Optimising treatment of Bell's Palsy in primary care: the need for early appropriate referral.

British Journal of General Practice, December 2014 e807 IntrOduCtIOn Bell’s palsy remains the most common cause of lower motor neurone facial nerve paralysis. While 71% experience complete spontaneous resolution, including 61% who demonstrate a complete palsy and 94% who demonstrate a partial palsy, the remaining 29% exhibit lifelong residual hemifacial weakness.1,2 In 55% of these cases, the deficit is moderate to severe. In addition to stigmatising facial asymmetry, other distressing and socially embarrassing sequelae include: facial spasms and mass-movement contractions (synkinesis); loss of oral competence; facial pain and paraesthesia; nocturnal corneal exposure; dry mouth and eyes caused by loss of parasympathetic innervation to the submandibular/sublingual salivary glands and lacrimal glands respectively; and intolerance to loud noise caused by involvement of the nerve branch to stapedius, resulting in loss of acoustic dampening. Unsurprisingly, anxiety and depression are common.3 Therapeutic targets for acute Bell’s palsy seek to reach these 29%, accepting that prognostic indicators of an incomplete or minimal recovery may be of some value but require further validation.4 As GPs are likely to see, on average, one acute case every 2 years, it is highly improbable that they will have sufficient expertise to know what to do in the event that acute medical management fails. Worse still, referral to a facial reanimation service is critically time dependent, with the reconstructive options dwindling as the months progress.5 This article explores this referral pathway, making a case for early referral in every patient failing to demonstrate evidence of resolution by around 6 weeks.