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Antiviral treatment for Bell's palsy (idiopathic facial paralysis)

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Abstract

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Background

Antiviral agents against herpes simplex virus are widely used in the treatment of idiopathic facial paralysis (Bell’s palsy), but their effectiveness is uncertain. Significant morbidity can be associated with severe cases.

Objectives

This review addresses the effect of antiviral therapy on Bell’s palsy.

Search methods

We updated the search of the Cochrane Neuromuscular Disease Group Trials Register (December 2008), MEDLINE (from January 1966 to December 8 2008), EMBASE (from January 1980 to December 8 2008) and LILACS (from January 1982 to December 2008).

Selection criteria

Randomized trials of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy.

Data collection and analysis

Twenty‐three papers were selected for consideration.

Main results

Seven trials including 1987 participants met the inclusion criteria, adding five studies to the two in the previous review.

Incomplete recovery at one year. There was no significant benefit in the rate of incomplete recovery from antivirals compared with placebo (n = 1886, RR 0.88, 95% CI 0.65 to 1.18). In meta‐analyses with some unexplained heterogeneity, the outcome with antivirals was significantly worse than with corticosteroids (n = 768, RR 2.82, 95% CI 1.09 to 7.32) and the outcome with antivirals plus corticosteroids was significantly better than with placebo (n = 658, RR 0.56, 95% CI 0.41 to 0.76).

Motor synkinesis or crocodile tears at one year. In single trials, there was no significant difference in long term sequelae comparing antivirals and corticosteroids with corticosteroids alone (n = 99, RR 0.39, 95% CI 0.14 to 1.07) or antivirals with corticosteroids (n = 101, RR 1.03, 95% CI 0.51 to 2.07).

Adverse events.There was no significant difference in rates of adverse events between antivirals and placebo (n = 1544, RR 1.06, 95% CI 0.81 to 1.38), between antivirals and corticosteroids (n = 667, RR 0.96, 95% CI 0.65 to 1.41) or between the antiviral‐corticosteroid combination and placebo (n = 658, RR 1.15, 95% CI 0.79 to 1.66).

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.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

Antiviral treatment for Bell's palsy

Bell's palsy is a disease of the facial nerve which causes one side of the face to be paralysed. Some studies have suggested that it is caused by infection with the cold sore (herpes simplex) virus. If this is correct, antiviral drugs against herpes simplex would be likely to help recovery. It has also been suggested that corticosteroids may help. The paralysis is usually temporary even when untreated, although without treatment about one person in five is left with permanent facial disfigurement or pain.

This updated review provided high quality evidence that antivirals are no more effective than placebo (dummy) treatment in producing complete recovery. On the other hand moderate quality evidence showed that antivirals were less effective than corticosteroids and that combined antiviral‐corticosteroid treatment were more effective than placebo. Taken together, these results suggest that corticosteroids might be effective but this requires confirmation from the Cochrane review of corticosteroids which is being updated. There was no evidence that antivirals produced significantly more or significantly fewer adverse events than dummy treatment.

As this analysis shows that antivirals against the cold sore virus are not significantly effective, other causes for Bell's palsy than infection by the cold sore virus now need to be considered.