J Neurol Res

Journal of Neurology Research, ISSN 1923-2845 print, 1923-2853 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Neurol Res and Elmer Press Inc

Journal website https://jnr.elmerpub.com

Review

Volume 16, Number 1, March 2026, pages 1-8

Pediatric Facial Nerve Palsy: A Narrative Review of Etiology, Diagnosis, and Management

↓ Figure 1. Schematic representation of upper motor neuron (central) and lower motor neuron (peripheral) facial palsy patterns. The figure illustrates basic anatomical and clinical differences relevant to initial neurological assessment (Photo by Dr. Rahul Bagla ENT Textbook, used with permission).

↓ **Table 1.** The House-Brackmann Grading System
Grade	Description	Characteristics
I	Normal	Normal facial function in all areas.
II	Mild dysfunction	Gross: Slight weakness noticeable only on close inspection; may have very slight synkinesis. At rest: Normal symmetry and tone. Motion: – Forehead: Moderate to good function. – Eye: Complete closure with minimum effort. – Mouth: Slight asymmetry.
III	Moderate dysfunction	Gross: Obvious but not disfiguring difference between two sides; noticeable but not severe synkinesis, contracture, or hemifacial spasm. At rest: Normal symmetry and tone. Motion: – Forehead: Slight to moderate movement. – Eye: Complete closure with effort. – Mouth: Slight weakness with maximum effort.
IV	Moderately severe dysfunction	Gross: Obvious weakness and/or disfiguring asymmetry. At rest: Normal symmetry and tone. Motion: – Forehead: None. – Eye: Incomplete closure. – Mouth: Asymmetric with maximum effort.
V	Severe dysfunction	Gross: Only barely perceptible motion. At rest: Asymmetry. Motion: – Forehead: None. – Eye: Incomplete closure. – Mouth: Slight movement.
VI	Total paralysis	No movement in any region.

↓ Table 1. The House-Brackmann Grading System

Grade

Description

Characteristics

Normal

Normal facial function in all areas.

Mild dysfunction

Gross: Slight weakness noticeable only on close inspection; may have very slight synkinesis.
At rest: Normal symmetry and tone.
Motion:
– Forehead: Moderate to good function.
– Eye: Complete closure with minimum effort.
– Mouth: Slight asymmetry.

III

Moderate dysfunction

Gross: Obvious but not disfiguring difference between two sides; noticeable but not severe synkinesis, contracture, or hemifacial spasm.
At rest: Normal symmetry and tone.
Motion:
– Forehead: Slight to moderate movement.
– Eye: Complete closure with effort.
– Mouth: Slight weakness with maximum effort.

Moderately severe dysfunction

Gross: Obvious weakness and/or disfiguring asymmetry.
At rest: Normal symmetry and tone.
Motion:
– Forehead: None.
– Eye: Incomplete closure.
– Mouth: Asymmetric with maximum effort.

Severe dysfunction

Gross: Only barely perceptible motion.
At rest: Asymmetry.
Motion:
– Forehead: None.
– Eye: Incomplete closure.
– Mouth: Slight movement.

Total paralysis

No movement in any region.

↓ **Table 2.** Major etiologies of pediatric facial nerve palsy according to age, clinical presentation, and evidence level
Etiology	Typical age group	Clinical presentation	Key diagnostic clues	Representative references	Level of evidence (CEBM)
Bell’s palsy (idiopathic)	Older children, adolescents	Acute unilateral peripheral FNP, partial > complete	No systemic illness, rapid onset, favorable prognosis	[1, 3, 7]	III
Birth-related (postpartum) palsy	Neonates	Facial asymmetry during crying/feeding	History of difficult or instrumental delivery	[4, 15]	IV
Congenital/syndromic (MBS)	Neonates, infancy	Bilateral facial weakness, ophthalmoplegia	Absence of recovery, craniofacial anomalies	[9, 16]	IV
Infectious (Lyme disease, EBV)	Infants, children	Acute unilateral or bilateral palsy ± systemic symptoms	Tick exposure, fever, rash, lymphadenopathy	[17, 21, 22]	III
Otitis media–related	Infants, young children	Facial palsy with ear symptoms	Otalgia, fever, otoscopic findings	[23]	IV
Guillain–Barré syndrome	Children, adolescents	Bilateral or sequential palsy ± limb weakness	Areflexia, progressive symptoms	[23–25]	III
Traumatic/iatrogenic	All pediatric ages	Immediate or delayed palsy	Head trauma, temporal bone fracture, surgery	[8, 26, 27]	IV
Neoplastic/structural	Rare (all ages)	Progressive or recurrent palsy	Lack of recovery, additional neurological signs	[14, 28]	IV

