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Steroids only indicated for Bell's palsy with complete paralysis

Three Part Question

In [an adult with Bell's palsy] would [ early steroid therapy] improve [time to recovery and outcome]?

Clinical Scenario

A 35 year old man presents to the emergency department with a 1 day history of a right sided facial weakness. Examination reveals a complete right facial nerve palsy, without any evidence of herpes zoster, middle ear disease, trauma or further neurology. A diagnosis of idiopathic (Bell's) facial nerve palsy is made. You wonder whether early high dose steroids would improve his prognosis or speed of recovery.

Search Strategy

Medline 1966-07/99 using the OVID interface.
({exp facial paralysis OR facial OR bells} AND {exp steroids OR steroid$.mp} AND (maximally sensitive RCT filter) LIMIT to human AND english.

Search Outcome

72 papers found of which 65 irrelevant and 3 of insufficient quality for inclusion. The remaining 4 papers are shown in the table.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
May M et al,
51 patients Prednisolone vs controlPRCTVisual assessment of motor recoveryNo differenceSmall study
Autonomic dysfunctionNo difference
Time of recoveryNo difference
Wolf SM et al,
239 patients Prednisolone (60 mg) vs controlPRCTElectromyographyNo differenceNot blinded Control group not treated with placebo Only 30% of patients had complete denervation, and 20% had mild Bells palsy on entry into the trial.
Facial strength,No difference
Autonomic dysfunctionPrednisolone is beneficial in preventing autonomic synkinesis
Time to recoveryNo difference
Austin JR et al,
107 patients Prednisolone (60 mg) vs controlPRCTFunctional nerve testingSignificant improvement in facial nerve function.Small study 29% lost to follow up after randomisation.
Time to recoveryNo difference in recovery time
ElectromyographyNo difference in denervation
Shafshak TS et al,
160 patients with complete facial palsy Prednisolone (1 mg/kg) vs controlClinical trialFacial nerve excitabilitySignificantly better recovery with steroids, especially if given <24hrs after onsetNon randomised Non blinded Controls were those that refused steroids or had a contraindication


No studies have demonstrated a benefit in commencing steroids in those with incomplete facial paralysis as they have a good prognosis. In addition, no studies have demonstrated an improvement in the time to recovery in any patients with Bell's palsy. If any benefit has been demonstrated, then it is in those with a complete facial paralysis with steroids being started early. There are significant criticisms with all the studies conducted so far, and a large prospective randomised controlled trial demonstrating a clear benefit has yet to be conducted.

Clinical Bottom Line

Current evidence does not support the early use of high dose steroids in idiopathic incomplete facial nerve palsy. In patients with complete paralysis early steroids may be of benefit.


  1. May M, Wette R, Hardin WB Jr et al. The use of steroids in Bells Palsy: a prospective controlled study. Laryngoscope 1976;86:1111-22.
  2. Wolf SM, Wagner JH, Davidson S et al. Treatment of Bell Palsy with prednisolone: a prospective, randomized study. Neurology 1978;28:158-61.
  3. Austin JR, Peskind SP, Austin SG et al. Idiopathic facial nerve paralysis: a randomized double blind controlled study of placebo versus prednisolone. Laryngoscope 1993;103:1326-33.
  4. Shafshak TS, Essa AY, Bakey FA. The possible contributing factors for the success of steroid therapy in Bells palsy: a clinical and electrophysiological study. J Laryngol Otol 1994;108:940-3.