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FACIAL PARALYSIS IN CHILDREN: Review of the Differential Diagnosis and Report of Ten Cases Treated with Cortisone Richmond

S. Paine Pediatrics 1957;19;303-316

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1957 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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REVIEW FACIAL Review of

ARTICLE IN CHILDREN Report of Ten

PARALYSIS

the Differential Cases Treated


By Richmond
Harvard
the Childrens of

Diagnosis and with Cortisone


S. Paine,
Medical

M.D.
School,
Center,

Department

of Pediatrics,
Medicine

Medical

and

the
Boston

Department of

P
Sir course its

ARALYSIS

of to

the as Bell facial from

facial Bells in nerve that

nerve Palsy 18211 and of the

is

often

re-fibers
ganglion as

join
is
of

the
found

facial
at an

nerve.
acute

The
turn at

geniculate
the distal

ferred Charles of function

inasmuch described differentiated trigeminal.

the

end the fibers point Beyond runs with the


to

the via the laterally

internab the greater genicubate and

auditory in lacrimation superficial ganglion, chiefly gives It

meatus; leave petrosal the downward, off then turns the anserinus mandibular, the fibers
in the

the

nerve at this nerve through branch through and gland its terncernerve.

concerned

He

also
or

presented
some infection, and of can causes. facial and of is be a

several
them and due

cases

of

facial

facial

paralysis, trauma Facial


a of

associated others idiopathic. rather a wide reviewing have Collier,3 to

the

facial canal, stapedius pass in

and muscle.

a small passes upward parotid into and

paralysis underlying subject

symptom Articles paralysis Watkins,2

disease

than the stybomastoid variety anteriorly to and


porab, been

foramen, through pes the buccal, which Visceral


originate

divide
zygornatic,

the published

( Park
and
these of children of experience will be facial the are Experience subject may

vical
of

branches, the face.


salivation

innervate efferent

musculature concerned
superior sali-

Sullivan
but adults. view and causes and
cortisone

Smith,4
concerned has as be paralysis with presented.

James
indicated it of applies interest

and
principally

Russell)

with with vatory that a renervus to infants tympani and value. within

nucleus, intermedius, nerve, the surface bone, mandibular activity glands ganglion. nerve their central the at lie single ends
into

join which

the and canal

facial nerve pass into the the passes the lingual drum, to finally sublingual in geniculate divide passing via near the the facial the tractus
Sensations

in the chorda nerve over the the branch the subof ganglion, the

leaves and ear joins nerve the a synapse sensory the

facial through affect and the

facial of and

Differential

diagnosis
10

among
will cases be

the
treated

various
discussed,

inner

the then of via

petrous with of the secretory maxillary larv facial is where bo-

ANATOMY
The cated tract From
ward,

OF THE
(See Figure
of of the
beneath

FACIAL
I)
the the axones
the floor

NERVE
nerve near the slightly
of the

submaxil-

The in then the part nucleus


sensation.

neurones into the point nerve,

motor in the and the


passing

nucleus pontine nucleus nucleus,

facial trigeminal run around


then end of

processes pons of of neurones


tongue, are

a T, nervus of and
taste,

tegmentum,

spinal the

nerve.intermedius exit of upfourthending

motor the
taste

solitarius,
of

ventricle
of the
iIitO

and
abducens brainstem

form
nerve. at the

genu
They lower

the
emerge the

the

nucleus conveying subserved from


pons, two-thirds

by
of

these
the

from nerves

the and

anterior
in the

conveyed

the
nerve

cerebebbopontine
runs

space. and
in meatus,

From forward
close

there to
association

lingual

and

chorda

tympani in fibers to the otic

reach as the then

the

upward nerve

internal

auditor

geniculate ganglion the the salivatorv impulses but taste tvmpani sensation chorda

by the same the reverse may pass ganglion

route direction. from and

with
intermedius,

the

acoustic
through April 9,

and

with
visceral July 3, Boston

the

nervus Some
efferent

which accepted
Avenue,

(Submitted
ADDRESS:

1956.) 15, Massachusetts.

300 Longwood

303

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304 return
to

PAINE in the greater Some

FACIAL
petrosal according impulses

PARALYSIS

IN

CHILDREN
and taste. The occurrence

superficial ganglion salivatory

the

geniculate

to may

nervelingual glands, someof hyperacusis of

should
branching muscle,

place
of but is

the
the

lesion
nerve not children to
various at

above
to generally give evaluate findings the

authorities.

conthe point ceivablv follow a similar path in reverse, while stapedius others probably pass originally in the gbossoclinically pharyngeal nerve, from the petrosal ganglion a history via an extracraniab anastomotic branch, to the objectively. facial, upward through the stybomastoid foramen, and thence into the chorda tympani. Thein facial facial nerve also transmits superficial sensation anatomical
from part of

useful of it, and Details paralysis locations

because it of clue are is the to

few difficult

clinical lesions given in

Table it in

I.

the
ear

palate and,
near

and the the

posterior
from part

nasal In is auditory is
in

child manner extend

past

the
possible

age
to

of
test

4 5 or years,
taste

mucous
of

membranes external the association Finally, facial


from

debatably, external innervation vagus, sensation probably is thought

frequently

the

the

meatus;

last-mentioned with proprioceptive but itself, nerve. the face facial

usual him
fact solutions

used with the tongue


flavored sweet,

adults, and then


salty,

by

having dropping
and

close
exists.

