clinical challenge
❖défi clinique
VOL 46: JUNE • JUIN 2000❖Canadian Family Physician•Le Médecin de famille canadien 1293
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ell’s palsy involves partial or complete paralysis of the facial nerve 15% to 30% of the time and can be a devastating condition for patients. Although the etiology is unclear, some think that an inciting factor causes inflammation that leads to compression and ischemia of the facial ner ve within the temporal bone. To review current treatment of this condition, I searched the Bandolier evidence-based medicine website, Mednet’s family medicine literature search engine, the Cochrane Library, and PubMed, using the search word “Bell’s palsy” back to 1996.Mounting evidence now suggests the culprit is herpes simplex virus, type 1, and studies indicate that adding acyclovir (400 mg five times daily for 10 days) to prednisone substantially improves out- comes.1,2Level 2 evidence indicates that acyclovir used alone might also be beneficial.1,2 The num- bers in the study by Adour et al are small (99), but the study is double-blinded and there are objec- tive, measurable outcomes.
Although studies of using prednisone3-5 for patients with Bell’s palsy are not perfect, evidence from them indicates that it should be given within the first 5 days after onset of symptoms (1 mg/kg for 5 days, maximum 70 mg, gradually tapered to 10 mg daily over the next 5 days) (level 2 evidence). In the study by Shafshak and associates,3when subgroups were examined, the extra benefits conferred by steroids were seen only
when treatment was given within the first 24 hours (satisfactory recover y was 100%) Number-needed-to- treat was 3.2; or, for ever y three patients treated with pred- nisolone within 24 hours of onset of paral- ysis, one extra patient had a satisfactor y
recovery compared with untreated patients. The Shafshak study is not randomized; absence of ran- domization and blinding can lead to overestimation of treatment effects.
No level 1 evidence defines the most effective treatment for Bell’s palsy. Studies in the future might clarify the issue. In the meantime, based on the evidence at hand, I will treat my patients with prednisone and acyclovir as soon as possible after onset of paralysis and hope for the best.
Acknowledgment
I thank Dr David Kirkpatrick, consultant otolaryngolo- gist, at the QE 2 Health Science Centre in Halifax, NS, for reviewing the draft of this article.
References
1. Adour KK, Ruboyianes JM, Doersten PG, Byl FM, Trent CS, Quesenberry CP Jr, et al. Bell’s palsy treatment with acyclovir and prednisone compared with prednisone alone: a double-blind, randomized, controlled trial. Ann Otol Rhinol Laryngol1996;105(5):371-8.
2. De Diego Sastre JI, Prim Espada MP. Use of acyclovir in acute peripheral idiopathic facial paralysis. Acta Otorrinolaringol Esp1999;50(2):121-4.
3. Shafshak TS, Essa AY, Bakey FA. The possible contribut- ing factors for the success of steroid therapy in Bell’s palsy: a clinical and electrophysiological study. J Laryngol
Otol1994;108:940-3.
4. Wolf SM, Wagner JH, Davidson S, Forsythe A.
Treatment of Bell’s palsy with prednisone: a prospec- tive randomized study.
Neurology1978;28:158-61.
5. May M, Wette R, Hardin WB. The use of steroids in Bell’s palsy: a prospective controlled study.
Laryngoscope1976;86:1111-22.
“Just the Berries” for Family Physicians originated at St Martha’s Regional Hospital in 1991 as a newsletter for members of the Department of Family Medicine. Its purpose was to provide use- ful, practical, and current information to busy family physicians. It is now distributed by the Medical Society of Nova Scotia to all family physicians in Nova Scotia. Topics discussed are suggested by family physicians and, in many cases, articles are researched and written by family physicians.
Just the Berries has been available on the Internet for the past 3 years at www.theberries.ns.ca. Visit the site and browse the Archives and Berries of the Week. If you are interested in con- tributing an article, contact us through the site. Articles should be short (350 to 1200 words), must be referenced, and must include levels of evidence and the resources searched for the data. All articles will be peer reviewed before publication.
Just the Berries
Bell’s palsy: Does anything help?
John Hickey,MD
Dr Hickey is a family physician at St Martha’s Regional Hospital in Antigonish, NS, and editor of “Just the Berries” for Family Physicians.
