Structural Mimics of Recurrent Bell’s Palsy: A Case Report Highlighting Diagnostic Red Flags in Facial Nerve Schwannoma and Metastasis

Background and Clinical Significance: Recurrent peripheral facial palsy is most often attributed to idiopathic Bell’s palsy (BP), yet a minority of patients harbor underlying structural lesions. Early recognition of such lesions is essential for timely and appropriate management. Case Presentation: We retrospectively reviewed recurrent unilateral facial palsy at a single tertiary center and selected two illustrative patients in whom serial clinical, electrodiagnostic, and magnetic resonance imaging (MRI) findings ultimately indicated structural pathology. The first patient experienced three strictly right-sided episodes over 3.5 years, with worsening House–Brackmann grades (II → III → V) and progressive axonal loss on serial facial nerve conduction studies, culminating in a mass-like enhancing lesion at the geniculate ganglion consistent with schwannoma. The second patient had two left-sided recurrences within seven months. MRI evolved from a subtle intrameatal nodular suspicion without enhancement to a clearly enhancing intrameatal nodule with dural thickening. Additional intracranial nodular enhancements were discovered later and the patient was diagnosed with leptomeningeal metastasis. Conclusions: These cases illustrate that strictly ipsilateral recurrences, progressive electrophysiologic deterioration, and atypical or evolving MRI enhancement patterns should prompt thorough re-evaluation for structural causes rather than repeated labeling as idiopathic BP.