SGEM #14: You Can Ring My Bell (Steroids and Antivirals for Bell’s Palsy)

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Date: December 9, 2012
Title: You Can Ring My Bell (Steroids and Antivirals for Bell’s Palsy)

Guest: Dr. Tony Seupal

Question: Steroids Y/N, Antivirals Y/N or both?

Case Scenario: 35yo healthy awakes with unilateral facial droop. Triage nurse brings promptly this case to your attention for query CVA.Bell’s Palsy:  Here is the Wikipedia entry for Bell’s Palsy. It is a reasonable primer to get everyone on the same page to discuss today’s podcast.

“Bell’s palsy is a form of facial paralysis resulting from a dysfunction of the cranial nerve VII (the facial nerve) that results in the inability to control facial muscles on the affected side. Named after Scottish anatomist Charles Bell, who first described it, Bell’s palsy is the most common acute mononeuropathy and is the most common cause of acute facial nerve paralysis. Bell’s palsy is defined as an idiopathic unilateral facial nerve paralysis, usually self-limiting. The hallmark of this condition is a rapid onset of partial or complete paralysis that often occurs overnight. In rare cases (<1%), it can occur bilaterally resulting in total facial paralysis. It is thought that an inflammatory condition leads to swelling of the facial nerve. The nerve travels through the skull in a narrow bone canal beneath the ear. Nerve swelling and compression in the narrow bone canal are thought to lead to nerve inhibition, damage or death. No readily identifiable cause for Bell’s palsy has been found.”

Washington University: They have the BEST EM journal club. WashU covered the issue of Bell’s Palsy in September 2010. It is an excellent review of the topic.

• Populations: 1569 adults in eight trials.
• Intervention: Steroids
• Control: No steroids
• Outcome: Primary outcome was incomplete recovery of facial motor function six months or more after randomisation. Secondary outcome was cosmetically disabling persistent sequelae six months or more after randomisation.

Results: Primary outcome of incomplete recovery was 23% in patients receiving steroids vs. 33% in patients not receiving steroids. Risk ratio (RR) 0.71, 95% confidence interval (CI) 0.61 to 0.83). Therefore the NNT was 10. A significant reduction in motor synkinesis during follow-up in those receiving corticosteroids was also observed (RR 0.6, 95% CI 0.44 to 0.81).

Secondary outcome in the reduction of cosmetically disabling sequelae at six months showed NO difference (RR 0.97, 95% CI 0.44 to 2.15)

Authors Conclusions: “The available evidence from randomised controlled trials shows significant benefit from treating Bell’s palsy with corticosteroids.”

EBM Comments: “Relative risk or risk ratio (they mean the same thing and are both abbreviated as RR) is simply the risk of the event in one group divided by the risk of the event in the other group. The most common way to go about calculating the risk ratio (and nearly all other statistics from dichotomous data) is to start by presenting your results in a 2×2 table, where each cell in the table contains the number of participants in each category. Now, if you think through what you are comparing (risk in the treated group with risk in the control group), the risk ratio is easy to calculate.If an experimental intervention has an identical effect to the control, the risk ratio will be 1. If it reduces the chance of having the event, the risk ratio will be less than 1; if it increases the chance of having the event, the risk ratio will be bigger than 1. The smallest value the risk ratio can take is zero when there are no events in the treated group.” See Example Below:

BEEM Bottom Line: Steroids for Bell’s Palsy – YES.

You don’t need to email me about Hans and Franz from Saturday Night Live. We do realize that they were talking about anabolic steroids in the skit while we are referring to catabolic steroids in the treatment of Bell’s Palsy like prednisone. The “pump you up” quote was just to emphasize the need for steroids in the treatment of this idiopathic facial paralysis.

 

One last thing. David Newman has a great site which looks at the literature. TheNNT He has covered the use of steroids for the treatment of Bell’s Palsy. If you have not checked out www.thennt.com we highly suggest you take a look.

Reference: Antiviral treatment for Bell’s palsy (idiopathic facial paralysis). Lockhart et al. Cochrane 2009

• Populations: 1987 adults in seven trials.
• Intervention: Antivirals with or without corticosteroids
• Control: No antivirals
• Outcome: Primary outcome was incomplete recovery of facial function at the end of study measured using a validated rating scale.  Secondary outcomes were motor synkinesis or crocodile tears at the end of the study, complete facial paralysis at the end of the study and adverse events.

Results: Primary outcome of incomplete recovery showed NO difference. Secondary outcome of motor synkinesis or crocodile tears at one year also showed NO difference. In addition, there was NO significant difference in rates of adverse events.

Authors Conclusions: “High quality evidence showed no significant benefit from anti-herpes simplex antivirals compared with placebo in producing complete recovery from Bell’s palsy. Moderate quality evidence showed that antivirals were significantly less likely than corticosteroids to produce complete recovery.”

EBM Comment: The power of the meta-analysis was shown in these two Cochrane reviews. Some of these advantages and disadvantages of meta-analysis can be found in the paper by Nordmann et al. 

BEEM Bottom Line: Antivirals for the treatment of Bell’s Palsy – NO

– But if the diagnosis is Ramsay Hunt Syndrome the treatment does include antivirals –

Case Resolution: 35yo woman was given a 10day course of oral steroid. She was advised on how to protect her eye from corneal damage. Appropriate follow-up was arranged with her primary care physician or neurologist. Like most individuals she was expected to have complete recovery.

KEENER KONTEST: Last weeks winner was Sarah Scott from Ottawa. She correctly defined oligoanalgesia as inadequate pain control in the emergency department. This weeks question ironically has a Canadian connection.

Name the Canadian Prime Minister who suffered from Bell’s Palsy and was one of the few patients that did not have a full recovery? For the American SGEM listeners, name the Star Trek character who can help you remember if the forehead is involved?

For all the American listeners who did not realize we had a Prime Minister and not a President I suggest you check out this YouTube video called “I am Canadian”. If you want the runner up prize for the Keener Kontest then name the Star Trek character that helps me recognized that Bell’s Palsy prevents patients from lifting up their brown on the effected side.

Email your answer to TheSGEM@gmail.com or go to the “Contact Us” link at the top of the home page. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)