 3
Congenital 3 (5.4) 2 1 1 (33)
years, and 4 years, respectively, with all recovering
Infection 2 (3.6) 1 1 1 (50)
within 3 months.

Table II. Results of medication and non-medication of Bell’s palsy after 3 months.
Parameter
Prednisolone medication
Non-prednisolone medication
Total
Duration between syndrome onset to visiting clinic for medication 51 week
Duration from syndrome onset to visiting clinic for medication 1 week
Total
Tumor
There were four cases with incomplete facial palsy
associated with neoplasms including cerebellopon-
tine angle tumor (2 years old), cerebellar astrocy-
toma (4 years old), glomus tympanicun (12 years
old), and facial hemangioma (1 month old). Only
the patient with facial hemangioma recovered com-
pletely 7 months after the operation. In the other
three cases the facial palsy persisted after surgery.
Trauma
There were three patients (1, 2, and 13 years old,
respectively) whose palsy was caused by head
injuries (two incomplete facial palsy, one complete
facial palsy). Only the patient (13 years old) with
complete facial palsy due to temporal bone fracture
had persistent defects, despite the fact that he
received facial nerve decompression surgery. The
other two patients had totally recovered within 1
year after prednisolone treatment at the initial stage
for 14 days.
Congenital
Three patients had congenital facial palsy. Their
family histories were not contributory. Case 1 was a
female infant who had left facial palsy and abducent
palsy as well as a cleft palate. Case 2 was a preterm
male baby who had an incomplete right facial palsy
associated with congenital pneumonia and G6PD
deficiency. Case 3 was a male infant with Prader-
Willi syndrome, who had left facial palsy since birth.
Only the facial nerve function of case 2 returned
after he was 3 months old.
Infection
There were two cases with infectious causes of palsy;
one was Ramsay-Hunt syndrome. The 4-year-old
boy visited our clinic after 2 weeks of facial palsy. We
prescribed oral acyclovir (5 mg/kg/day) and predni-
solone (1 mg/kg/day) for 8 days. He recovered
completely after 3 months. The other case involved
viral encephalopathy. The 7-year-old boy had a
Facial palsy in children 917
Recovery Non-recovery p value (Fisher’s
(n) (n) Total exact test)
26 0 26 0.4091
17 1 18
43 1 44
18 0 18 0.1364
7 1 8
25 1 26
seizure episode at the age of 6 years. After taking
medication and receiving rehabilitation the left
mouth angle deviation persisted.
Discussion
Bell’s palsy was the most common cause of facial
palsy in our experience, making up 78.6% of the
causes in 56 patients. In our study, there was no
predominance in gender or side involved as in the
previous study [2]. As in Bell’s palsy that is the most
common cause of facial palsy in the human popula-
tion, the incidence of Bell’s palsy is 20.2 per 100 000
population according to the study of the largest
population by Rowlands et al. [3], and 32 per 100
000 population according to Peitersen’s study [4].
However, regarding age distribution, the disease is
described as being less common in persons younger
than the age of 20 years [2] or 15 years [4],
respectively. The incidence of Bell’s palsy is thought
to increase with age.
Bell’s palsy is a lower motor neuron disease of the
facial nerve characterized by a transient paralysis,
and it is associated with significant edema and
ischemia of the facial nerve as it passes through its
bony canal. Herpes simplex reactivation has been
shown to be associated with a large proportion of
cases. Regarding the treatment of Bell’s palsy in
adults, one randomized controlled trial revealed that
patients treated with prednisolone had better com-
plete recovery rates than those treated with acyclovir
[5]. Another study demonstrated that patients trea-
ted with a combination of prednisolone and acyclo-
vir had a higher rate of complete recovery compared
with those treated with prednisolone alone [6].
However, in a randomized, controlled trial of
children 2
6 years of age, no significant differences
were found in short-term recovery after treatment
with methylprednisolone when compared with an
untreated group [7]. In our study, 43 of 44 (97.7%)
cases with Bell’s palsy recovered completely. The
statistical analysis also demonstrated that there was
no significant difference between the treatment
modality and recovery rate. Furthermore, no sig-
nificant difference was found with the period from
918 W.-H. Shih et al.
the disease onset to seeking medical help compared
with the result of recovery. This consequence can be
explained by the histological finding of the temporal
bone in children. Because the facial nerve in children
occupies a smaller percentage of the fallopian canal
than in adults [8], the facial nerve is less prone to
damage caused by pressure, and pediatric patients
require facial nerve decompression less often than
adults. In our study no patient with Bell’s palsy
underwent decompression surgery. In a comparative
study of age and degree of facial nerve recovery in
Bell’s palsy by Danielidis et al. [9], the percentage of
complete recovery between age 4 and 50 years varied
from 83% to 74.5%, respectively, and the percentage
decreased to B54% at age 80. The same result also
can be found in Peitersen’s study [4]; above the age
of 60 years, only about one-third of patients will
experience the return of normal function. Thus the
age of patients is an important factor influencing the
final results and children usually have better results
than adults.
The recurrence rate of Bell’s palsy in adults is
around 2
9% [1]. Recurrent Bell’s palsy may be due
to either a recurrent viral attack or recrudescence of
indolent viral antigens within the nerve with recur-
rent viral exposure. We further reviewed the recur-
rence rate in the literature. In a study conducted in
Hong Kong in 1995 [10], of 24 children with facial
palsy, 6 of them (25%) suffered recurrent episodes.
In a study in Israel in 2001 [11], 11 (6%) of 182
children had recurrent episodes of facial palsy.
Finally, the recurrence rate of Bell’s palsy in our
study was 6.8%. Although recurrent Bell’s palsy was
indicated as a poorer prognostic factor than non-
recurrent Bell’s palsy, Pitts et al. [12] showed that
the recurrent facial palsy did not indicate a worse
prognosis for recovery regardless of which side was
affected. Although all our patients recovered com-
pletely, it seems that recurrent facial palsy did not
indicate a worse prognosis for recovery.
Regarding the etiology of facial palsy in children,
the incidence of children with facial palsy compli-
cated by acute otitis media was 0.4
9% of all facial
palsies [13]. In 1998 Goldstein et al. [14] reported
that of 100 children with the diagnosis of intratem-
poral complication of acute otitis media, 22 (22%)
patients had facial palsy after conservative therapy
(18 cases) and surgery (4 cases), with 15 cases
(68%) recovering completely. In 2005 Evans et al.
[15] reported that in 35 children with facial palsy 13
cases (37.14%) had an infection etiology and 9 of
them (69%) had complete recovery. However, in our
series the incidence of infection etiology was low
(5%) and there was 50% recovery. This may be due
to the low number of cases in our study and overuse
of antibiotics by general practitioners in Taiwan.
Congenital facial palsy may be more appropriately
termed as developmental anomalies of facial nerve
function. It is frequently due to intrauterine hypo-
plasia of the facial nerve and usually appears as a
component of a syndrome. It is presented at birth or
soon after birth. In children facial palsy at birth can
be traumatic or congenital in origin. For a differ-
ential diagnosis patient should be evaluated within a
few days of birth. A history of long labor, forceps
delivery, ecchymosis around the temporal bone or
hemotympanum may indicate a traumatic cause.
Bilateral facial palsy or upper branch or involvement
of other cranial nerve abnormality suggests a con-
genital facial palsy. These may include Mobius
syndrome, congenital unilateral lower lip palsy, and
hemifacial microsomia. In our three cases of con-
genital facial palsy only case 2 with incomplete facial
palsy had return of function.
The tumors that induce facial palsy can be divided
into intracranial and extracranial causes. Astrocy-
toma, neuroblastoma, acoustic neuroma, and pon-
tine glioma are intracranial tumors that can induce
facial palsy. Extracranial lesion could involve parotid
mass and cheek lesion such as pleomorphic adenoma
or rhabdomyosarcoma of the cheek. May et al. [16]
reported that the incidence of tumor causing facial
palsy in children was 7 of 170 cases (2%), which
included neurinoma and glioma. Evans et al. [15]
reported only 1 case in 35 children (2.86%). The
incidence is very low and the outcome is usually
incomplete recovery. In our series the incidence of
tumor in children was 7.1% and there were three
intracranial lesions and one extracranial lesion; only
one case had recovery. The incidence is about 7
cases in 100 patients, although besides detailed
history taking and careful physical examination,
other imaging modalities such as CT or MRI were
suggested to prevent misdiagnosis.
In children trauma-induced facial palsy could
include birth trauma, temporal bone fracture, mid-
dle ear surgery or cochlear implantation. Peitersen’s
data collection of facial palsy in children showed that
birth trauma (145/349) is the most common cause
of trauma in children, but the incidence decreased
to 15% in the past 25 years as a result of improved
obstetric techniques [4]. May et al. [16] reported
that trauma accounted for palsy in 21% of children
with facial palsy. The status of hearing and tearing
are the two most important findings that determine
surgical indications for exploration. Odebode and
Ologe [17] reported that in 794 head injury cases, 40
(5%) had facial palsy, the elderly are more likely to
sustain a facial nerve injury than young adults and
children, and only 30% of cases had completely
recovery of facial nerve function. The incomplete
type and delayed onset palsy usually recover fully.
 Facial palsy in children 919
Table III. Literature review of etiology of facial palsy in children.

