For health professionals: When to refer patients with facial paralysis

Bell's palsy

The majority of patients will recover following a course of steroids. If the patient is unable to close their eyelids they will require advice on eye care (including eye protection) such as artificial tear drops and ointments and taping the eyelids shut at night. If the cornea remains exposed or there are any concerns regarding the health of the eye refer to ophthalmology.

Patients may benefit from referral to the Face Place who can provide the patient with practical help and support in the acute phase of the facial palsy and assist in addressing some of residual problems such as synkinesis during the later stages of  the condition.

Please see the Map of Medicine for further guidance.

Referral to other specialists

When the diagnosis is in doubt. Consider an urgent referral to ENT or neurology if:

  • ear symptoms especially ear discharge
  • a parotid or neck mass
  • neurological symptoms other than seventh nerve especially audiovestibular symptoms  such as hearing loss or imbalance
  • facial palsy progressing over one month
  • partial palsy showing no signs of recovery after six weeks
  • recurrence of facial weakness or bilateral facial weakness.

When the cornea is at risk. Consider an urgent referral to ophthalmology if:

  • eyelid closure is incomplete and the cornea remains visible on attempting to close the eye
  • the eye remains at risk despite the use of eye drops/ointments and taping shut at night
  • the eye becomes red or painful.

When to refer to the Wessex Facial Nerve Centre multidisciplinary team

Severe facial weakness (of any cause) where there is incomplete or no recovery.

  • Incomplete or no recovery (in facial weakness of any cause)
  • Partial palsy showing no signs of recovery after six weeks
  • Signs of synkinesis (mass movement)
  • Severe functional impairment impacting on quality of life, for example difficulty eating speaking or severe emotional impact.

References 

1. Kanerva M, Mannonen L, Piiparinen H, et al. Search for herpes virus in cerebrospinal fluid of facial palsy patients by PCR. Acta Otolaryngol 2007; 127:775-9

2. Gilden DH; Clincal practice. Bell’s Palsy. N Engl J Med. 2004 Sep 23:351(13):1323-31

3. Sandoval C C, Nunez F A, Lizama C M, Margarit S C, Abarca V K, Escobar H R. [Ramsay Hunt syndrome in children: four cases and review]. Rev Chilena Infectol. Dec 2008; 25(6):458-64. 

4. Clark JR, Carlson RD, Sasaki CT, et al Facial Paralysis in Lyme Disease. Laryngoscope. Nov 1985; 95 (11):1341-5.

5. Alpen Patel, M.D.., Eli Groppo M.d Craniomaxillofac Trauma Reconstr. 2010 June; 3(2): 105–113.  

6. Green JD Jr, Shelton C, Brackmann DE. Surgical management of iatrogenic facial nerve injuries. Otolaryngol Head Neck Surg 1994; 111(5):606-10.