GENERAL MEDICINE/SYSTEMATIC REVIEW SNAPSHOT
TAKE-HOME MESSAGE
Antivirals, combined with corticosteroids, reduce the risk of incomplete recovery
of Bells palsy more than corticosteroids alone.
METHODS
DATA SOURCES
The Cochrane Neuromuscular
Disease Group Specialized
Register, CENTRAL, MEDLINE,
EMBASE, Latin American and
Caribbean Health Sciences
Literature, Database of Abstracts
and Reviews of Effects, National
Health Service Economic
Evaluation Database, and Health
Technology Assessment were
searched through October 2014.
To ensure the inclusion of all
sources, the authors examined
bibliographies of searched studies
and contacted trial authors, experts
in the eld, and drug companies.
STUDY SELECTION
Randomized controlled trials or
quasi-randomized controlled trials
comparing antivirals alone or in
combination with corticosteroids
versus control therapies
(corticosteroids alone, placebo, or
no treatment) were included,
although some of the trials were
small and incompletely blinded.
Trials with high risk for bias were
excluded. The primary outcome
was incomplete recovery of facial
nerve function. Secondary
outcomes included motor
synkinesis, crocodile tears, and
adverse events (which were not
specied).
DATA EXTRACTION AND
SYNTHESIS
At least 2 authors independently
reviewed studies for relevance,
Volume -, no. - : - 2016
Do Antiviral Medications Improve Symptoms
in the Treatment of Bells Palsy?
EBEM Commentators
Jeremy M. Hernandez, MD, PhD
Jonathan Sherbino, MD, MEd
Division of Emergency Medicine
McMaster University
Hamilton, Ontario, Canada
Results
Combined antiviral and corticosteroid treatment compared with corticosteroid plus
placebo or no treatment for Bells palsy.
Number of Studies
Outcomes
Incomplete functional recovery
Motor synkinesis or crocodile tears
Adverse events
CI, Condence interval; RR, risk ratio.
Ten trials were included in the
nal analysis (N2,280). There
was improvement in the recovery
of facial function when combina-
tion therapy (antivirals plus corti-
costeroids) was used compared
with corticosteroids alone or no
treatment. Moreover, there was a
reduction in long-term sequelae of
Bells palsy, such as motor synki-
nesis and crocodile tears, when
patients were treated with the
combination of antivirals and cor-
ticosteroids. There was no differ-
ence in adverse events between
any of the treatment groups
(Table).
Of the 10 trials, only 3 were of
lower risk of bias. The quality of
evidence was either low or low to
moderate for both the primary and
secondary outcomes.
Effect Size,
(Participants) RR (95% CI) I2, %
8 (1,315) 0.61 (0.390.97) 47
2 (469) 0.56 (0.360.87) 0
3 (877) 1.18 (0.831.69) 0
Commentary
Bells palsy is an idiopathic, acute,
unilateral paralysis or weakness of
facial musculature stemming from
peripheral facial nerve (cranial
nerve VII) dysfunction. Up to 30% of
patients with Bells palsy never fully
recover facial function. Recent
studies have suggested an annual
incidence of Bells palsy up to 37 per
100,000 people per year.1,2
Corticosteroids are widely used in
the treatment of Bells palsy.3,4
However, the effectiveness of
combining an antiviral with a
corticosteroid continues to be
debated. This Cochrane review
was rst published in 2001 and
revised in 2009. In the latter
version, only 2 randomized
controlled trials were included and
suggested that antivirals did not
Annals of Emergency Medicine 1
Systematic Review Snapshot
inclusion, and risk of bias. When
appropriate, data were pooled with
a xed-effect model. A sensitivity
analysis using a random-effect
model was performed when there
was signicant unexplained
statistical heterogeneity. The
Grades of Recommendation,
Assessment, Development and
Evaluation working group
methodology was used to assess
the quality of evidence.
signicantly improve functional
recovery compared with placebo.5
The current review updates these
ndings with the inclusion of 10
randomized controlled trials. An
11th randomized controlled trial6
was initially included in the
Cochrane review published
7
earlier ; however, the trial by
Abdelghany et al6 is currently
being investigated to determine
the reliability of the reported data.
