Referral criteria from primary care - Bell's Palsy

Referral criteria to secondary care: (1)

• urgent referral for ear, nose, and throat (ENT) or neurological review if there is:
  
  
  • diagnostic uncertainty
    
    
  • bilateral Bell's palsy
    
    
  • recurrent Bell's palsy
    
    
• refer for urgent ophthalmological review if the cornea remains exposed after attempting to close the eyelid
  
  
• refer urgently to ENT if the paralysis shows no sign of improvement after 1 month, or there is suspicion of a serious underlying diagnosis (e.g. cholesteatoma, parotid tumour, malignant otitis externa)
  
  
• consider referral to a plastic surgeon with a special interest in facial reconstructive surgery If there is residual paralysis after 6-9 months

NICE guidance suggests (2):

• 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
  
  
• advise adults with Bell's palsy about eye care, and explain that Bell's palsy improves at different rates and maximum recovery can take several months
  
  
• consider referring adults with Bell's palsy who have developed symptoms of aberrant reinnervation (including gustatory sweating or jaw-winking) 5 months or more after the onset of Bell's palsy for neurological assessment and possible treatment.

Reference:

• 1. Gilden DH. Clinical practice. Bell's palsy. N Engl J Med. 2004 Sep 23;351(13):1323-31.
• 2. NICE (May 2019). Suspected neurological conditions: recognition and referral