Title: “Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis.

Article Citation: de Almeida JR, Al Khabori M, Guyatt GH, Witterick IJ, et al. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA. 2009 Sep 2;302(9):985-93.PMID: 19724046

What we already know about the topic: Bell Palsy, while not dangerous, is an especially impactful diagnosis as it affects the most visible parts of our bodies. Paralysis of the facial muscles changes how we see ourselves and how the world interacts with us. Until now there has been no standardized evidence-based approach to treatment which has consisted of antiviral medication, steroids or some combination of the two. Some studies have suggested that steroids alone have some benefit whereas antiviral medication alone does not.

Why this study is important: In this study, the authors propose that there could be a superior approach to the treatment of Bell Palsy consisting of a combination of steroid and antiviral medication. They propose that this combined treatment modality potentially provides maximal short and long term benefits in the treatment of Bell Palsy.

Brief overview of the study: A systematic review and meta analysis was performed involving 2786 patients from 18 studies from 5 different continents. They showed that treatment with corticosteroids alone compared to no treatment was associated with reduced risk of unsatisfactory recovery and no increase risk of autonomic dysfunction, synkinesis or adverse events (P=0.001).  Antiviral agents alone were not associated with reduced unsatisfactory recovery (P=0.48) when compared to no treatment. The combination of corticosteroids and antiviral treatments demonstrated benefit in comparison with antivirals alone and possibly a reduction in unsatisfactory recovery when compared to corticosteroids alone (P=0.05). They also assert that treating with corticosteroids after 72 hours is as effective as those presenting within 72 hours.

Limitations: My primary issues with this study are: (1)The study has basically corroborates what previous studies have already demonstrated. Corticosteroids are more effective than antivirals in treating Bell Palsy. In this study, the combination of the two methods was not clearly superior to steroids alone. (2)  As with all meta-analyses, data is being compared from studies in which goals and processes are different.  Mathematical attempts to compensate for these differences only go so far though the authors did go beyond what is usually seen in meta analyses to mitigate differences.  (3) Many studies excluded people presenting with symptoms after 72 hours and so subgoup analysis suggesting corticosteroid use is as effective after 72 hours as before is weak. (4) Evaluation of “unsatisfactory reduction of symptoms” and severity of facial muscle paralysis is subjective and very difficult to equilibrate across studies.

Take home points: To date the best evidence suggests that corticosteroids are superior to no treatment or antivirals alone in treatment of Bell Palsy. There is a some evidence suggesting that the combination of the two may be superior to corticosteroids alone however the evidence for this is not strong.