As a result, the previous version of
the 2015 Cochrane review was
withdrawn and the current version
was republished, excluding the
trial by Abdelghany et al.6
Unfortunately, the quality of
evidence included in the current
review remains mainly low to
moderate.
Clinical guidelines published by
the Canadian Medical Association
and the American Association of
2 Annals of Emergency Medicine
OtolaryngologyHead and Neck
Surgery suggest that a combina-
tion of antivirals and corticoste-
roids may provide benet in the
treatment of Bells palsy while
tempering the suggestion by once
again indicating that the quality of
evidence remains weak to
moderate.3,4
In the current Cochrane review,
the antivirals used included
acyclovir, valacyclovir, and famci-
clovir. A sensitivity analysis
revealed a larger magnitude of ef-
fect when trials using acyclovir
were excluded (risk ratio 0.65;
95% condence interval 0.36 to
1.16), which is consistent with a
recent study by Kim et al8 that
suggested famciclovir improves
facial nerve recovery compared
with acyclovir in patients with
severe Bells palsy. Caution
should be taken when
prescribing antivirals to patients
with renal failure because
creatinine clearance will affect
the dosing regimen. Last, in
practice, given the prolonged
morbidity associated with Bells
palsy, it is important to provide
an adequate follow-up plan and
proper eye care, and inform pa-
tients that symptoms may take
weeks to months to resolve.
Editors Note: This is a clinical
synopsis, a regular feature of the
Annals Systematic Review Snapshot
(SRS) series. The source for this
systematic review snapshot is:
Gagyor I, Madhok VB, Daly F, et al.
Antiviral treatment for Bells palsy
(idiopathic facial paralysis).
Cochrane Database Syst Rev.
2015;(11):CD001869. http://dx.
doi.org/10.1002/14651858.
CD001869.pub8. (Assessed as
up-to-date: October 7, 2014.)
1. Martyn CN, Hughes RA. Epidemiology of
peripheral neuropathy. J Neurol Neurosurg
Psychiatry. 1997;62:310-318.
2. Morales DR, Donnan PT, Daly F, et al. Impact
of clinical trial ndings on Bells palsy
management in general practice in the UK
2001-2012: interrupted time series
regression analysis. BMJ Open. 2013;3:
e003121.
3. Baugh RF, Basura GJ, Ishii LE, et al. Clinical
practice guideline: Bells palsy. Otolaryngol
Head Neck Surg. 2013;149(3 suppl):S1-27.
4. de Almeida JR, Guyatt GH, Sud S, et al.
Management of Bell palsy: clinical practice
guideline. CMAJ. 2014;186:917-922.
5. Lockhart P, Daly F, Pitkethly M, et al. Antiviral
treatment for Bells palsy (idiopathic facial
paralysis). Cochrane Database Syst Rev.
2009;(4):CD001869.
6. Abdelghany AM, Kamel SB. The effect of
prednisolone and/or acyclovir in relation to
severity of Bells palsy at presentation.
Egyptian J Ear Nose Throat Allied Sci.
2013;14:155-159.
7. Gagyor I, Madhok VB, Daly F, et al.
Withdrawn: antiviral treatment for Bells
palsy (idiopathic facial paralysis). Cochrane
Database Syst Rev. 2015;(9):CD001869.
8. Kim HJ, Kim SH, Jung J, et al. Comparison of
acyclovir and famciclovir for the treatment of
Bells palsy. Eur Arch Otorhinolaryngol;
2016.
Michael Brown, MD, MSc, and
Alan Jones, MD, serve as editors
of the SRS series.
Volume -, no. - : - 2016