Steroids beneficial, but antiviral agents are of uncertain value for Bell palsy

Clinical Question: Are both corticosteroids and antiviral agents beneficial for the treatment of Bell palsy?

Bottom Line: Corticosteroids alone are beneficial in the treatment of Bell palsy, but antiviral agents alone are not. The value of combined treatment with corticosteroids and antiviral agents compared with corticosteroids alone remains uncertain. Total corticosteroid treatment doses greater than an equivalent dose of 450 mg of prednisone are superior to lower doses.

Reference: 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.

Study Design: Meta-analysis (randomized controlled trials)

Synopsis: The value of both corticosteroids and antiviral agents in the treatment of Bell palsy remains uncertain. These investigators thoroughly searched multiple databases including MEDLINE, EMBASE, Web of Science, conference proceedings and abstracts, bibliographies of relevant articles, clinical trial registries, and noted experts for randomized controlled trials evaluating either corticosteroids or antiviral agents in the management of Bell palsy. No language restrictions were applied. Two individuals independently critiqued all studies for inclusion criteria and methodologic quality using standard criteria. Differences were resolved by consensus agreement. A total of 18 studies (N = 2786 patients) -- 8 evaluating corticosteroids, 7 evaluating antiviral agents, and 3 evaluating both corticosteroids and antiviral agents -- met all criteria. Follow-up occurred for a median of 6 months. Evidence quality was graded as moderate to high for the individual studies. Corticosteroids alone significantly reduced the risk of unsatisfactory facial recovery (number needed to treat [NNT] = 11; 95% CI, 8-25) and synkinesis and autonomic dysfunction (NNT = 7; 6-10). Higher doses (greater than the equivalent of 450 mg prednisone) produced a significantly greater benefit than lower doses. Antiviral agents alone were not significantly beneficial, but antiviral agents combined with corticosteroids were borderline significantly superior to corticosteroids alone (relative risk = 0.75; 0.56 - 1.00). The authors found no evidence for publication bias or significant heterogeneity in the results.