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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 paralysis.mp OR bells palsy.mp} 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, 1976, USA	51 patients Prednisolone vs control	PRCT	Visual assessment of motor recovery	No difference	Small study
			Autonomic dysfunction	No difference
			Time of recovery	No difference
Wolf SM et al, 1978, USA	239 patients Prednisolone (60 mg) vs control	PRCT	Electromyography	No difference	Not 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 dysfunction	Prednisolone is beneficial in preventing autonomic synkinesis
			Time to recovery	No difference
Austin JR et al, 1993, USA	107 patients Prednisolone (60 mg) vs control	PRCT	Functional nerve testing	Significant improvement in facial nerve function.	Small study 29% lost to follow up after randomisation.
			Time to recovery	No difference in recovery time
			Electromyography	No difference in denervation
Shafshak TS et al, 1994, Egypt	160 patients with complete facial palsy Prednisolone (1 mg/kg) vs control	Clinical trial	Facial nerve excitability	Significantly better recovery with steroids, especially if given <24hrs after onset	Non randomised Non blinded Controls were those that refused steroids or had a contraindication

Comment(s)

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.

References

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.