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The Cochrane Database of Systematic... Sep 2019Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is...
BACKGROUND
Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. This review was first published in 2001 and most recently updated in 2015. Since a significant benefit of corticosteroids for the early management of Bell's palsy has been demonstrated, the main focus of this update, as in the previous version, was to determine the effect of adding antivirals to corticosteroid treatment. We undertook this update to integrate additional evidence and to better assess the robustness of findings, taking risk of bias fully into account.
OBJECTIVES
To assess the effects of antiviral treatments alone or in combination with any other therapy for Bell's palsy.
SEARCH METHODS
We searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS in July 2019. We reviewed the bibliographies of the identified trials and contacted trial authors to identify additional published or unpublished data. We searched clinical trials registries for ongoing studies.
SELECTION CRITERIA
We considered randomised controlled trials (RCTs) or quasi-RCTs of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy. We excluded trials that followed-up participants for less than three months.
DATA COLLECTION AND ANALYSIS
We independently assessed trials for relevance, eligibility, and risk of bias, using standard Cochrane procedures. We performed sensitivity analyses excluding trials at high or unclear risk of bias in at least five domains, and reported these data as the primary analyses.
MAIN RESULTS
Fourteen trials, including 2488 participants, met the inclusion criteria. Most were small, and most were at high or unclear risk of bias in multiple domains. We included four new studies at this update.Incomplete recoveryA combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in people with Bell's palsy compared to corticosteroids alone (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.38 to 1.74; 3 trials, N = 766; random-effects; low-certainty evidence). We excluded 10 trials that were at high or unclear risk of bias in several domains from this analysis and limited all analyses to studies at lower risk of bias. Recovery rates were better in participants receiving corticosteroids alone than antivirals alone (RR 2.69, 95% CI 0.73 to 10.01; 2 trials, N = 667; random-effects), but the result was imprecise and allowed for the possibility of no effect. The rate of incomplete recovery was lower with antivirals plus corticosteroids than with placebo or no treatment (RR 0.56, 95% CI 0.42 to 0.76; 2 trials, N = 658; random-effects). Antivirals alone had no clear effect on incomplete recovery rates compared with placebo, but the result was imprecise (RR 1.10, 95% CI 0.87 to 1.40; 2 trials, N = 658; fixed-effect). For people with severe Bell's palsy (House-Brackmann score of 5 and 6, or equivalent on other scales), we found that the combination of antivirals and corticosteroids had no clear effect on incomplete recovery at month six compared to corticosteroids alone, although the result was again imprecise (RR 0.82, 95% CI 0.57 to 1.17; 2 trials, N = 98; random-effects).Motor synkinesis or crocodile tearsAntivirals plus corticosteroids reduced the proportion of participants who experienced these long-term sequelae from Bell's palsy compared to placebo plus corticosteroids (RR 0.56, 95% CI 0.36 to 0.87; 2 trials, N = 469; fixed-effect; moderate-certainty evidence). Antivirals plus corticosteroids reduced long-term sequelae compared to placebo but there was no clear difference in this outcome with antivirals alone compared to placebo.Adverse events Adverse event data were available in four studies providing data on 1592 participants. None of the four comparisons showed clear differences in adverse events between treatment and comparison arms (very low-certainty evidence); for the comparison of antivirals plus corticosteroids and corticosteroids alone in studies at lower risk of bias, the RR was 1.17 (95% CI 0.81 to 1.69; 2 trials, N = 656; fixed-effect; very low-certainty evidence).
AUTHORS' CONCLUSIONS
The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in comparison to corticosteroids alone in Bell's palsy of various degrees of severity, or in people with severe Bell's palsy, but the results were very imprecise. Corticosteroids alone were probably more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no clear benefit from antivirals alone over placebo.The combination of antivirals and corticosteroids probably reduced the late sequelae of Bell's palsy compared with corticosteroids alone. Studies also showed fewer episodes of long-term sequelae in corticosteroid-treated participants than antiviral-treated participants.We found no clear difference in adverse events from the use of antivirals compared with either placebo or corticosteroids, but the evidence is too uncertain for us to draw conclusions.An adequately powered RCT in people with Bell's palsy that compares different antiviral agents may be indicated.
Topics: Anti-Inflammatory Agents; Antiviral Agents; Bell Palsy; Drug Therapy, Combination; Humans; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 31486071
DOI: 10.1002/14651858.CD001869.pub9 -
Toxins Feb 2021Unilateral peripheral facial nerve palsy jeopardizes quality of life, rendering psychological consequences such as low self-esteem, social isolation, anxiety, and... (Review)
Review
Unilateral peripheral facial nerve palsy jeopardizes quality of life, rendering psychological consequences such as low self-esteem, social isolation, anxiety, and depression. Among therapeutical approaches, use of Botulinum toxin type A (BoNT-A) on the nonparalyzed side has shown promising results and improvement of quality of life. Nevertheless, the correct technique is paramount, since over-injection of the muscles can result in lack of function, leading to a "paralyzed" appearance, and even worse, functional incompetence, which may cause greater distress to patients. Therefore, the objective of this article is to provide a practical guideline for botulinum toxin use in facial palsy. To this aim, adequate patient assessment, BoNT-A choice, injection plan and dosage, and injection techniques are covered.