Reference Bell’s (%) Trauma (%) Tumor (%) Congenital (%) Infection (%) Others (%) Total number

Manning et al. [19] (1972) 60.7 11.5 3.3 14.8 9.7 61

May et al. [16] (1981) 42 21 2 8 13 13 170
Grundfast et al. [20] (1990) 16 24 12 8 28 12 25
Peitersen [4] (2002) 39.5 43.3 6.9 4 6.3 349
Evans et al. [15]. (2005) 8.6 34.3 2.8 11.4 37.1 5.8 35
Ogita et al. [21] (2006) 70 7 23 30
This study (2008) 78.6 7.1 5.4 5.4 3.6 56

Falco and Erisksson [2] reported that among 44 292
infants born, there were 92 recorded cases of facial
palsy, for an incidence of 2.1 per 1000. Of these, 81
were acquired and 89% of the total had completely
recovery. Congenital traumatic facial palsy has a
predictably favorable outcome.
Unlike facial palsy in adults, in children it is
frequently associated with tumor (2
12%), congeni-
tal anomalies (3.3
11.4%) or trauma (7
43.3%)
(Table III). The facial palsy might be the first
manifestation of a systemic disease, such as acute
lymphoblastic leukemia. There are several case
reports in the literature that show facial palsy as
the first alarming sign of serious diseases [18]. In our
study, four cases (7.1%) had tumor lesions and three
cases (5.4%) had congenital facial palsy associated
with other anomalies. Therefore, when a child with
facial palsy visits the clinic, more careful history
the electrodiagnostic tests. This is mostly due to the
fact that children do not cooperate with electro-
diagnostic tests or become introverted after facial
palsy and resistant to subjective evaluation. In the
future a new facial nerve function test acceptable by
children and a new facial palsy grading system
suitable for them may be necessary for the study of
children’s facial palsy.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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