Neurologic disorders

What Is the Cause of This Child's Facial Asymmetry?

Sachin Tadphale, MD, and Rebecca Butterfield, MD

Albany Medical Center, Albany, NY

Bell palsy

THE CASE: This 7-year-old girl has had a sore throat for the past 3 days. She reports that only the right side of her mouth moves when she talks and she is unable to completely close the left eye. She cannot recall any recent insect bites, trauma to the head or face, or rash. She has
had no facial pain, limb weakness, fever, or headache and no difficulty in ambulating or swallowing.

The patient’s face looks symmetrical when at rest, with the mouth closed. She has blunting of the nasolabial fold on the left. When she smiles, her lips deviate upward on the right side and her right eyebrow raises, with wrinkling of the forehead; however, the left side of the face remains unchanged; there is no wrinkling of the forehead on the left side. When she closes her eyes, the left eyelid remains partially open. Neurological findings are otherwise normal.

What is the cause of this child's facial asymmetry?

• Guillain-Barre syndrome

• Bell palsy

• Brain tumor

• Anterior circulation stroke

Answer on next page.

Answer: Bell Palsy

Bell palsy, or idiopathic facial paralysis, is the most common cause of unilateral facial paralysis in the absence of other cranial neuropathies or brainstem involvement (bulbar paralysis). A wide range of conditions are associated with isolated seventh cranial nerve palsy, including infection (with herpes simplex virus, varicella virus, Mycoplasma, or Epstein-Barr virus) as well as trauma, tumor, and sarcoidosis, which are less common. The Bell palsy in this child was probably associated with a vial syndrome; results of both a rapid Streptococcus antigen test and throat culture were negative.

Bell palsy

Bell palsy is most common in teens and adults aged 15 to 40 years1 and rare in children younger than 13 years. More than 50% of patients have a taste disorder, although some have normal taste sensation on the unaffected side of the tongue, and the symptom may not be reported.2 A few patients have ipsilateral facial numbness. This child had Bell phenomenon, which is described as the upward rolling of the involved eyeball on attempted closure of the eyelid. This is a normal response to eye closure that is usually hidden by the closed lid but visibly apparent in patients with Bell palsy.

Spontaneous recovery of Bell palsy is likely to occur in most patients. Although treatment with oral prednisone (1 to 2 mg/kg/d for 1 to 2 weeks) has been shown to be effective at speeding up recovery of the facial nerve palsy, its use remains controversial because of the likelihood of resolution without treatment.3 In addition, randomized controlled trials have shown no benefit of antiviral therapy given either alone or with corticosteroids.4 It is recommended that patients apply artificial tears, especially at night, to prevent dry eye, corneal abrasions, and corneal ulcers.

Prognosis is excellent. Only 10% to 15% of children have some degree of residual weakness; a positive prognostic indicator is recovery of function within the first 3 weeks of symptoms.1 Our patient recovered fully within 2 months.



  1. Holland J, Bernstein J. Bell’s palsy. Clin Evid (Online). 2011 Mar 7;2011. pii:1204.
  2. Peitersen E. The natural history of Bell’s palsy. Am J Otol. 1982;4:107-111.
  3. Hazin R, Azizzadeh B, Bhatti MT. Medical and surgical management of facial nerve palsy. Curr Opin Ophthalmol. 2009;20:440-450.
  4. Goudakos JK, Markou KD. Corticosteroids vs corticosteroids plus antiviral agents in the treatment of Bell palsy; a systematic review and meta-analysis. Arch Otolaryngol Head Neck Surg. 2009;135:558-564.