Facial Nerve palsy in children

Objectives:
At end of this lecture the student
should know:-
1.Anatomy and course of Facial nerve.
2. Localization of the site of lesion in L.M.N. facial
paralysis:
3. Facial palsy and differences between UMN and LMN facial palsy.
4. Bell’s palsy.
5. Evaluation infants and children with LMN facial palsy and Bell’s palsy .
6. Treatment of infants and children with LMN facial palsy and Bell’s palsy.

 Anatomical Structure of the Facial Nerve

The facial nerve (CN VII) is the seventh paired cranial

nerve. It emerges from the brainstem between the pons
and the medulla, anterior to 6th cranial nerve and medial
to 8th cranial nerve. It controls the muscles of facial
expression, and functions in the conveyance of taste
sensations from the anterior two-thirds of the tongue and
oral cavity. It has 2 pathways: Supranuclear and
Infranuclear pathway:

1. Supra-nuclear pathway:
Contralateral lower third of precentral gyrus

Corona Radiata

Genu of the internal capsule

Nucleus at the level of pons

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- Lower half of the face has contralateral supranuclear
control while the upper half of the face has bilateral
supranuclear control. Some of corticobulbar fibers
descend into the aberrent pyramidal tract to medullary
levels, decussate there and ascend contralaterally into
the dorsal medulla to converge into the facial nucleus.

2. Infra-nuclear pathway:

The facial nerve is a mixed nerve that has 4 anatomical branches in 2 courses
(intracranial and extracranial pathways). These
branches are:

I. Motor: Innervates the muscles of facial

expression, the posterior belly of the digastric, the
stylohyoid and the stapedius muscles.
II. Sensory: A small area around the concha of the
auricle.
III. Special Sensory: Provides special taste
sensation to the anterior 2/3 of the tongue.
IV. Parasympathetic: Supplies many of the glands
of the head and neck, including: - Submandibular
and sublingual salivary glands.
- Nasal, palatine and pharyngeal mucous glands.
- Lacrimal glands.

A. Intracranial pathway:

It is the course of the facial nerve

through the cranial cavity, and the
cranium itself. It begins as two
roots; a large motor root, and a
small sensory root (the part of the
facial nerve that arises from the
sensory root is sometimes known as
the intermediate nerve). The two
roots travel through the internal

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 auditory meatus. Then, they enter
into the facial canal. The canal is a
‘Z’ shaped structure.

- Within the facial canal, three

important events occur:
Firstly the two roots fuse to form the
facial nerve.
Next, the nerve forms the geniculate
ganglion (a ganglion is a collection of
nerve cell bodies).
Lastly, the nerve gives rise to:

1. Superficial Greater petrosal nerve

– parasympathetic fibres to mucous
glands and lacrimal gland.

2. Chorda tympani – special sensory

fibres to the anterior 2/3 tongue and
parasympathetic fibres to the submandibular and sublingual glands.

3. Nerve to stapedius – motor fibres to stapedius muscle of the middle ear.

B. Extracranial pathway:

It is the course of the facial nerve outside the cranium, through the face and neck. After
exiting the skull, the facial nerve turns superiorly to run just anterior to the outer ear. It
supplies mainly 5 group of muscles :
1. Muscles of facial expressions.
2. Stapedius muscle.
3. Stylohyoid.
4. Posterior belly of digastric muscle.
5. Platysma.

1. Stapedius muscle:
It is the smallest skeletal muscle in the human
body. It controls the amliptude of waves to the
inner ear.

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2. Stylohyoid muscle:
It is the smallest slender muscle lying
anterior and superior to posterior belly of
digastric muscle. It elevates the hyoid
bone during swallowing.
3. Posterior belly of digastric muscle:
It assists the Stylohyoid muscle be
elevating the hyoid bone during swallowing.
4. Platysma:
It is a superficial muscle that overlaps the
sternocleidomastoid. It draws the corner of the
mouth inferiorly and skin of the neck superiorly.
5. Muscles of facial expressions :
Through 5 terminal branches:
a. Temporal: Supplies frontal belly of occipito Frontalies, Orbicularis oculi and
Corrugators.
b. Zygomatic: Supplies Orbicularis oculi.
c. Buccal: Supplies Procerus, Zygomaticus major, levator labii superiors, levator
anguli oris, Zygomaticus minor, Buccinator, Nasalis, and Orbicularis oris.
d. Mandibular; Supplies Risorius, Depressor labii inferior, depressor anguli oris
and Mentalis.
e. Cervical: Supplies Platysma.

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 Signs and Symptoms of lesions at different sites in L.M.N. facial
paralysis:

a. Lesion in the nucleus:

1. Paralysis of the facial muscles.

2. No impairment of salivation or
lacrimation.

3. No impairment of taste sensation.

4. May be other cranial nerve paralysis on

the same side or hemiplegia on the opposite
side.

b. Cerebello-pontine angle lesion:

1. Paralysis of the facial muscles.

2. Diminished taste sensation on the anterior

2/3 of the tongue.

