When should I consider referring a patient with Bell's Palsy to a specialist for further evaluation?

You should consider referring a patient with Bell's Palsy to a specialist for further evaluation in several situations, particularly if there are atypical features, lack of improvement, or signs of a more serious underlying condition ¹.

• Immediate or Urgent Referral:
  • Arrange immediate emergency admission if a stroke is suspected ¹.
  • Refer urgently if clinical features, history, and examination suggest an upper motor neurone cause (e.g., limb paresis, facial paraesthesia, other cranial nerve involvement, postural imbalance) ¹.
  • Refer using a suspected cancer pathway (for an appointment within 2 weeks) if cancer is suspected (e.g., gradual onset of symptoms, persistent facial paralysis for more than 6 months, pain in the distribution of the facial nerve, head or neck lesion suggestive of cancer, history of head and neck cancer, or hearing loss on the affected side) ¹.
  • Refer using a suspected cancer pathway if facial pain is associated with persistent facial numbness or abnormal neurological signs ³.
  • Refer urgently if trauma is the suspected cause ¹.
  • Refer urgently if there is an acute systemic or severe local infection ¹.
  • Refer if existing neurological findings worsen, or if new neurological findings develop ¹.
• Referral to an Appropriate Facial Nerve Specialist (e.g., Neurologist, ENT Specialist):
  • Refer if atypical features are present ¹.
  • Refer if there is no improvement after 3 weeks of treatment ¹.
  • Refer if there is incomplete recovery after 3 months of onset of symptoms ¹.
  • Refer if the diagnosis is uncertain ¹.
  • Consider referral if the patient has developed symptoms of aberrant reinnervation (including gustatory sweating or jaw-winking) 5 months or more after the onset of Bell's palsy ¹.
  • Consider referral for further support or counselling if there are emotional consequences of persistent facial paralysis or paresis ¹.
• Referral to an Ophthalmologist:
  • Refer if ocular symptoms develop at any time (e.g., pain, irritation, or itch) ¹.
• When Not to Routinely Refer:
  • Do not routinely refer adults with an uncomplicated episode of Bell's palsy (unilateral lower motor neurone pattern facial weakness affecting all parts of the face and including weakness of eye closure) and no evidence of another medical condition such as middle ear disease ¹.