if not to

it deep be

in from

sour,

the
sation

muscles, the

con-

bitter senright point card,

on the anterior portion of side. Since young children to as the can after to say
and

the a more

left or cannot printed satisin- is

veved

correct adults, first the it

answer may be explaining words


and

on

A study
that tion
of

of
some the lesion

Figure
extent lesion

1 will
the causing

make
a

it apparent

to of facial

anatomical peripheral

factory, tended, locasour, type

what sweet,
ask the

salty,
child to

bitter,

paralysis in

( bearing
the brain

in of

mind
stem

nuclear

his a nod produces description. that may be ing to ing sub-with

head

when Needless without into to patients

one

reaches the correct to say, the test must the child mouth taste are withdrawand spreadareas. not Even able to

the
possible

peripheral from
accompanying

type

weakness) according
in

predicted tion, salivation

classification
defects

completed the tongue the substance young

his

bacrima-

other who

from

submaxillary

and

-TASTE

SALIVATION

LACRIMATION

Anatomical arrangement of the facial nerve. The course of the niotor fibers isshown in gray. Relative length and size have been somewhat distorted for clarity and to permit labelling. There is an anastoniotic connection from the facial nerve to the auricular branch of the vagus; this leaves the nerve in the facial canal, but has been omitted from the drawing. Possible secondary pathways for taste and salivation are described in the text, but have b2en omitted from the drawing for simplification.
FIG.

1.

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REVIEW
TABLE
(iixii FINnINGS IN F.cJ.&L IAUALYSES 1)uE

ARTICLE
I
TO LESIONS OF VARIOUS ANATOMI( LOCATIONS

305

Voluntary ifore!/)catioFt of Lesion meat. tp/)er Iae upra Nuclear


IIUC1ear

Voluntary
Morements Lower Fare
Lost
Bmolwnai

Salivation Movements Lacrimalion


Subma.r.

and lingual

Sub-

Taste

perOPUSlX

Retained
lost

Retained Lost Lost Lost Lost Lost


Lost

Retained Retained Usually lost Lost

Retained
Retained Usually lost Lost

Retained Retained Usually lost Lost Lost Lost


Retained

Al,sent

Lost Lost Lost


Lost

Present
Present

hit racranial
jut.
illl(l.

(between
meatus)
or above

pons

and

Lost

lii (311011 at
gil oglion

geniculate

Lost

Preseilt Present Al)seiit

Between stape(lius Between tyinpani


BetW(Pil hraiicliing

ganglion

and and
tynipani

nerve

to

Lost Lost Lost Sariable

Retained
Retained
Retained

Lost
Lost
Retained

stapedius

chorda
aiicl

Lost Lost \ariahle

charlia
aiiseriiius

Al,sent
Al)seflt

Iii

J,tS

lartlv
lost

Retained

Retained

Retaine(l

identify
the facial something will indicate

flavor,
expression

it

may
that unpleasant) of

be
the

obvious
patient and Taste this

from maxillary
tastes is sensa- loss

or

sublingual difficult
inasmuch parallels

salivation. to perform
as that of

The and
retention taste.

test not
or A

technically
useful, of salivation

( usually
retention

especially

taste.

tion palsy
that ential
an

was
as an

lost

in

52 by

of Park
test,

the and
it It is is

cases
not

of
of

Bells technique so flow


differ-of to be tion

similar saliva ammonia. facial on the


intracranial

to can after It be

that used

used to some loss can


and

to measure by of result
also,

measure rate inhalalacrimafrom


in rare

described
isolated diagnostic unfavorable

Watkins2
supposed

of of

lacrimation

stimulation is of with side


lesions

value.

importance,

a
with

lesion
late

prognostic relatively high


complete and only

Eventual

sign, indicating since in the facial canal. tion reaction degeneration of some
partial recovery was cases,

paralysis affected of the


reported

50% of It
tively have against

more is
by l)een the

common poSSil)le
the use

among to
of

patients salivation
cotton

with quantitaballs orifice

boss petrosal
as in

from tumors nerve near


the case

the great geniculate

superficial ganglion, and of of retained. by the noted because mother the cases, idioReens-

by Tremble
majority all is the of

test
small

Penfield.l7 pathic
the assurance

In all group, may statement

the or

great practically

which including of

weighed.
previously

One sublingual
weighed salivation

of
dried

a pair duct

is placed on
in been its

lacrimation be of the obtained

submaxillary
side
ing

or
then after

either tomary
weigh- that stimu- at

patients tears) paralysis was

and bottle

again has

epiphora the onset

( overflow
of

facial

lated stance
that gland

by on
the

placing the
flow of

mustard tongue.
saliva

or
from

a similar in
the

subthe mind on

eye
this

remained
point of

open.
is obtained,

If a clear
gravimetric is unnecessary.

statement
meas-

Bearing the

parotid urement

lacrimation

is

controlled nerve, parotid one duct

through

auricubo-

temporal of the
ton
Only

must cover the orifice on each side with cotneed difference the in cases not he weighed. thesuit subof of between

CLASSIFICATION
FACIAL
It is obvious from the facial lesions nerve, that

AND
facial anywhere and

ETIOLOGY
paralysis in that the

OF
can re-

PARALYSIS
course

which,
sides

however,
is significant

a several-fold

two

there must

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306

PAINE a wide frequent


postnatally in Table

FACIAL
causes.

