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edema of the facial nerve as it passes through the facial canal within the temporal
bone. There is often a history or preceding upper respiratory tract infection, and
in at least a subset of patients, there is evidence of reactivation of infection with
Epstein–Barr virus or HSV. Seventh nerve palsy may occur in association with
otitis media, in which case it may indicate the presence of mastoid involvement.
Facial palsy may also be a manifestation of early-disseminated Lyme disease. In
general most cases of facial nerve palsy in children are of the idiopathic (or viral
reactivation) type; however, in endemic areas, Lyme disease may be the most
common cause.
Facial weakness may be partial or complete. On the affected side, there is
flattening of the nasolabial fold at rest, and the child has difficulty closing the eye
or raising the corner of the mouth to smile. With upper motor neuron
involvement, there will be some residual capacity to furrow the brow because of
crossed innervation, whereas the entire face is involved with peripheral disease.
The diagnosis of idiopathic facial nerve palsy is clinical and based on diffuse
involvement of all distal branches of cranial nerve VII, an acute onset with
progressive course, and an associated prodrome typically consisting of ear pain or
dysacusis. In endemic areas, testing for Lyme disease is recommended. Further
evaluation with imaging and CSF is not necessary in patients with a typical
presentation. Other associated neurologic abnormality, specifically involvement
of other cranial nerves, or concomitant otitis media, necessitates further
evaluation, including CT or MRI. Peripheral nerve palsy in association with acute
otitis media may require myringotomy.
Symptomatic treatment for facial nerve palsy consists of protection of the
cornea by the instillation of bland ointments (e.g., Lacri-Lube). The most recent
Cochrane Review (2010) demonstrated that treatment with systemic
corticosteroids significantly improves the likelihood of complete resolution for
patients with idiopathic facial paralysis. A separate Cochrane Review (2009) did
not demonstrate any improvement in the rate of recovery for those treated with
antivirals against herpes virus alone compared to placebo or to antivirals plus
corticosteroids. Patients treated with antiviral and corticosteroids did have

improved rates of recovery. As such, antiretroviral therapy is not recommended
without evidence of recent or active herpes infection. Regardless of treatment,
complete recovery is seen in 60% to 80% of children, beginning during the
second to third week of illness. Those with partial paralysis generally have a
better prognosis. Patients should be referred for reexamination to ensure recovery
during the expected time period.