“Combined Corticosteroid and Antiviral Treatment for Bell Palsy A Systematic Review and Meta-analysis”

Background/Study Question

This article aimed to answer the question: Do steroids PLUS antivirals offer reduced risk of unsatisfactory facial recovery in patients with Bells Palsy?

A little background about Bell’s Palsy; it is a cranial nerve 7 palsy thought to be viral in etiology in most cases. The lifetime risk of Bell’s Palsy is approximately 1 in 60, so this is an extremely relevant article regarding a treatment for a condition we are likely to encounter multiple times throughout our ED careers. When diagnosing Bell’s Palsy it is important to consider other causes of facial paralysis (i.e. stroke) but ultimately your physical exam should clue you in the on diagnosis (i.e forehead involvement = Bell’s; forehead NOT involved = CVA/TIA).  

Design:

This was a systematic review and meta-analysis where the researches searched certain key words inputted in certain electronic databases and ultimately selected 18 trials, 8 of which evaluated steroids, 7 evaluated antivirals, and 3 evaluated steroids and antivirals. This study involved a total of 2786 patients. The measured outcomes were: 1) unsatisfactory facial recovery (>/= 4 months), 2) unsatisfactory short-term recovery (6 weeks to <4 months), 3) synkinesis and autonomic dysfunction, and 4) adverse effects.

Results:

This is where we really dive in. Based on prior studies, we know that steroids are beneficial in Bell’s Palsy. This study also confirms this. This study also confirms that antivirals on their own (without steroids) do not provide benefit. This study also FAILED to provide clear cut, statistically significant, benefit of steroids PLUS antivirals. Meaning, steroids plus antivirals are no better than steroids on their own.

Discussion:

Although this study is slightly dated (published in 2009) and there have been more studies on this topic, this study taken alone doesn’t prove that there is any benefit of steroids PLUS antivirals. It shows maybe slight benefit, but the results were not statistically significant. Current practice recommendations promote the use of a severity scale such as the House-Brackmann scale and if severe enough (i.e. >4 score) to prescribe combination of steroids PLUS antivirals if possibly provides benefit and antivirals are relatively low risk. Another consideration this study brought up was the cost associated with a week of both steroids and antivirals, and while prices have decreased since publication of this article this is something to take into consideration. A week worth of Prednisone 60mg comes out to $6-10 and a week of valacyclovir 1g three times daily is ~$18-73 in Chicago and without insurance.

Citation:

de Almeida JR, Al Khabori M, Guyatt GH, et al. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA. 2009;302(9):985‐993. doi:10.1001/jama.2009.1243

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