PARALYSIS
The extensor as well of
are carpi

IN

CHILDREN
of and as fingers well of syndrome the as the wrist, and webbing right is bilateral butin of long the of hand. generally sixth
a

be more
as

variety causes
acquired II.

of

possible of congenital
facial

muscles fingers ulnaris, third Moebius to

flexors extensor second The apand Hencases alone. nerves,


frequent others

the

thumbs

paralysis

given

and as a congenital with anomaly


phenomenon,

Facial
seldom

paralysis
occurs as

term plied abseventh


sense

an

isolated

but in and

usually 1888 seventh

in described bilateral

association neurobogic. a 35-year-old paralysis nerves,

other Moebius6 man of the

congenital nerve paralysis, a in 1939 14 had paralysis


the sixth, anomaly, Mental

broad

normabities, congenital

chiefly

includes only

number tabulated

variants. 69 diplegia cranial


most many

withderson7 sixth which Congenital of the


especially accompanying

of

cranial

paralysis

facial of other
is the but deficiency,

TABLE
ETI0LOGI( CLAssIFIcATIoN OF

II
FACIAL PARALYSIS

may

occur.

however,

is

infrequent.
I. Congenital
50011

Four facial of
We have to be

of the
seen

Hendersons and half


patients

cases one of
with

had inface
what

(i.e.,

present

at birth

or

at least

ncted

unilateral volvement
only. is

paralysis, lower
two

had the

A.
B.

afterward) Congenital

anomaly

(Moebius

syndrome6)

Trauma 1. Skull
l. S. 4. Intracranial

fracture
hemorrhage

believed

congenital of the lower affected. considers in man

facial face part Such that has the and of a

paralysis in one of the face situation the a lower that may from half. In
paralyses and The should prin-

Pressure
Pressure

from
against

forceps
maternal sacrum7

of only these, seemed plausible half of supranuclear corticobulbar

one only to if the

side the be one face cortical tract

is upper

I!.

Postnalally A. Trauma
1.
.

Acquired fractures

Skull

bilateral by the half reprethe be that any to

Surgical

representation whereas

3.

B.

Accidental I)iseases of the 1. Osteomyelitis . Osteopetrosis 3. Idiopathic type)8


Intracranial

skull (Albers-Sch#{246}nbergs infantile hypercalcemia


causes abscesses or other space-occupy-

disease) (severe portion

of the sented with some concerned


event,

face and of the extent


unilateral be

is it the is

only contralaterably therefore possible facial half the


and

nucleus of the upper


lower are rare

concerned

bower with

face discrete
facial

C.

anatomically

I . Neoplasms,
ing
2. 3.
lesians

Hypertension9

Intracranial eluding

pressure hemorrhage
mass le8ions
or

of

whatever

cause,

in-

as

congenital

anomalies viewed with

always
(in neck)

suspicion.

1). Extracranial E. Infections I . Otitis


2. 3. 4.

cipal
mastoiditis

differential paralysis or by cases than may those the

diagnosis due to maternal recover. occur also described

is from pressure pelvis, Congenital in other by

persistent either although facial combinaHenderson. by

media

with

without

Poliomyelitis

facial forceps such paralysis

Meningitis

usually

Encephalitis
Guillain-Barr#{233} syndrome

5.
6.

lions
with other insis

Facial neuritis associated fectious processes a. Cephalic tetanu&#{176} b. Trichinosis


Neurosyphilis2 d. Leprosy3
c. e.

It is the
drome port them

most
of

common
the

cranial
pterygium

nerve
colli

paralysyn-

accompanying

Bonnevie-Ullrich in

and

in

one

re1 of and such tumor is recon-

Herpes
of

zoster familial

(Ramsay relapsing

Hunt

was found unilateral.8 also be tract differentiation raised the

11 of 177 cases, It may be familial, with from question pontine others, whether contrabateral in has

syiidron:e)4
facial paralysis

F.

Syndrome

it

may

associated signs

I.
i.

Occurring

as isolated

finding5
oflip or face (Mel-

pyramidal cases
important.

( Trautman9);

Associated
kerssons

with

edema

syndrome)6

Ford,2#{176} among

G. Idiopathic

cently

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REVIEW
genital
aplasia the facial

ARTICLE
the sociated of
gener- Some

307

facial
of nerve

paralysis
muscle nucleus

is in fact
rather as than has

a congenital
absence been

great authors palsy

majority with to otitis restrict the


are the skull,

of media

cases or the use


to

are are of

either idiopathic. the

asterm Some
Facial

ably
the ports frontalis

assumed to by
three muscle external

to
rectus

be Duanes

the
muscles

case, syndrome
of

and in
the

may
eye of

Bells be
are paralysis

idiopathic
due results or

group.
trauma. from hyperostosis comosteo-

comparable replaced

which cases, remyelitis pressing the nerves, of or the

however, occasionally of

fibrous
cases in showed

cords.
which total

Richards2
biopsy absence

the such severe of

facial as type

among occasionally disease of infantile

other occurs (osteopetrosis)

cranial in

muscle
a

tissue.
at seventh necropsy

Rainy child
nucleus

and with
showed and

Fowler22 facial
degeneration facial

reported diplegia
of nerve

Albers-Schonbergs

10-week-old

hypercalparother
in facial isolated

who the but most

cemia.8 fibers A number


seems space occupying These

intracranial abscesses
lesions, only can rarely

processes, and
result cause

not
of

total
the

aplasia.
scanty

On
necropsy

the

other
material

hand, ticularly as well paralysis. facial The signs,


structures be and be its

neoplasms,

to
as as

indicate
of for

absence central the


in present. defect at

of nervous case
this The

nuclear system of
situation entity

cells b23
can needs will

other
example

elements,
not to

paralysis because
in nucleus.

without of
the The

other proximity
to most the frequent

neurologic of
facial

the
pons

other
nerve tumors

primary stated

well
one, narily genital

known
although suggest or

as
a

it
whether

is

relatively
history the situation

frequent in
is

the

posterior

fossa and tumor


of facial paralysis

are pontine may


as tract cause pressure

the cause
well) signs.

astrocytoma, glioma. the


with Supratenparalysis mechanisms,

patients

ordimedulboblastoma, conlast-mentioned iar combination abducens pyramidal tumors through at times can

The familcon(usually

postnataliy

acquired.

paralysis

Congenital present
generally sure and from pes

facial birth
been anserinus.

