A 12-year-old girl presented with the onset of unilateral facial weakness. She had developed some mild tingling over her left cheek and reported that blinking with her left eye felt unusual.
She dribbled a small amount of fluid when she drank and her mother had noticed a asymmetry of her face. There was no local pain or any other symptom.
The girl was well and did not take medication. There had been no recent head injury, dental intervention or other trauma. She did not have fever, cough, aches or pains suggestive of infection. She did not have a tick bite or ear discharge.
The patient was apyrexial and not distressed. There was a noticeable droop of the left side of her face, which was more obvious during an examination of her facial nerve: attempts at a grin and blowing the cheeks up showed a clear weakness on the left side.
She was unable to fully close her left eye and examination indicated a probable peripheral facial nerve problem. Her ear canals looked healthy with no sign of infection. There were no swollen glands.
There are numerous possible causes of unilateral facial palsy, although several of them are rare (tumours, MS, trauma, Lyme disease, HIV and sarcoidosis) and typically accompanied by additional symptoms.
The clinician needs to identify causative infections, such as herpes zoster oticus (Ramsay Hunt syndrome), otitis media, malignant otitis externa, mastoiditis or cholesteatoma.
In more than three quarters of cases of facial palsy no apparent mechanism is found. Bell's palsy, the idiopathic form of a facial palsy, is the most common overall cause.
The majority of cases of facial palsy make a spontaneous and often complete recovery within weeks or a couple of months.
No resolution in this time warrants further investigation.
A complicating element in this case was that the patient was due to go on holiday in two weeks, which limited the options for further investigations. I liaised with the ENT registrar and ophthalmology registrar to discuss management.
We agreed that there was no urgent need for investigations. We discussed preventing complications, especially of her partially closing left eye.
The patient was given oral prednisolone 40mg for one week, then reduced by 5mg a day and hypromellose eye drops at least four times a day. A thicker ocular lubricant was prescribed for night-time use.
I advised the patient on gentle taping of the eye lid at night and supplied a roll of surgical tape. Wearing an eye patch can actually worsen the condition if the patch gets dislodged and starts rubbing against the eye.
Unfortunately, we had to discourage the patient from swimming during the holiday, due to the risk of acquiring an eye infection. She was scheduled for a follow-up appointment at ENT outpatients after her holiday.
Although facial palsy is unusual in a child, there is no evidence that the cause will be different or more significant than in an adult.
Indeed, she made a full recovery within a month and was advised that the chance of recurrence was very small.
- Dr Jacobi is a GP in York