When to refer a patient with Bell's palsy (Idiopathic Facial Paralysis) to an Ear, Nose, and Throat (ENT) specialist?

From the Guidelines

Referral to an ENT specialist is recommended for Bell's palsy patients with new or worsening neurologic findings, ocular symptoms, or incomplete facial recovery 3 months after initial symptom onset. According to the clinical practice guideline for Bell's palsy 1, clinicians should reassess or refer to a facial nerve specialist those patients who meet these criteria. The guideline provides a strong recommendation for patient history and physical examination to exclude identifiable causes of facial paresis or paralysis, and a recommendation against routine laboratory testing and diagnostic imaging for patients with new-onset Bell’s palsy.

Key considerations for referral include:

• New or worsening neurologic findings at any point
• Ocular symptoms developing at any point
• Incomplete facial recovery 3 months after initial symptom onset While waiting for the ENT appointment, patients should implement eye protection measures, such as artificial tears and lubricating eye ointment, if eye closure is affected 1. Clinicians should also prescribe oral steroids within 72 hours of symptom onset for Bell’s palsy patients 16 years and older, as recommended by the guideline 1.

In terms of management, the guideline recommends oral steroids, such as prednisolone, within 72 hours of symptom onset, and suggests that antiviral therapy may be offered in addition to oral steroids in certain cases 1. However, the decision to refer to an ENT specialist should be based on the presence of concerning features or incomplete recovery, rather than the specific treatment regimen. ENT specialists can provide specialized testing and management, including electroneuronography and surgical decompression, if necessary 1.

From the Research

Referral to ENT for Bell's Palsy

When considering referral to an ENT specialist for Bell's palsy, several factors should be taken into account:

• The severity of the condition: Patients with severe Bell's palsy or those who are at risk of developing long-term disfigurement may benefit from early referral to an ENT specialist 2.
• The presence of comorbidities: Patients with diabetes, obesity, or pregnancy may require closer monitoring and management, and referral to an ENT specialist may be necessary 3.
• The effectiveness of initial treatment: If the patient does not respond to initial treatment with corticosteroids, referral to an ENT specialist may be necessary to consider alternative treatment options 4, 5.
• The need for further evaluation: If the diagnosis is uncertain or if the patient presents with atypical symptoms, referral to an ENT specialist may be necessary for further evaluation and diagnosis 6.

Timing of Referral

Referral to an ENT specialist should be considered:

• Early in the course of the disease, ideally within 72 hours of symptom onset, to maximize the effectiveness of treatment 6.
• If the patient has a high risk of developing long-term disfigurement or residual facial weakness, such as those with severe Bell's palsy or those who do not respond to initial treatment 2, 4.
• If the patient requires further evaluation or diagnosis, such as MRI or electromyography (EMG) to assess the extent of nerve damage 6.

Key Considerations

When referring a patient to an ENT specialist for Bell's palsy, the following key considerations should be kept in mind:

• The importance of early recognition and treatment to improve outcomes 2, 6.
• The need for a thorough ENT and neurological clinical examination to confirm the diagnosis and rule out other conditions 6.
• The potential benefits and risks of treatment options, including corticosteroids and antiviral therapy 4, 5.