paralysis subsequently
to forceps The if pressure not study be on of most, of the due

which clears,
to the Hepner,7

is with has tralateral


tonal presface and, may

at

but
assumed

also

facial

obstetrical

obscure simulate

the

however,
dicates probably that

is
due

extremely
many, to

challenging

and
cases

lower inrather are facial that sixth

motor than pressure paralysis, nerve is may far do


reported

neuron, the alone but with commoner.


as a cause

peripheral, type of

or weakness Intraproduces of intracranial has


palsy9

supranuclear.2426 occasionally involvement its longer


of

infants cranial

face the all were the 16


matic is

against sacral of 40 born situation with facial


due to

the mothers prominence. infants from right


pressure

pelvis, Hepner left or LOT facial

particularly found position in the Most

the

with LOA was facial


on

paralysis course while been and case of period course. lacerations, necessary,
great that

Hypertension
facial

reversed paralysis. in the


and

so or

by

a variety of a

of vessel

mechanisms, against aneurysm, the or

frau-including nerve itself,


aboutintracranial

pressure pressure.

paralysis nerve in with intervention


takes should be

newborn
swelling

hemorrhage,

the Except

facial for
recovery It

its

extracranial obvious is not

Of
paralysis without

identifiable
in children, mastoiditis

infectious
otitis is by

causes
media far the

of facial
with commonor

cases

neurosurgical
and jority.

place borne

in in

the mind

est. ma-

The

prognosis than recover of the mastoids in

is usually idiopathic with infection. should be by that in

felt cases, prompt

to

be but effective in

less the

favorable in
treatment

the

newborn may

period, be most

as a symptom

in

later of

life, intracranial hemorrhage paralysis

facial majority of the of is

paralysis abnormality, in

Roentgenograms taken facial every paraly-

frequently newborn. with facial


to the

the case of the Among children


subsequent

quired

newborn

case acsis. It period,

otitis well

accompanied known

poliomyelitis,

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308

PAINE
facial other
is nuclear,

FACIAL
involved

PARALYSIS
together geniculate The paraby- 1944

IN

CHILDREN
herpes by Denny-Brown32 in

the with
sis

nerve lower
and

is

often
of the

cranial

nerves.

peripheral

with geniculate type.


were

a case ganglion
found
cervical

in

which at was normal


in the
There

necropsy the but herpetic


of
are anasto-

In some occurred poliomyelitis.27


also be

outbreaks as an
due to

it has isolated facial in were epidemic, during from blood


that patient in of an facial cranial poliomyelitis

lesions not infrequently sign of bubbarsecond paralysis


even in

ganglion

the

nerve.

Isolated of pbeocytosis cases Center of


titer in stated

the

absence Three drens 1955 by


it ses is antibody usually in

the seen and the orboth.28

spinal at the stool,


While nerve they number of

such Medical poliomyelitis isolation

the

connections several other fluid.directly with the Chiland herpes zoster and
paralysis ment of has the been fifth,

may motic

between the facial nerve cranial nerves and inhigher cervical nerves, of the ear and facial
reported eighth, and with tenth involvecranial
third

extensive confirmed rise


paraly-

virus the

nerves in
cervical.a3h5 More
paralysis may( not

as

well

as

the

second and
causes
case with

obscure
such

reported
as a

of

facial

bulbar if persistence

poliomyelitis
the

almost
survives, appreciable paralysis

invariably

impacted

disappear be and otit gins permanent of 37 with

necessarily
inevitably representing palsy.

infected)
viewed with coincidental

wisdom
some idiopathic

teeth,#{176}
suspicion

are
10of

cases

was

reported syndrome
flaccid

in

one
paralysis

series.29 be-

Bells

Guillain-Barr#{233} the
ings,

classically sensory diplegia of


have

It

is

in
of
for

the

evaluation
facial most
found

andifferential d
paralysis that of his
in

symmetrical

in diagnosis

idiopathic faces
the cases

extremities,
and in many

with
cases

variable
symmetrical

find-the
cranial Except

pediatrician
otitis

prol)lems.
association

nerve
any with

palsy, other.
facial

more Other
paralysis

often syndromes the in


in

facial

than with in fact


reported

media, be idiopathic.

the the motor

great The acute neuron

majority first question

will to

polyneuritis findings of
pathologically but

been

with elevated
typical should typical

or

without protein
of be borne

spinal the
mind

fluid absence
syndrome, that

answer is of of

is whether the lower whether

facial paralysis ( peripheral) in origin.

cells3#{176} or type

it is supranuclear

Guillain-Barr#{233}

Itit is neuron
entire

usually type
half

stated of facial
of the face,

that the paralysis


whereas

lower involves
the

motor the
upper

with Most
facial

Guillain-Barr#{233} syndrome almost any spinal fluid of


paralysis by

may finding.31
II are

occur

face in of
labo-of readily tionab or

is spared supranuclear

entirely paralysis, to This must recovering show upper facial with of to


of the more

or volitional)

at

least and

relatively that orno-

the

other
listed their in other

infectious
Table symptoms

causes

( as

opposed are

movements spared in in supraa reis generally mind that facial of signs

identifiable ratorv

the

face

relatively statement bear earliest

findings. herpes meatus

Facial zoster of

paralysis the external

associated ear

with auditory

nuclear valid, or patient

cases. but one with may in the lower

( the

Hunt,
the in be children. based

deserves
relative on
with

syndrome some comment


of syndrome zoster
vesicular

of

Ramsay in spite

peripheral

of paralysis

infrequency This herpes


the

herpes

is supposed of the genicubate


eruption

zoster covery nantly to

face, leaving predomiweakness which might a the involve


facial than

ganglion sensory

the in
has

be confused Further, lesions are likely that


involved

supranuclear face and only


nerve.

