Bell's Palsy ============ þ Should you give steroids and/or acyclovir? - Yes and No. [Salinas, R. A., G. Alvarez, et al. (2010) Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database of Systematic Reviews DOI: 10.1002/14651858.CD001942.pub4] BACKGROUND: Inflammation and oedema of the facial nerve are implicated in causing Bell's palsy. Corticosteroids have a potent anti-inflammatory action which should minimise nerve damage. OBJECTIVES: The objective of this review was to assess the effect of corticosteroid therapy in Bell's palsy. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (9 December 2008) for randomised trials, as well as MEDLINE (January 1966 to December 2008), EMBASE (January 1980 to December 2008) and LILACS (9 December 2008). We contacted known experts in the field to identify additional published or unpublished trials. SELECTION CRITERIA: Randomised trials comparing different routes of administration and dosage schemes of corticosteroid or adrenocorticotrophic hormone therapy versus a control group where no therapy considered effective for this condition was administered, unless it was also given in a similar way to the experimental group. DATA COLLECTION AND ANALYSIS: Two authors independently assessed eligibility, trial quality, and extracted the data. MAIN RESULTS: Eight trials with a total of 1569 participants were included. Allocation concealment was appropriate in six trials, and the data reported allowed an intention-to-treat analysis in four, while unpublished data from the fifth and sixth trials were provided by the authors. The data included in the main outcome of this meta-analysis were collected from seven trials with a total of 1507 participants. Overall 175/754 (23%) of the participants allocated to corticosteroids had incomplete recovery of facial motor function six months or more after randomisation, significantly less than 245/753 (33%) in the control group (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.61 to 0.83). There was, also, a significant reduction in motor synkinesis during follow-up in those receiving corticosteroids (RR 0.6, 95% CI 0.44 to 0.81). The reduction in the proportion of patients with cosmetically disabling sequelae six months after randomisation, however, was not significant (RR 0.97, 95% CI 0.44 to 2.15). The trial not included in the primary outcome of this meta-analysis showed a non-significant difference in outcomes between the arms. AUTHORS' CONCLUSIONS: The available evidence from randomised controlled trials shows significant benefit from treating Bell's palsy with corticosteroids. CORTICOSTEROIDS FOR BELL'S PALSY: Bell's palsy is a paralysis or weakness of muscles in the face, usually on one side, with no certain cause. Usually people recover, although some do not. Corticosteroid drugs are anti-inflammatory. Bell's palsy is caused by inflammation of the facial nerve. Reducing the inflammation should limit nerve damage. In this review of eight trials involving 1569 participants, corticosteroids significantly reduced the number of people left with weak faces after Bell's palsy and did not cause serious harm. [Lockhart, P., F. Daly, et al. (2009) Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database of Systematic Reviews DOI: 10.1002/14651858.CD001869.pub4] BACKGROUND: Antiviral agents against herpes simplex virus are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but their effectiveness is uncertain. Significant morbidity can be associated with severe cases. OBJECTIVES: This review addresses the effect of antiviral therapy on Bell's palsy. SEARCH STRATEGY: We updated the search of the Cochrane Neuromuscular Disease Group Trials Register (December 2008), MEDLINE (from January 1966 to December 8 2008), EMBASE (from January 1980 to December 8 2008) and LILACS (from January 1982 to December 2008). SELECTION CRITERIA: Randomized trials of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy. DATA COLLECTION AND ANALYSIS: Twenty-three papers were selected for consideration. MAIN RESULTS: Seven trials including 1987 participants met the inclusion criteria, adding five studies to the two in the previous review.Incomplete recovery at one year. There was no significant benefit in the rate of incomplete recovery from antivirals compared with placebo (n = 1886, RR 0.88, 95% CI 0.65 to 1.18). In meta- analyses with some unexplained heterogeneity, the outcome with antivirals was significantly worse than with corticosteroids (n = 768, RR 2.82, 95% CI 1.09 to 7.32) and the outcome with antivirals plus corticosteroids was significantly better than with placebo (n = 658, RR 0.56, 95% CI 0.41 to 0.76).Motor synkinesis or crocodile tears at one year. In single trials, there was no significant difference in long term sequelae comparing antivirals and corticosteroids with corticosteroids alone (n = 99, RR 0.39, 95% CI 0.14 to 1.07) or antivirals with corticosteroids (n = 101, RR 1.03, 95% CI 0.51 to 2.07).Adverse events.There was no significant difference in rates of adverse