Topics: Acetylcholine Release Inhibitors; Adult; Bell Palsy; Botulinum Toxins, Type A; Facial Muscles; Facial Paralysis; Female; Humans; Injections, Intramuscular; Quality of Life; Treatment Outcome
PubMed: 33670477
DOI: 10.3390/toxins13020159 -
BMJ Clinical Evidence Mar 2011Bell's palsy is characterised by an acute, unilateral, partial, or complete paralysis of the face (i.e., lower motor neurone pattern). The weakness may be partial... (Review)
Review
INTRODUCTION
Bell's palsy is characterised by an acute, unilateral, partial, or complete paralysis of the face (i.e., lower motor neurone pattern). The weakness may be partial (paresis) or complete (paralysis), and may be associated with mild pain, numbness, increased sensitivity to sound, and altered taste. Bell's palsy remains idiopathic, but a proportion of cases may be caused by reactivation of herpes viruses from the geniculate ganglion of the facial nerve. Bell's palsy is most common in people aged 15 to 40 years, with a 1 in 60 lifetime risk. Most make a spontaneous recovery within 1 month, but up to 30% show delayed or incomplete recovery.
METHODS AND OUTCOMES
We conducted a systematic review to answer the following clinical question: What are the effects of treatments in adults and children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically. Please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 14 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiviral treatment, corticosteroids (alone or plus antiviral treatment), hyperbaric oxygen therapy, facial nerve decompression surgery, and facial retraining.
Topics: Administration, Oral; Adrenal Cortex Hormones; Antiviral Agents; Bell Palsy; Drug Therapy, Combination; Facial Nerve; Facial Paralysis; Humans; Incidence
PubMed: 21375786
DOI: No ID Found -
Autoimmunity Reviews Dec 2012To review our current knowledge of the etiopathogenesis of Bell's palsy, including viral infection or autoimmunity, and to discuss disease pathogenesis with respect to... (Review)
Review
OBJECTIVES
To review our current knowledge of the etiopathogenesis of Bell's palsy, including viral infection or autoimmunity, and to discuss disease pathogenesis with respect to pharmacotherapy.
SYSTEMATIC REVIEW METHODOLOGY
Relevant publications on the etiopathogenesis, clinical presentation, diagnosis and histopathology of Bell's palsy from 1975 to 2012 were analysed.
RESULTS AND CONCLUSIONS
Bell's palsy is an idiopathic peripheral nerve palsy involving the facial nerve. It accounts for 60 to 75% of all cases of unilateral facial paralysis. The annual incidence of Bell's palsy is 15 to 30 per 100,000 people. The peak incidence occurs between the second and fourth decades (15 to 45 years). The aetiology of Bell's palsy is unknown but viral infection or autoimmune disease has been postulated as possible pathomechanisms. Bell's palsy may be caused when latent herpes viruses (herpes simplex, herpes zoster) are reactivated from cranial nerve ganglia. A cell-mediated autoimmune mechanism against a myelin basic protein has been suggested for the pathogenesis of Bell's palsy. Bell's palsy may be an autoimmune demyelinating cranial neuritis, and in most cases, it is a mononeuritic variant of Guillain-Barré syndrome, a neurologic disorder with recognised cell-mediated immunity against peripheral nerve myelin antigens. In Bell's palsy and GBS, a viral infection or the reactivation of a latent virus may provoke an autoimmune reaction against peripheral nerve myelin components, leading to the demyelination of cranial nerves, especially the facial nerve. Given the safety profile of acyclovir, valacyclovir, and short-course oral corticosteroids, patients who present within three days of the onset of symptoms should be offered combination therapy. However it seems logical that in fact, steroids exert their beneficial effect via immunosuppressive action, as is the case in some other autoimmune disorders. It is to be hoped that (monoclonal) antibodies and/or T-cell immunotherapy might provide more specific treatment guidelines in the management of Bell's palsy.