↓ Table 2. Major etiologies of pediatric facial nerve palsy according to age, clinical presentation, and evidence level

Etiology

Typical age group

Clinical presentation

Key diagnostic clues

Representative references

Level of evidence (CEBM)

Bell’s palsy (idiopathic)

Older children, adolescents

Acute unilateral peripheral FNP, partial > complete

No systemic illness, rapid onset, favorable prognosis

[1, 3, 7]

III

Birth-related (postpartum) palsy

Neonates

Facial asymmetry during crying/feeding

History of difficult or instrumental delivery

[4, 15]

Congenital/syndromic (MBS)

Neonates, infancy

Bilateral facial weakness, ophthalmoplegia

Absence of recovery, craniofacial anomalies

[9, 16]

Infectious (Lyme disease, EBV)

Infants, children

Acute unilateral or bilateral palsy ± systemic symptoms

Tick exposure, fever, rash, lymphadenopathy

[17, 21, 22]

III

Otitis media–related

Infants, young children

Facial palsy with ear symptoms

Otalgia, fever, otoscopic findings

[23]

Guillain–Barré syndrome

Children, adolescents

Bilateral or sequential palsy ± limb weakness

Areflexia, progressive symptoms

[23–25]

III

Traumatic/iatrogenic

All pediatric ages

Immediate or delayed palsy

Head trauma, temporal bone fracture, surgery

[8, 26, 27]

Neoplastic/structural

Rare (all ages)

Progressive or recurrent palsy

Lack of recovery, additional neurological signs

[14, 28]

↓ **Table 3.** Management of Pediatric Facial Nerve Palsy: Indication-Based Approach
Etiology/scenario	Recommended management	When to consider treatment	When NOT recommended	Key references
Bell’s palsy – partial palsy	Observation, eye care	Mild weakness (HB II–III), early improvement	Routine steroids or antivirals	[3, 7]
Bell’s palsy – moderate/severe	Corticosteroids (short, weight-adjusted course)	Initiation ≤ 72 h, HB IV–V	Delayed presentation, mild palsy	[7, 29]
Bell’s palsy – antivirals	Not routine	Selected cases with strong viral suspicion	Monotherapy or routine use	[30, 31]
Lyme disease–associated palsy	Antibiotic therapy	Endemic area, positive serology	Delayed treatment	[17, 22]
GBS with facial palsy	IVIG or plasmapheresis	Based on neurological severity	Facial palsy alone	[23, 25]
Traumatic palsy	Surgical consultation	Evidence of nerve disruption	Incomplete palsy with recovery	[8, 26]
Physiotherapy	Targeted facial exercises	Delayed recovery, residual weakness	Routine early use in mild cases	[26, 33]
Electrical/laser stimulation	Not routinely recommended	Experimental settings only	Routine pediatric use	[34, 35]

↓ Table 3. Management of Pediatric Facial Nerve Palsy: Indication-Based Approach

Etiology/scenario

Recommended management

When to consider treatment

When NOT recommended

Key references

Bell’s palsy – partial palsy

Observation, eye care

Mild weakness (HB II–III), early improvement

Routine steroids or antivirals

[3, 7]

Bell’s palsy – moderate/severe

Corticosteroids (short, weight-adjusted course)

Initiation ≤ 72 h, HB IV–V

Delayed presentation, mild palsy

[7, 29]

Bell’s palsy – antivirals

Not routine

Selected cases with strong viral suspicion

Monotherapy or routine use

[30, 31]

Lyme disease–associated palsy

Antibiotic therapy

Endemic area, positive serology

Delayed treatment

[17, 22]

GBS with facial palsy

IVIG or plasmapheresis

Based on neurological severity

Facial palsy alone

[23, 25]

Traumatic palsy

Surgical consultation

Evidence of nerve disruption

Incomplete palsy with recovery

[8, 26]

Physiotherapy

Targeted facial exercises

Delayed recovery, residual weakness

Routine early use in mild cases

[26, 33]

Electrical/laser stimulation

Not routinely recommended

Experimental settings only

Routine pediatric use

[34, 35]