events between antivirals and placebo (n = 1544, RR 1.06, 95% CI 0.81 to 1.38), between antivirals and corticosteroids (n = 667, RR 0.96, 95% CI 0.65 to 1.41) or between the antiviral-corticosteroid combination and placebo (n = 658, RR 1.15, 95% CI 0.79 to 1.66). AUTHORS' CONCLUSIONS: High quality evidence showed no significant benefit from anti- herpes simplex antivirals compared with placebo in producing complete recovery from Bell's palsy. Moderate quality evidence showed that antivirals were significantly less likely than corticosteroids to produce complete recovery. ANTIVIRAL TREATMENT FOR BELL'S PALSY: Bell's palsy is a disease of the facial nerve which causes one side of the face to be paralysed. Some studies have suggested that it is caused by infection with the cold sore (herpes simplex) virus. If this is correct, antiviral drugs against herpes simplex would be likely to help recovery. It has also been suggested that corticosteroids may help. The paralysis is usually temporary even when untreated, although without treatment about one person in five is left with permanent facial disfigurement or pain.This updated review provided high quality evidence that antivirals are no more effective than placebo (dummy) treatment in producing complete recovery. On the other hand moderate quality evidence showed that antivirals were less effective than corticosteroids and that combined antiviral-corticosteroid treatment were more effective than placebo. Taken together, these results suggest that corticosteroids might be effective but this requires confirmation from the Cochrane review of corticosteroids which is being updated. There was no evidence that antivirals produced significantly more or significantly fewer adverse events than dummy treatment.As this analysis shows that antivirals against the cold sore virus are not significantly effective, other causes for Bell's palsy than infection by the cold sore virus now need to be considered. - Yes and probably yes, but see above [Grogan PM, Gronseth GS. Practice parameter: Steroids, acyclovir, and surgery for Bell's palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001 Apr 10;56(7):830-6.] Summary of Practice Recommendations For patients presenting with Bell's palsy: + Early treatment with oral steroids is recommended as probably effective to improve facial functional outcomes (Level B). (Custom is to give 1 mg/kg daily for 7-10 days, but dosage not evidence-based.) + Early treatment with acyclovir in combination with prednisone is recommended as possibly effective to improve facial functional outcomes (Level C). + There is insufficient evidence to make recommendations regarding the use of facial nerve decompression to improve facial functional outcomes (Level U). - recent review in NEJM recommends "valacyclovir (1 g twice daily for seven days) or famciclovir (750 mg three times daily) and oral prednisone (1 mg per kilogram per day for seven days)." (cites better compliance with Valtrex or Famvir) [Gilden, D. H. (2004). "Clinical practice. Bell's Palsy." N Engl J Med 351(13): 1323-31.] þ Differential Diagnosis (and non-idiopathic causes) of Bell's Palsy: - brainstem CVA or tumor: associated sixth-nerve palsy, uncrossed fibers from other nucleus prevent weakness of upper face (eyes), Acoustic Neuroma, parotid tumors. - otitis media - herpes zoster oticus (Ramsay Hunt syndrome) - Lyme Disease or Guillian-Barre mononeuritis, especially if bilateral; Guillain-Barre disease and Lyme disease are the two major causes of bilateral facial nerve palsy. It may occur sequentially (one side, then the other). - If Bell's Palsy in a kid, treat for Lyme Disease. þ Nerves affected by Bell's Palsy - Stapedius (damps loud sounds) - Taste to anterior 2/3 of tongue - Face movement (upper and lower) þ Natural History of Bell's Palsy: - better than 90% spontaneous remission rate. - 98% regain at least partial function. (Tintinalli 4E) - Common: 20/100,000/year. - Worse cases take longer to recover. þ multiple causes for Bell's Palsy (suspected): - viral infection - ischemia (especially in diabetics) - autoimmune - familial - Sarcoid (can be bilateral) - Lyme Disease (can be bilateral) þ Prednisone for Bell's Palsy: - 30 mg BID for 6 days then tapered over another 4 improved ultimate outcome (extended for five days if patient worsened during treatment). Study below had to be post-hoc analyzed re: poor outcome. [Austin JR, Peskind SP, Austin SG, Rice DH. Idiopathic facial nerve paralysis: a randomized double-blind controlled study of placebo vs. prednisone. Laryngoscope 1993;103:1326-33.] - per Adour, prednisone helps pain, but not placebo-controlled; above was placebo-controlled and found no effect on pain. þ Sequelae of Bell's Palsy: - synkinesis: an involuntary twitch accompanying a voluntary motion (in a different distribution) - hemifacial spasm inappropriate linking of nerves (e.g., spasm around the eye when smiling; a worse case of the above) - crocodile tears syndrome: tearing with eating and salivation (12%)