pes part
It has

lesion. anseriof face the


been

distribution external whether a sensory auditory


mentioned,

of the
it

facial
is at

nerve As
beast

about nus
debat- stated

the able such it is vagus.

meatus. nerve and, association on the

beendistribution indeed usually it does, One

previously

in

leprosy,

the
the

upper
lower face.1

is

the facial distribution in was close cast

has if

certainly Doubt

with validity

the cranial

promise of

must mass the

also bear in mind that extralesions in the neck can cornfacial nerve at or near its exit

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REVIEW
froni voive

ARTICLE
inX, CASES
OF ISOLATED MEDICAL

309
TABLE
FACIAL CENTER,

tlw other

StylOmaStOi(l cranial

foramen, nerves as

and well

may (IX,

HI
PARALYSIS 1943-5() AT CIiIInRExs

XII).
fore Neoplasms, phoma
of

Such
not

a combination
always due to an including

of those
the most cervical be of on

palsies of the

is therelesion.

intracranial

Season

of Onset WinierSpring

bymcause (ause

sumher of Cases

SummerFall

group, situation, may the not average

are but occasionally

frequent lymphadenitis responsible.

this In

alone paralysis explanation,

Congenital

case based

a child some of the lesion fairly

with

facial obvious

Congenital

anomaly

Birth
Postnatal

trauma

18

consideration

anatomic

Surgical

trauma
trauma 3

factors
the

previously
conclusion that

discussed
the

will
is

lead
probably

to Other

Intracranial
Extracranial

tumor
tumor

in
fails and

the
to the

facial
yield is
as

canal.
frn-ther

Examination
diagnostic of iodiopathic

usually
information

hypertension
Poliomyelitis

diagnosis made by Of and to but of adults. this In more cases still Table
of

facial
other causes reported each small 87% composed infectious media, but the the a the face were riumwere a over was the

Otitis Idiopathic with

media
upper resp.

16 19

6 10

10 9

paralysis
insofar

excluding 517 only infection, and series children cases 6%

possible. incI \iVatkins,2

inoti(9) (6)
(4) (6)

l)y due her

Park to were

feet.

(hut
upper

not

trauma due

tis)
without infect.

(3)

resp. (10) HO

tumor

i(1i01)athic, chiefly
group,
is

18

19

particularly

those

with numerous, constitute III

otitis

proportionately group.

part

of

the

Melkersson paralysis of of

syndrome

of

re-

idiopathic single
experience

largest current and Any possible

facial lip. consideration means

with
facial treatment

edema
paralysis

of

the
and

summarizes

the 8-year

Childrens period
is time-honored due were ought the by summer unrecognized equal and an rarely other etiobogic obtains to based true, to of

Medical ending
some is of on occur cases poliomyeseasonal studies agent, the the great during exposure theory edema

Cenin
that its 1950. interest, an

ter
The

over
seasonal

a
as

depends

on

incidence a is the If cases this canal

assessment The
to make

of percentage
evaluation

the

prognosis of
of

in
various

untreated is so high
means of

inasmuch Bells
nerve

cases.
facialas

recovery the be barge required

palsy
in

treatment to of mapatients
controlled the

difficult, which
study are

since would
not

number for
in most

cold jority winter accounted litis. cidence against the history sional cepted. paralysis
neuritis

air. of

available

unless for The in cold fact that of case It is


of

could inas

centers. be better disease In does years

in

Further, children less valid the

the

prognosis than in almost

is adults which of

probably and renders

the

approximately this as one exposure, it seems usually facial edematous. idiopathic the or is too more

itself past,

frequent, study follow-up

argues a statistically

impossible. our cases was were

at often lost exThe

a convincing

although
striking probable due nerve It facial is to

in
not some whether

an
to that

occabe form

the Childrens unsuccessful, from accept of contact. majority those was group. due rate

Medical and many Of of to those all among Park and congenital groups

Center cases followed,

however, recovered, anomaly. due to in their fair the

facial the toxic, recovery of media can pathic

cases less than Watkins2 66% of 9% with

otitis idio-

ischemic, note be that that recurrent recurrent

worthy paralysis

somewhat recovery in good results,

reported adults, and 4%

( 7%,

Park

and
palsy

Watkins2),
is not

facial

and complete necessarily 21% with

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310

PAINE poor to
90%

FACIAL Other

PARALYSIS reports of Govern,46 ofof facial age covery, rebeen ing at is inter- in
question

IN

CHILDREN

with
recovery
75

or
rates

no

recovery.
include those

who palsy of

estimated cases without

that

of complete
80%. in

the 20% rehas nerve done facial incomonly by facial


and

of

Collier3

and Taverner40

better
of 80 to

in reported

the of but
raise

younger Bierman39 complete comparithe

group,

Moor38

90% and

crocodile Asymmetry reported unilateral birth. man,

tears occurred the bones of rats and of has section one

the facial

skull

of
covery sons

92%.
in of

in

rabbits47 not been at least, with followed Congenital


bilateral

follow-

only this sort

45

of

100ases, c

always

of

how In

strictly general,

complete cases quite have of recovery of

recovery Bells courses, without palsy

A careful study but superficially acquired postnatally seem asymmetry.


are almost

preted. one and course of two is one for


is

palsies follow plete as The James soft first paralyses therefore

recovery tissue

to

be
always

separate

Russell5

emphasized.

