Steroids only indicated for Bell’s palsy with complete paralysis
Date First Published:
March 1, 2000
Last Updated:
April 26, 2001
Report by:
Joel Desmond, Senior House Officer (Manchester Royal Infirmary)
Search checked by:
Paul Wallman, Manchester Royal Infirmary
Three-Part Question:
In [an adult with Bell's palsy] would [ early steroid therapy] improve [time to recovery and outcome]?
Clinical Scenario:
A 35 year old man presents to the emergency department with a 1 day history of a right sided facial weakness. Examination reveals a complete right facial nerve palsy, without any evidence of herpes zoster, middle ear disease, trauma or further neurology. A diagnosis of idiopathic (Bell's) facial nerve palsy is made. You wonder whether early high dose steroids would improve his prognosis or speed of recovery.
Search Strategy:
Medline 1966-07/99 using the OVID interface.
Search Details:
({exp facial paralysis OR facial paralysis.mp OR bells palsy.mp} AND {exp steroids OR steroid$.mp} AND (maximally sensitive RCT filter) LIMIT to human AND english.
Outcome:
72 papers found of which 65 irrelevant and 3 of insufficient quality for inclusion. The remaining 4 papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The use of steroids in Bells Palsy: a prospective controlled study. May M, Wette R, Hardin WB Jr et al. 1976, USA | 51 patients Prednisolone vs control |
PRCT | Visual assessment of motor recovery | No difference | Small study |
| Autonomic dysfunction | No difference | ||||
| Time of recovery | No difference | ||||
| Treatment of Bell Palsy with prednisolone: a prospective, randomized study. Wolf SM, Wagner JH, Davidson S et al. 1978, USA | 239 patients Prednisolone (60 mg) vs control |
PRCT | Electromyography | No difference | Not blinded Control group not treated with placebo Only 30% of patients had complete denervation, and 20% had mild Bells palsy on entry into the trial. |
| Facial strength, | No difference | ||||
| Autonomic dysfunction | Prednisolone is beneficial in preventing autonomic synkinesis | ||||
| Time to recovery | No difference | ||||
| Idiopathic facial nerve paralysis: a randomized double blind controlled study of placebo versus prednisolone. Austin JR, Peskind SP, Austin SG et al. 1993, USA | 107 patients Prednisolone (60 mg) vs control |
PRCT | Functional nerve testing | Significant improvement in facial nerve function. | Small study 29% lost to follow up after randomisation. |
| Time to recovery | No difference in recovery time | ||||
| Electromyography | No difference in denervation | ||||
| The possible contributing factors for the success of steroid therapy in Bells palsy: a clinical and electrophysiological study. Shafshak TS, Essa AY, Bakey FA. 1994, Egypt | 160 patients with complete facial palsy Prednisolone (1 mg/kg) vs control |
Clinical trial | Facial nerve excitability | Significantly better recovery with steroids, especially if given <24hrs after onset | Non randomised Non blinded Controls were those that refused steroids or had a contraindication |
Author Commentary:
No studies have demonstrated a benefit in commencing steroids in those with incomplete facial paralysis as they have a good prognosis. In addition, no studies have demonstrated an improvement in the time to recovery in any patients with Bell's palsy. If any benefit has been demonstrated, then it is in those with a complete facial paralysis with steroids being started early. There are significant criticisms with all the studies conducted so far, and a large prospective randomised controlled trial demonstrating a clear benefit has yet to be conducted.
Bottom Line:
Current evidence does not support the early use of high dose steroids in idiopathic incomplete facial nerve palsy. In patients with complete paralysis early steroids may be of benefit.
References:
- May M, Wette R, Hardin WB Jr et al.. The use of steroids in Bells Palsy: a prospective controlled study.
- Wolf SM, Wagner JH, Davidson S et al.. Treatment of Bell Palsy with prednisolone: a prospective, randomized study.
- Austin JR, Peskind SP, Austin SG et al.. Idiopathic facial nerve paralysis: a randomized double blind controlled study of placebo versus prednisolone.
- Shafshak TS, Essa AY, Bakey FA.. The possible contributing factors for the success of steroid therapy in Bells palsy: a clinical and electrophysiological study.