3. Diminished salivary and lacrimal

secretions.

4. Associated 5th, 6th and 8th cranial nerve palsies on the same side.

c. Lesion at the geniculate ganglion:

1. Paralysis of the facial muscles.

2. Diminished taste sensation on the anterior 2/3 of the tongue.

3. Diminished salivary secretion.

4. Diminished lacrimal secretion.

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 d. Lesion between the greater superficial nerve and the chorda tympani:

1. Paralysis of the facial muscles.

2. Diminished taste sensation on the anterior 2/3 of the tongue.

3. Diminished salivary secretion.

4. No impairment of lacrimation.

e. Lesion in the extracranial portion of the nerve:

1. Paralysis of the facial muscles.

2. No impairment of taste.

3. No impairment of salivation.

4. No impairment of lacrimation.

 Types of Facial Palsy:

The lesion may be:

1. U.M.N.L. affecting the pyramidal tract above the facial nucleus.

2. L.M.N.L. affecting the facial motor nucleus or the nerve itself.

U.M.N.L L.M.N.L

1.Lesion is contralateral supranuclear. 1.Lesion is ipsilateral nuclear or infranuclear.

2. Paralysis of the muscles of lower half of 2. Paralysis of the muscles of the upper and
the face on the opposite side of the lesion. lower halves of the face on the same side of
the lesion.
3.Paralysis involves the voluntary movement
but spares the emotional and associative 3. Paralysis affects voluntary, emotional and
movements. associative movements.

4.Paralysis is associated with hypertonia and 4. Paralysis is associated with hypotonia and
hyper-reflexia. hypo-reflexia.

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5. There is associated hemiplegia on the 5. If (here is hemiplegia, it is on the opposite
same of the paralysis. side of the paralysis (crossed hcmiplegia).

Bell’s palsy
I. Definition

It is an acute, non suppurative inflammation of the facial nerve at the stylomastoid

foramen. It is the most common lower motor neuron lesion affecting the seventh cranial
nerve with resultant paralysis of the facial musculature.

II. Stages of Bell’s palsy:

1. Acute stage: from the onset of paralysis till two weeks (after subsidance of pain).

2. Recovery stage: start after the acute stage and extends up to 17 to18 months and may
be extending to two years.

3. Chronic stage: after the two years where, there is little hope in recovery.

N.B: Causes of decrease hope in recovery after two years:

1. Slowness or increase difficulty in the formation of a new motor end plate.

2. Abnormality in the pattern of nerve re-innervations, as the axon grows in parallel with
the muscle fibers instead of being perpendicular on them.

III. Etiology:

1. Usually idiopathic.
2. Ischemia.
3. Peripheral Neuritis.
4. Nerve stretching or traction injury.
5. Pressure around the nerve.

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IV. Incidence and Risk factors for Bell’s palsy

 Incidence:

- Commonly 15-30 cases per 100.000 persons

- Bell's palsy is the most common cause of acute unilateral facial paralysis,
accounting for approximately 60-75% of such cases.

- The right side is generally affected more often, i.e. 63% of the time.

- Although bilateral facial paralysis can also occur, the occurrence rate is less than
1% when compared to unilateral Bell's palsy.

- The condition can also be recurrent in 4-14% of affected individuals.

 Risk Factors:

1. Exposure to air draft.

2. Diabetic persons.

3. Children with Guillian Bare’ Syndrome.

4. Direct trauma behind ear.

5. Psychological stress.

 Physical Evaluation of infants and Children

with Bell’s palsy:
a. History:

Ask the child and parents for the possible risk

factors.

b. Informal Evaluation:

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1. Pain behind ear. 5. Obliteration of nasolabial
fold.
2. Can’t raise his eye 6. Dropping the angle of the
brows. mouth.
3. Loss of horizontal 7. Accumulation of food
wrinkles in frontal area. behind cheeks.
4. Can’t close his eyes. 8. Bell’s phenomena.

c. Formal Evaluation:

It should be done against mirror.

1. Test of pain: Tenderness behind or infront of the ear is carried out firstly on the
sound side then on the affected one (if the child's tone of crying is increased →
acute stage).
2. Test of adhesions: The passive range of each muscle movement must be tested
before the application of the muscle testing. It should be done through deep
circular movement on forehead and buccal area.
3. Muscle test: Functional muscle test should be done in form of Functional,
Subfunctionl, or zero are three grades usually used in grading.

1. Orbicularis Occuli:-

-Orbital part: Ask the child to close his eyes firmly.

-Palperal part: Ask the child to close his eyes lightly.

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2. Corregator:-

Ask the child to approximate his eye brows.

