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CLINICAL QUESTION Compared with oral corticosteroids alone, are oral antiviral drugs
associated with improved outcomes when combined with oral corticosteroids in patients
presenting within 72 hours of the onset of Bell palsy?
BOTTOM LINE Compared with oral corticosteroids alone, the addition of acyclovir,
valacyclovir, or famcyclovir to oral corticosteroids for treatment of Bell palsy
was associated with a higher proportion of people who recovered at 3- to 12-month
follow-up. The quality of evidence is limited by heterogeneity, imprecision of the result
estimates, and risk of bias.
874 JAMA August 23/30, 2016 Volume 316, Number 8 (Reprinted) jama.com
Figure. Antivirals Plus Corticosteroids vs Corticosteroids Plus Placebo or No Treatment for Patients With Bell Palsy
0.1 1.0 10
Risk Ratio (95% CI)
The size of the data markers is proportional to the study’s weight in the meta-analysis.
lower rates of incomplete recovery and long-term sequelae at 3 to ing corticosteroids with antiviral therapy in severe cases.6,7 Data
12 months compared with oral corticosteroids alone. from this review suggest that the combination of oral corticoste-
roids plus antiviral therapies is associated with lower rates of
Limitations incomplete recovery compared with oral corticosteroids alone
The analyses are limited by data heterogeneity, imprecision of the (RR, 0.61; 95% CI, 0.39-0.97). However, the quality of the evi-
study results, and risk of bias. Some of the trials were small; other dence is low.
trials did not meet current best standards in allocation conceal-
ment and blinding. Only 4 studies provided data on severe cases Areas in Need of Further Study
(n = 487). There were no studies that included children. An individual patient meta-analysis that includes an analysis accord-
ing to severity of the Bell palsy and patient subgroups based on age
Comparison of Findings With Current Practice Guidelines may be warranted to identify subgroups of patients, such as chil-
Guidelines from the American Academy of Otolaryngology dren and patients with facial paralysis of varying severity, who may
and the Canadian Society of Otolaryngology recommend using benefit from the addition of antivirals to corticosteroids and those
corticosteroids alone but suggest that clinicians consider combin- who may not.8
ARTICLE INFORMATION Submissions: We encourage authors to submit 5. Fattah AY, Gurusinghe AD, Gavilan J, et al;
Author Affiliations: UTOPIAN FMTU, North York papers for consideration as a JAMA Clinical Sir Charles Bell Society. Facial nerve grading
General Hospital, Toronto, Ontario, Canada Evidence Synopsis. Please contact Dr McDermott at instruments: systematic review of the literature and
(Sullivan); Department of Family and Community mdm608@northwestern.edu. suggestion for uniformity. Plast Reconstr Surg.
Medicine and Dalla Lana School of Public Health, 2015;135(2):569-579.
University of Toronto, Ontario, Canada (Sullivan); REFERENCES 6. Baugh RF, Basura GJ, Ishii LE, et al. Clinical
Scientist Institute for Clinical Evaluative Sciences, 1. De Diego-Sastre JI, Prim-Espada MP, practice guideline: Bell’s palsy. Otolaryngol Head
Toronto, Ontario, Canada (Sullivan); Frontier Fernández-García F. Epidemiología de la parálisis Neck Surg. 2013;149(3)(suppl):S1-S27.
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Department of General Practice, Goettingen 287-290. Working Group, Canadian Society of
University Medical Center, Goettingen, Germany 2. Morales DR, Donnan PT, Daly F, Staa TV, Otolaryngology-Head and Neck Surgery and
(Gagyor). Sullivan FM. Impact of clinical trial findings on Bell’s Canadian Neurological Sciences Federation.
Corresponding Author: Frank Sullivan, FRSE, palsy management in general practice in the UK Management of Bell palsy: clinical practice
University of Toronto, Department of Family and 2001-2012: interrupted time series regression guideline. CMAJ. 2014;186(12):917-922.
Community Medicine, 500 University Ave, Toronto, analysis. BMJ Open. 2013;3(7):e003121. 8. Riley RD, Lambert PC, Abo-Zaid G. Meta-analysis
ON M5G1V7, Canada (frank.sullivan@nygh.on.ca). 3. Holland NJ, Weiner GM. Recent developments in of individual participant data: rationale, conduct,
Section Editor: Mary McGrae McDermott, MD, Bell’s palsy. BMJ. 2004;329(7465):553-557. and reporting. BMJ. 2010;340:c221.
Senior Editor. 4. Gagyor I, Madhok VB, Daly F, et al. Antiviral
Conflict of Interest Disclosures: The authors have treatment for Bell’s palsy (idiopathic facial
completed and submitted the ICMJE Form for paralysis). Cochrane Database Syst Rev. 2015;(11):
Disclosure of Potential Conflicts of Interest and CD001869.
none were reported.
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