Topics: Autoimmunity; Bell Palsy; Humans
PubMed: 22684016
DOI: 10.1016/j.autrev.2012.05.008 -
Handbook of Clinical Neurology 2020Many neuromuscular disorders preexist or occur during pregnancy. In some cases, pregnancy unmasks a latent hereditary disorder. Most available information is based on... (Review)
Review
Many neuromuscular disorders preexist or occur during pregnancy. In some cases, pregnancy unmasks a latent hereditary disorder. Most available information is based on case reports or series or retrospective clinical experience or patient surveys. Of special interest are pregnancy-induced changes in disease course or severity and likelihood for baseline recovery of function postpartum. Labor and delivery present special challenges in many conditions that affect skeletal but not smooth (uterine) muscle; so labor complications must be anticipated. Anesthesia for cesarean section surgery requires special precautions in many disorders. The types of conditions reviewed are broad and include examples of autoimmune, hereditary, and compressive/mechanical processes. Disorders include carpal tunnel syndrome and other focal neuropathies, Bell palsy, myasthenia gravis, and other neuromuscular junction disorders, acute and chronic inflammatory neuropathy, hereditary and acquired muscle diseases, spinal muscular atrophy, amyotrophic lateral sclerosis, channelopathies, autonomic neuropathy, and dysautonomia. Many commonly used therapies have fetal animal but no proven human toxicity concerns, complicating treatment and risk decisions. Weaning off effective therapeutic agents or preemptive aggressive treatment or surgery prior to planned pregnancy is an option in some conditions.
Topics: Animals; Cesarean Section; Female; Humans; Muscular Diseases; Myasthenia Gravis; Neuromuscular Diseases; Pregnancy; Pregnancy Complications; Retrospective Studies
PubMed: 32768089
DOI: 10.1016/B978-0-444-64240-0.00012-X -
BMJ Clinical Evidence Jan 2008Bell's palsy is characterised by an acute, unilateral, partial or complete paralysis of the face, which may occur with mild pain, numbness, increased sensitivity to... (Review)
Review
INTRODUCTION
Bell's palsy is characterised by an acute, unilateral, partial or complete paralysis of the face, which may occur with mild pain, numbness, increased sensitivity to sound, and altered taste. Bell's palsy remains idiopathic, but a proportion may be caused by reactivation of herpes viruses from cranial nerve ganglia. Bell's palsy is most common in people aged 15-40 years, affecting 1 in 60 in their lifetime. Most make a spontaneous recovery within 1 month, but up to 30% have delayed or incomplete recovery.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments in adults and children? We searched: Medline, Embase, The Cochrane Library and other important databases up to February 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found eight systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiviral treatment, corticosteroids (alone or plus antiviral treatment), facial nerve decompression surgery, and mime therapy.
Topics: Administration, Oral; Adrenal Cortex Hormones; Antiviral Agents; Bell Palsy; Facial Nerve; Facial Paralysis; Humans; Treatment Outcome
PubMed: 19450338
DOI: No ID Found -
The Lancet. Infectious Diseases Apr 2021
Topics: Bell Palsy; COVID-19; COVID-19 Vaccines; Humans; Influenza Vaccines; SARS-CoV-2; United States; United States Food and Drug Administration
PubMed: 33639103
DOI: 10.1016/S1473-3099(21)00076-1 -
Medicina (Kaunas, Lithuania) Mar 2021Non-motor symptoms in the form of increased sensitivity are often associated with the onset of idiopathic Bell's palsy (IBP). The aims were to determine whether the...
Non-motor symptoms in the form of increased sensitivity are often associated with the onset of idiopathic Bell's palsy (IBP). The aims were to determine whether the pain threshold in the retroauricular regions (RAR) in IBP patients and the time of its occurrence is related to IBP severity. The study was conducted among 220 respondents (142 IBP patients, 78 healthy subjects (HS)). The degree of IBP was graded using the House-Brackmann and Sunnybrook Grading Scales (II-mild dysfunction, VI-total paralysis), whereas the pain thresholds were measured using the digital pressure algometer. We found no difference in the degree of the pain threshold between the right and left RAR in the HS group. IBP patients belonging to groups II, III, IV, and V had lower pain thresholds in both RARs than HS and IBP patients belonging to group VI. There was no difference in the degree of pain threshold in RAR between the affected and unaffected side in IBP patients. The incidence of retroauricular pain that precedes paralysis and ceases after its occurrence in groups II and III of IBP patients is noticeably lower and the incidence of retroauricular pain that occurred only after the onset of paralysis is more frequent. Also, we found that the incidence of retroauricular pain that precedes paralysis and ceases after its occurrence in groups V and VI of IBP patients was more frequent. The degree of pain threshold lowering in RAR (bilaterally) is inversely related to the severity of IBP. We suggest that the occurrence of retroauricular pain before the onset of facial weakness is associated with higher severity of IBP while the occurrence after the onset is associated with lower severity of IBP.
Topics: Bell Palsy; Facial Paralysis; Humans; Incidence; Pain Threshold
PubMed: 33805591
DOI: 10.3390/medicina57030263