Wablerian

difficult and

to

evaluate. Watkins2 the

As

emphaelectrical are if and tested Watin in of de-

degeneration. required degeneration


days) and

This begins within a total electrical to appear ( not less


probably always

the period sized by Park reaction of signs of the than 18 of considerable


followed by at 14 usu-kins2

reaction of prognostic the their poor with onset.


reaction total

degeneration value Park


of

days
reported

after 13% of or and which the faradic

complete
ally within

or
a

almost
months

complete time or involves

recovery, slightly slow in a distal complete, invariably regrowth those more. reaction a total

degenera-

A second degeneration covery tion. quires eludes of fibers they which phenomenon
probably 1906 by monkey

course with only by recovery

tion of 35%. re- 13% reaction, reinby

in A of

cases result partial

and was reaction

partial obtained

fair those

subsequent regrowth is never and misdirected

direc- generation compete

Such

in 43% of was rarely In

those with total if ever followed the reaction of to respond current. The current is galvanic closing cathodal reverse quick the to manner Testing nerve
to

several phenomena to other were of


first

months, or

recovery.

muscles originally misdirected


described by

than

degeneration, withto either Thismuscle was(rapid ritable in does

nerve ceases or galvanic respond current), to anodal than the fewer is the slow normal the
its

connected. regrowth
Lipschitz4

not

to the

faradic but

alternating than although is greater or threshold, situation. replaces muscle. is


lost

more

ircurcon-

normally the requires which A the

and
Ford

has
and

been

discussed
and by Howe,

in

some
confirmed Tower

detail rent tracture in


and contracture

Woodhabl42

closing of jerk the reof will


faradic

experiments

milliamperes vermicular of degenera-

Duel.
regrowth paralysis

The
in are

manifestations
incomplete of several recovery types:

of

misdirected
from

for
facial normal

its

sponse effect in which the group tion


muscle have

1.
results

Mass
in

action activity
activity

or
of

overflow of
several

Before complete,
only

reaction
response

attempted groups.

one

muscle
different

however, will a the is similar muscle. moderately respond

stimulation which
effect, syndrome of crocodile tears

and in for

galvanic to for that this

2. Tics,
mass 3. action The

may

actually

be

a form

of stimulation described phenomenon in

uncomfortable A is l)e-

which food be in

after the

several mouth sometimes by The from a or

months other the lacrimation anatomic study


by

the gustatory smell

presence of food) rather

of and difficult of stimuli because willsimpler, than whether this fore is 1. The Such andthan if the time apparent 18 days followed

to carry out in young children their lack of co-operation. more is superficial, observed to criterion begin for degeneration. beginning sooner experience always or at least

( including
followed salivation. plausible
entity has was been

recovery

of
by

basis of Figure
Bogorod44 and Ford45

first

described

required recovery has in our by

reviewed

Mcbeen

complete

Downloaded from www.pediatrics.org. Provided by Washtenaw Comm Coll on March 10, 2011

REVIEW
nearly would will rather growth. follow than complete seem the to course secondary eventual indicate of thathe t primary by recovery recovery.

ARTICLE
It nerve
cause

311 in its canal, whatever may edema reports edema. evidence of recovery tendency cases logic benefit
it should

the

underlying recases, to of bein have and be are produced before inescapable most for debeen not

patient
recovery re-

ports and and produce surgical

of the edema macroscopic

be. KetteI48 in 28 of 50 both It on the rate to which select is the canal microscopic difficult

Cawthorne macroscopic statistical decompression


of the high

TREATMENT
In physical
local splinting
ill front of

value

the
heat,

acute therapy

stage, are
face

several available
stimulation, and

modalities including
massage, active

of cause cases, compression

and for well.

the those

electrical of the

exercises followed

several The

weeks seems is to be
difficult if one

a mirror.
recovery

According
rate was

to but

Bierman,19
not much

doing that indailyby

the

final

if substantial
decompression,

fluenced treatment, 4 weeks


with was 38

by

physiotherapy, 68% were in 12


twice

with to recover

done
to

reported weeks,
a

degeneration in within
that tinely and one to to

has 18 days),
ought decompression

taken and it
to is subject

place

( namely
argue rouan patients expects

and 90%
and 72%, given

respectively,

as compared if treatment
week. of Park

only

Watkins2 difference

on
in

the
the

other
percentage

hand, with
trying

reported

no

80

90% recovery decompression apparent

rate justification

with can
on recovery

no be
those

treatment. made
patients and a begin-

recovery

Considerable in

for

treated The
paralysis and (loes the thing. plain

as process

compared of waiting
is always and the the comfort

untreated out a case


for of and both

groups. attempting of facial showing no reaction patient fling


days that remain after

of
the

degeneration
but as
if

at
the question whether would

perhaps
would the be value ma-

14

parents offer

use

physiotherapy satisfaction

onset,

unanswered decompression, less

to

doctor
We the

is
have situation

at

least
preferred, quite

trying
frankly

to
however,

do
to

some- of
to terially exparents course

any,

if

of

the

undertaken disease. as a means was reported foundation in

so of

late treatment

in

the for

and
support cipal sary olive prevent used young

to

try
in

to
a

provide
more measure open

the
usually

necessary
manner. The found of eye chamber keep in mineral at

moral prin-

Histamine paralysis has some been

specific is oil but to in drying. is

place the A difficult

drop moist to

facial neces- and oil now or

by theory, by

Skinnerll but has cortisone years but its recovery and resuccess of of 300
studied

largely has in untreated In patients relatively


in adults.