3. Frontalis:-

Ask the child to raise his eye brows.

4. Proserus:-

Ask the child to shrink the skin of his

nose.

5. Nasalis:-

- Alar part: Ask the child to widen his nostrils.

- Transvers part: Ask the child to narrow his

nostrils.

6. Orbiculais Oris:

Ask the child to approximate his lips.

7. Buccinator:

Ask the child to press his cheeks against

teeth.

8. Zygomaticus major:

Ask the child to smile with showing teeth.

9. Resorius:

Ask the child to smile without showing teeth.

10. Mentalis:

Ask the child to shrink the skin of the chin.

11. Levator Labii Superioris:

Ask the child to raise the upper lip upward.

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12. Depressor Labii Inferioris:

Ask the child to depress the lower lip

downward.

13. Levator Anguli Superioris:

Ask the child to raise the angle of the

mouth upward.

14. Depressor Anguli Inferioris:

Ask the child to depress the angle of the

mouth downward.

4. Test of reflexes: -

- For all infants:

a. Blinking ( Corneal and

Corneoconjuctival reflex ).

b. Glabellar reflex.

- For neonates only ( 3-4 months):

a. Suckling reflex.

b. Rooting reflex ( 4 Cardinal point

reflex).

d. Standardized Evaluation:

It is an objective evaluation for Bell’s palsy. It includes:

1. Electromyography (EMG).
2. Electroneurography (ENG) such as Nerve Conduction Velocity Studies
(NCV) and Percentage of Degeneration.
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 3. Nerve Excitability test.

 Physical Therapy Intervention for infants and Children with Bell’s

palsy:
I. Acute and Subacute Stage:

a. Period of rest.

b. Corticosteroids.

c. Non-Steroidal anti-inflammatory agent.

d. Physical Therapy anti-inflammtory and

pain relief methods:

1. Pulsed Short wave diathermy.

- Effect: Because it has a strong anti-

inflammatory effect as it improves production of white blood cells.

- Certain precautions should be taken during application:

a. Test temperature by test tube before application.

b. Avoid crossing wires.

c. Remove any metal.

d. Avoid exposure to air draft after application.

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- Technique: It can be done through coplanar and contraplanar technique.

-Time, electrodes and intensity used:

a. For young infants: rubber padded electrode, low intensity for long duration (
about 20 min ).

b. For Older infants : Cup electrode, high intensity for short duration ( about 10
min)

2. Ice application as a pain relief and has anti-inflammatory effect.

3. LASER application as a pain relief and has anti-inflammatory effect.

4. TENS application as a pain relief at the site of pain.

5. Phonophoresis by using Reparil gel , Fastum gel and Voltaren emugel during
application of ultrasonic.

6. Iontophoresis by using analgesic and anti-inflammtory drugs as Lidocaine …

depending on repulsion property of the drug ions and electrode.

e. Active Exercises: If painless for the child.

f. Massage: If painless for the child.

- Aims:

1. Induce relaxation.

2. Regain symmetry of the face.

3. Removal of waste products.

4. Decrease skin impedance.

5. Breakdown adhesions.

- Types

1- Effleurage:

 Circular

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  Half circular

 Longitudinal.

 Whole.

 Segmental

2- Kneading: on sound side.

3- Deep Friction:

 Longitudinal.

 Transverse.

4- Vibration.

II. Recovery and Chronic Stage:

1. Massage: The same as in subacute stage

2. Hot packs.

For 10-15 min. to improve circulation and decrease skin impedence before electrical
stimulation.

3. Electrical Stimulation:

As in Erb’s palsy using the 2 techniques :

a. Unipolar: One electrode in front of ear on parotid gland while the other one is
moved between the upper and lower part of the face for 15- 20 min.

b. Bipolar : 2 electrodes are active electrodes on any 2 paralyzed muscles from 15-
20 min.

4. Reinforcement techniques and methods:

By Using:

a. Muscles of the sound side.

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 b. Neck muscles:

- Neck extensors with muscles that act in upward direction as Frontalis,…….

- Neck flexors with muscles that act in downward direction as Orbicularis

Occuli,…….

- Neck side bending with muscles that act in transvers direction as

Resorius,………

c. Upper limb Muscles : By :-

- pushing against wall.

- pushing both upper limbs against each other.

- Gendrisic maneuver.

d. Upper limb and trunk muscles: By:-

asking the child to raise the chair that he set on.

5. Splinting: -

- For young infants: adhesive plaster to gain symmetry between both sides.

- For older children: using hook splint to gain symmetry between both sides.

6. Advices: -

1. Avoid exposure to air draft especially after physical therapy sessions.

2. Use eye ointment and drops to avoid dryness of the eye.

3. Mouth and eye hygiene to avoid ulcers.

4. Wear sunglasses during exposure to sun rays.

5. Repetition exercises at home.

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