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Three Part Question

In [children with bell's palsy] does [giving oral steroids] [hasten recovery]

Clinical Scenario

You are a paediatric registrar on call. You have been called to the accident and emergency to see a 6-year-old boy with acute onset of weakness on the left side of the face. You diagnose it to be Bell's palsy. You wonder if there is any evidence to use steroids in this situation

Search Strategy

Cochrane Issue 4 2004 and Pubmed. February 2005.
Cochrane - bell * palsy.
Pubmed - Bell's palsy OR facial palsy AND steroids AND children. Limits – RCT, English, human and child < 18 years

Search Outcome

Cochrane - 3 systematic reviews, 1 relevant (included only one RCT in children). Pubmed - one RCT and one systematic review (included only one RCT in children). Limits excluding RCT – 60 hits, of which only 1 was directly relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Salinas RA et al 2001 Chile	3 RCTs with a total of 117 patients. One trial compared cortisone acetate with placebo; one compared prednosolone plus vitamins, with vitamins alone; and one, not placebo controlled, tested the effect of methylprednisolone	Systematic review (level 1a)	Effect of steroid therapy in the recovery of Bell's palsy	Overall 13/59 (22%) of patients allocated to steroid therapy had incomplete recovery 6 months after randomisation compared with 15/58 (26%) in control group	Only one trial was done exclusively in children (mentioned above, Unuvar et al) Small number of patients.
Salman and MacGregor 2001 Canada	8 RCTs in total. 5 trails comparing steroids with no intervention, 1 trial each comparing steroids with either acyclovir or vitamins, or hyperbaric oxygen.	Systematic review (level 1b)	Clinical and electrical recovery in 6 trials, clinical recovery with electromyography if no recovery in 1 trial, and in the remaining one 3 doctors assessing photos and complication rate.	3 trials found no significant difference with steroids, 4 trials showed some benefit with steroids while 1 trial showed hyperbaric oxygen to be more effective.	Only one trial was done exclusively in children (mentioned above, Unuvar et al) The paediatric cases in the remaining 7 trials were not analysed separately. 5 of the 8 trials were randomised. The trial designs, treatment schedule and outcome measures were heterogeneous.
Unuvar E 1995 Turkey	42 children with complete facial palsy Group 1(n=21) received methyl prednisolone 1mg/kg/day PO for 10 days; Group 2 (n=21) no treatment	RCT (level 1b)	Recovery at 4, 6 and 12 months	Recovery rate: group 1, 86% and 100% at 4 and 6 months and group 2, 72% and 86% at 4 and 6 months. All regained facial nerve function at 12 months	Small numbers Not placebo controlled or blinded
Dhiravibulya K 2002 Thailand	75 children with Bell's palsy, 28 excluded. 39 of the remaining 47 children in the study received oral prednisolone	Retrospective case series Jan 1996 –July 2001 (level 4)	Recovery from Bell's palsy	Of the 39 who received prednisolone, complete recovery in 24(61.5%), nearly complete in 15(38.5%). All children, including those who did not receive steroid, recovered completely within 7 months.	Uncontrolled, retrospective, observational study

Comment(s)

Bell's palsy (acute idiopathic facial nerve palsy) is a non-life threatening disorder with important functional and psychosocial effects (2,3,9). The aetiology of Bell's palsy remains unclear, but many consider it to be a reactivation to viral inflammation rather than ischaemia (1). Diagnosis depends on exclusion of known causes of facial palsy such as hypertension, trauma, tumour, acute otitis media, chronic ear disease, chronic systemic, neurological and metabolic disorders (14,5,11). The natural history of Bell's palsy in children is thought to be benign with a tendency towards complete resolution in many cases within two months of the onset of the facial paralysis and by six months in most cases (2,7,8). However corticosteroids have been widely used in the treatment of Bell's palsy, as it is believed to decrease the inflammation and oedema of the nerve sheath. Although many uncontrolled paediatric studies and case series suggested that steroids are beneficial, especially in cases with complete facial paralysis (4), other studies showed no benefit in the final outcome (6,10). We found only one randomised controlled trial done exclusively in children. This study reported a recovery rate of 80 – 90% in the first six months of the disease, which reached 100% by 12 months irrespective of the use of steroids (14). A recent systematic review found no positive evidence for the beneficial effects of corticosteroids in Bell's palsy (13). Therefore they concluded that the routine use of corticosteroids for the treatment of paediatric Bell's palsy is not recommended. Clearly there is a need for a well-designed, adequately powered, multicentred randomised control trial is needed to evaluate this issue.

Clinical Bottom Line

Currently there is no evidence to recommend the use of corticosteroids for the treatment of Bell's palsy in children.

References

1. Salinas RA, Alvarez G, Alvarez MI, Ferriera J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Most recent amendment 2001. Cochrane Database of Systematic Reviews. 2004;Issue 3. Art. No.: CD001942.pub2. DOI: 10.1002/14651858.CD001942.pub2.
2. Salman MS, MacGregor DL. Should children with Bell's palsy be treated with corticosteroids? A systematic review. Journal of child neurology 2001;16(7):565-568.
3. Unuvar E, Oguz F, Sidal M, Kilic A. Corticosteroid treatment of childhood Bell's palsy. Pediatric neurology 1999;21(5):814-816.
4. Dhiravibulya K. Outcome of Bell's palsy in Children. J Med Assoc Thai 2002;85(3): 334-339.
5. Marenda SA, Olsson JE. The evaluation of facial paralysis. Otolaryngol Clin North Am 1997;30(5):669-82.
6. Hughes GB. Practical management of Bell's palsy. Otolaryngol Head Neck Surg 1990;102(6):658-63.
7. Micheli R, Telesca C, Gitti F, Giordano L, Perini I. Bell's palsy: Diagnostic and therapeutic trial in childhood. Minerva Pediatr 1996;48(6):245-50.
8. Adour KK, Byl FM, Hilsinger RL, et al. The true nature of Bell's palsy: Analysis of 1000 consecutive patients. Laryngoscope 1978; 88(5):787-801.
9. Devriese PP, Schumacher T, Scheide A, DeJongh RH, Houtkooper JM. Incidence, prognosis and recovery of Bell's palsy. A survey of about 1000 patients (1974 – 1983). Clin Otolaryngol 1990;15(1):15-27.
10. Williamson IG, Whelan TR. The clinical problem of Bell's palsy: Is treatment with steroids effective? Br J Gen Pract 1996;46(413):743-7.
11. May M, Fria TJ, Blumenthal F, Curtin H. Facial paralysis in children: Differential diagnosis. Otolaryngol Head Neck Surg 1981;89(5):841-848.
12. Peitersen E. The natural history of Bell's palsy. Am J Otol 1982;4(2):107-111.
13. Devriese PP. Bell's palsy in children. Acta Otorhinolaryngol Belg 1984;38(3):261-267.
14. Inamura H, Aoyagi M, Tojima H, et al. Facial nerve palsy in children: Clinical aspects of diagnosis and treatment. Acta Otolaryngol (stockh) 1994;suppl 511:150-152.
15. Prescott CA. Idiopathic facial nerve palsy in children and the effect of treatment with steroids. Int J Pediatr Otolaryngol 1987;13(3):257-264.