replaced

affected

night can place

treatment. to he Cortisone

for on

treatment

been used of facial view of patients, 1953,

for several paralysis, the is high Rothendlerll with doses all They duration
onset have been

children. is less
The its

In severe,
corneal

the except
reflex arc

daytime in
is

the very the dusty


abolished

bern
mates. cause

prob- evaluation, rate in clinot beported in


600 on 26 at-

difficult

definitive. seven using


orally mg

efferent

through is corneal of a foreign

facial body his of


of

treated, large carefully, of age. of a


the may have Taverner53

nerve,
The the

but patient

there is and close protest


is by

iso n aware

anesthesia. make with

six,

to

cornea tempt to or at One


paralysis

will usually the eyelids to to


surgical

least

his

mother. treatment
decompression

patients an were over fingers lected on facialless


this than reason

quite 12 the
10 the

whom senot
for less

years basis
days results

were of
and been obtained

approach facial
by

from

the
favored rationale

canal,
the depends

which
majority on the

is
of

still

than might probably favorable with earlier treatment. otologists. Its

The to
of 2

paralysis be
total

was in

assumption

not that the facialall.

necessarily
The recovery

required
rate

complete
recoveries

the

paralysis

is

due

to

edema

of

Downloaded from www.pediatrics.org. Provided by Washtenaw Comm Coll on March 10, 2011

312

PAINE 10 partial with from


among

FACIAL among those

PARALYSIS cases but only

IN the began

CHILDREN impression, so soon as of


are Thomas,54

and treated different


recoveries

recoveries placebo, that


mean the

that after to prove Case 4 paralysis


after from 5

in

many initiation quite of this when midays his of with own

cases of strikseries
cortithe pa-

is

not

significantly

recovery

of the
duration same

4 total and cortisone


of in the two

10 partial cortisone treatment treated ing. Figure 2 shows on was


groups tially

group. approximately

The

paralysis

the
Our

second
seen and results of

day
again

and of

the cortisone.

study the the


it has they

cast doses watched, recovery


been

some used, and rate,


our

dubt has since

on

the

valuesone. treat- impression

consistent

Nevertheless

cortisone proved it may


to

ment, in if carefully fluence


early,

especially
practice

tients and review of others in the literature, safe that in cases of facial palsy treated with invirtually full recovery in 14 days if usedcortisone,

idiopathic
unless

cases
are

as
already

promptly
showing

as

isall the rule, compared treat those untreated possible, in urged prompt evidence Thomas 10 days of onset; results form if it is started a in owing of 300 mg daily
for earliest

with cases are later)

6 weeks which treatment much and The full average

or more recover. (within less unitime our favorably pawith for plan of in cortian seemed in1 week, to dosage

of recovery within for degeneration controlled to can clinical


12 idiopathic

the time period of the nerve. has an as not of been cases to


the

required Because done

study small offer number only impression


cases

adults. detectable

the

available,

admittedly the Childrens


in

required one unreliable ment, benefit. Onlytients

improvein treated comparable are available our mg for has been 150 age, week,

and in Table figures reliable

for for

final IV also adults

recovery, compares not no data It 75 second no recovery has to on

untreated

serieswith

from Center of ment presented all of recovered. these

1943 were

to

1950 adequately

at The from IV. It treated is no

Medical cortisone.2 and the noted hospital be and 9 of

Unfortunately, time

followed, details this will

recovered. of the in 10 patients Table patients There

children. treat- untreated treat children with are sone that daily, depending for dosage a if

with statistical

cortisone continuing proof, creased


TABLE IV
wITS!

CASES

OF IDIOPATHIC

FACIAL

PARALYSIS

TREATED

CORTISONE

AT ChILDRENS
Days of lie. lie.

MEI)I(AL

(ENTER

Side (,.,e No.


.IgC

of

%!o,ih of Onset Associated Symptoms

Duration at First (days) Cortiaone (dose,day)

Duration of mcntf (day.) TreatErentual Recovery

Treat. merit fore

Days O,,sct of Remarks

;ex

Paraly-

(yr)

,,
1 1

Jisit

gin niFty
Rrcorery

Fi,ial
Reeniery

8 9 F

Mare1 Jan March

PR!. none none none none

no

otitis

S 10 4

SO mg 75 75 75mg mg mg

7 5 8 6

total total total

4 1 5

2
a
4

11)
l(i(l(
Ill

7
7

F F F M

1 R R L R R
M

air
()l3SCt

5
6

May Oct
May

total
98r;..

1
I00

50mg mg 75mg

1 S
K unknown

5
it

day

before

7
15 total

7
8 9

F F
3

July Dec
Jan

URI, 14 days before onset URI,nootitis


none questionable otiti,

g,z
16

Ireious with

treatnient

tliian,,i,e

[100mg

8
S 4

total
almost total

.1 so

mg mg

S
6

(75mg

100
R I.
cases showed

4 10

100mg
75 mg

total
total

2
4

40
41

10
a None

S
of the

Feb none
any beginning from additional except this with recovery chart. days of extreme

at

the

time

first

seen.

Patients

already

improving

at

initial

examination

were

not

treated

with

cortisone

andare

excluded

t Not including in most cases few a *5 Face now entirely symmetrical

smaller dosage laughing

for gradual or crying.

withdrawal.

Downloaded from www.pediatrics.org. Provided by Washtenaw Comm Coll on March 10, 2011

REVIEW

ARTICLE

313

Fie.
SeCOn(l

2.

Case
day of

4,

a girl f o
paralysis.

7 years, with idiopathic (b) rig/it) ( Same child


complete, but

Bells after subsequently

palsy. (lays of became

(left) (a)
cortisone

Appearance therapy.

when Recovery

first

seen, is not

on yet

so.

to tion

take to have d(i(le(l

ilace. ekctrolvte etc., we Use salt,


of fruit

On are used of and


juice

such balance,

dosage, added

special not

atten- during such a

the
plan

polio
may

season.
be

In to

epidemic
other-

years, if far of
seen

potassium necessary,

contraindicated;

chloride, nor routinely.


110

ordinarily prophylactic regular the daily, seems

wise

it

is

probably has including

safe been
have,

use

cortisone so

antibiotics

table
urging have perfectly if

food
of been

with
4 to

poliomyelitis feasible,
spinal 16 fluid.

excluded examination
however,

as the the

We

three

OUI1CCS

ad- patients suitable

with Massachusetts

facial
identified

paralysis epidemic
as

(luring which
)oliomyelitis

\iS(a(I. for ViSC(l.


SOlIC

The aml)ulatory One


in

pltn is naturally presence


SO fl

1955 after

were cortisone

treatment

carefully
use to corti-

super- subsequently

reluctant

they
other any

had

been
complication

treated
None or

with
of worsening

the dolle

of two

otitis
instances

media, where taking

l)ut l)y
suffered

physicians.

these

three of

e
ho

ha\C
recoveiy first

seemed
administering

to he to and

place,
for

the

poliomyelitis, After giving presence


it has

and due of
been

none

had

permanent to and
to

after

antibiotics

paralysis.

several Because cases emily the naturally idiopathic of (bile

(lays of facial to

prior the

during number are because cortisone and

treatment. of undoubt-

consideration otitis
our

the poliotreat

considerable which that

possible
myelitis, is cortisone

media
practice

paralysis poliomyelitis, assumption


in

of idiopathic is supposed cortisone

cases according If at the

of end

facial to the of

paralysis plan 14 of to
and

with mentioned 18
a

oral there
or

general hesitant

contraindicated

poliomyelitis, about paralysis treating with

one

above.
is no

days
partial

apparent

recovery,

facial

total

electrical

reaction

degeneration

is

Downloaded from www.pediatrics.org. Provided by Washtenaw Comm Coll on March 10, 2011

314 found, concerning


sion of the

PAINE we obtain possible


canal. In

FACIAL

PARALYSIS consultation decompresThe


series various

IN

CHILDREN

otologic surgical
the

SUMMARY
anatomy etiobogic
acquired

of
facial

the

facial in
paralysis

nerve both
in of

and congenital
children

the

present

factors

since curred question Several


sisting

the so

use

of

cortisone, in arisen. of late all

recovery cases

has that of

ocand this have


among

promptly has not forms

been
the

reviewed.
more

Differential
important

diagnosis
these has

treatment
are available

facial

paralysis

their scope
of

detailed of this any sensory,


even and if the direction. and graft the major

discussion paper.
approaches

is A
to

beyond graft
problem.

nerve
the

per-been discussed but possible methods the This evaluation is one high recovery which mocareful andindicates be treatment in that of high the cortisone recovery average at children. may study its with While of

and

an evaluation of of treatment attempted. is difficult because of rate


90%

the the If

without in of children. facial nature, cortisone is case

treatment, paralysis prompt considered to establish an already


clear that

approach a oral idiopathic

Apparently tor
also used,

type whether

of

nerve, reversed

whether or
serves

or

not, can

degenerated graft

( Tickle55)
probably

merely indicated. paper

to
a

provide
distal

a better
Duel56

channel
The and in 932, 1

for
classical also and in about was

regrowth described
anastomotic

it is difficult greatly improved rate, it seems more time in Cortisone adults is seems and

Ballance both

recovery least

favorably probably the treat-

in-

treatment

procedures
hypogbossal ported anastomosis, plete and excellent

using
nerves. but amounted

the
Love results recovery to

spinal

accessory
Cannon57

fluenced, or also in
rement

using 50%
never than 75%

ing
com- 10

of choice at the present time an(l diirthe past 2 years at one hospital, all of patients so treated recovered. This has the decompression need for of consideration the facial canal. true with larger to be seen. of

no

more

of

normal

function. one must of degree

In recovery

undertaking whether be will

procedures, eventual than take


would mosis

this will remain greater numbers of cases remains if natural regrowth is permitted to REFERENCES place without interference, but it 1. Bell, Sir C. On the nerves: : seem reasonable to consider anastocount of some experiences in cases where the degree of recovery is considered of repair
facial

consider

eliminated such surgical the Whether

Giving

an to

ac-

on
leads

their

struca new Tr.,


: Facial

after
factory.

3 months variety
fascial

highly surgical

unsatisprocedures

ture Roy.

and Soc.
H.

function,
of

arrangement 2. Park, W.,

the
and

London, analysis

which systems. 3:398,


Watkins,

Phil. 1821.
A. L.

A
using

plastic
slings,

tantalum

mesh,58

etc.,

paralysis;

of

500

cases.

Arch.

for
sistent but

late these

of
paralysis

the

deformities
have been

of
described,

per3.

Collier,

are in not
warrant

generally has been

to largely

be

considered completed, group. syntroublea 5.

Med., 30:749, 1949. Spillane, J. D., and Bauwens, Symposium : Treatment of facial sis. Proc. Roy. Soc. Med., 43:746,

Phys.

J.,

P.:
paraly1950.

after
and Finally,

growth
scarcely although

4.

Sullivan,
logical
treatment.

J.

A.,
concept

and

Smith,
of

J.

B.,

The

otoits

(Irome
some to

is

the pediatric age the crocodile tears usually sufficiently


consideration of such

Ann. Otol. 59:1148, 1950. James, J. A., and Russell,


; treatment.
pals aetiobogv, clinical

Bells Rhin.

palsy and & Larvng.,

\V.
course

:H. Bells
and

procedure, vitt59 alcohol of


palsy and

the is of into

case the

of These

Gottesfeld authors idiopathic

and ganglion

Lea6.

interest. man

injected Bells
The croc-

sphenopalatine with
the epiphora.

a 23-year-old
abolished

7.

odile terval

tears of

returned, about 4%

however, months.

after

an

in-

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FACIAL PARALYSIS IN CHILDREN: Review of the Differential Diagnosis and Report of Ten Cases Treated with Cortisone Richmond S. Paine Pediatrics 1957;19;303-316
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