Bell’s palsy: a study of the treatment advice given by Neurologists
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《神经病学神经外科学杂志》
1 Glasgow Royal Infirmary, 10 Alexandra Parade, Glasgow G31 2ER, UK
2 Southern General Hospital, Govan Road, Glasgow
Correspondence to:
Dr Monica Shaw
drmonicashaw@hotmail.com
Keywords: Bell’s palsy; steroids; acyclovir
Bell’s palsy is defined as an isolated unilateral lower motor neurone facial weakness of no obvious cause. The incidence has been estimated at around 23 to 25 cases per 100 000 population annually.1 Although the prognosis is generally good, around 16% are left with varying degrees of permanent disability.2
The use of steroids and acyclovir in the treatment of Bell’s palsy has been addressed in two recent Cochrane reviews.3,4 These found no benefit from either but concluded that available studies were insufficiently powered to detect a treatment effect.
Neurologists are often asked by primary care physicians for treatment advice and in view of this uncertainty we were interested in studying the recommendations given. A questionnaire (appendix) was emailed to all consultant neurologists (n = 35) and specialist registrars (n = 21) in Scotland. Responses were collated at six weeks following an interim reminder. Fisher’s exact test was used to compare groups; odds ratios with 95% confidence intervals and significance were calculated (table 1).
Table 1 Treatment of Bell’s palsy by subcategory
Replies were Only 5% of neurologists said they would always see the patient, with further 29% if atypical features were present. The use of steroids depended strongly on the stage of presentation, 76% giving steroids within 24 hours of onset, 62% within three days, and only 28% up to seven days. Fewer gave steroids in certain subcategories (12% in pregnancy, 19% in Ramsay Hunt syndrome, 62% in a complete syndrome, and 45% in a partial syndrome).
The steroid regimen advised was variable, with most advocating 40 to 60 mg of prednisolone, with or without a tapering dose. Only 20% of neurologists gave acyclovir in every instance; a further 20% gave it if there was evidence of Ramsay Hunt syndrome.
On the whole the responses from consultants and registrars were similar. However, while both advised steroids early on, consultants still recommended steroids up to seven days (42%) compared with only 6% of specialist registrars (p = 0.009). Geographical variability was evident; Glasgow neurologists advised steroids more readily, with 95%, 74%, and 21% giving them at 24 hours, three days, and seven days, respectively. This compared with 42% (p = 0.002), 42% (p = 0.065), and 17% (p = 0.34) at Edinburgh. There was also a trend for Glasgow physicians to prescribe more acyclovir (21% v 11% (p = 0.37)).
COMMENT
Although many neurologists advise steroids and some would recommend acyclovir, the uncertainty regarding the treatment of Bell’s palsy is reflected in our questionnaire responses.
The majority of responders indicated that their advice was not based on local guidelines and many commented on the lack of evidence. Some felt it was imperative to discuss the uncertainty with the patient; others that better randomised controlled trials are needed.
A new Scotland based randomised controlled trial will start later this year (Morrison J, personal communication). This study, coordinated by primary care physicians and ear, nose and throat surgeons, will compare four treatment arms (comprising steroids, acyclovir, placebo) within 48 to 72 hours of onset. Assessment of treatment effect will include photographs and questionnaires about objective and subjective outcomes. The aim is to recruit up to 720 patients, of whom 480 will have begun treatment within 48 hours of onset. Given the annual incidence of Bell’s palsy in Scotland, the researchers estimate that this will take up to 18 months. Uncertainty in managing this condition can only be resolved by well conducted randomised controlled trials.
APPENDIX
Bell’s palsy questionnaire
How frequently in the last 3 months have you
Do you arrange to see the patient before giving advice? Yes/No
If you are satisfied with the clinical diagnosis:
Would you advise steroids
within 24 hours? Yes/No
within 3 days? Yes/No
within 7 days? Yes/No
in pregnancy? Yes/No
with Ramsay Hunt syndrome? Yes/No
with complete facial palsy (loss of taste/hyperacusis)? Yes/No
with partial facial palsy? Yes/No
If steroids are advised, what regime would you suggest? ________________
Is the advice you give on steroids based on local guidelines? Yes/No
Would you advise acyclovir? Yes/No
If yes:
Is the advice you give on acyclovir based on local guidelines? Yes/No
Any additional comments:
References
Martyn CN, Hughes RAC. Epidemiology of peripheral neuropathy. J Neurol Neurosurg Psychiatry 1997;62:310–18.
Peitersen E. The natural history of Bell’s palsy. Am J Otol 1982;4:107–11.
Cochrane review. Acyclovir for Bell’s palsy (idiopathic facial paralysis). 2003;3.
Cochrane review. Corticosteroids for Bell’s palsy (idiopathic facial paralysis). 2003;3.(M Shaw1, F Nazir2 and I B)
2 Southern General Hospital, Govan Road, Glasgow
Correspondence to:
Dr Monica Shaw
drmonicashaw@hotmail.com
Keywords: Bell’s palsy; steroids; acyclovir
Bell’s palsy is defined as an isolated unilateral lower motor neurone facial weakness of no obvious cause. The incidence has been estimated at around 23 to 25 cases per 100 000 population annually.1 Although the prognosis is generally good, around 16% are left with varying degrees of permanent disability.2
The use of steroids and acyclovir in the treatment of Bell’s palsy has been addressed in two recent Cochrane reviews.3,4 These found no benefit from either but concluded that available studies were insufficiently powered to detect a treatment effect.
Neurologists are often asked by primary care physicians for treatment advice and in view of this uncertainty we were interested in studying the recommendations given. A questionnaire (appendix) was emailed to all consultant neurologists (n = 35) and specialist registrars (n = 21) in Scotland. Responses were collated at six weeks following an interim reminder. Fisher’s exact test was used to compare groups; odds ratios with 95% confidence intervals and significance were calculated (table 1).
Table 1 Treatment of Bell’s palsy by subcategory
Replies were Only 5% of neurologists said they would always see the patient, with further 29% if atypical features were present. The use of steroids depended strongly on the stage of presentation, 76% giving steroids within 24 hours of onset, 62% within three days, and only 28% up to seven days. Fewer gave steroids in certain subcategories (12% in pregnancy, 19% in Ramsay Hunt syndrome, 62% in a complete syndrome, and 45% in a partial syndrome).
The steroid regimen advised was variable, with most advocating 40 to 60 mg of prednisolone, with or without a tapering dose. Only 20% of neurologists gave acyclovir in every instance; a further 20% gave it if there was evidence of Ramsay Hunt syndrome.
On the whole the responses from consultants and registrars were similar. However, while both advised steroids early on, consultants still recommended steroids up to seven days (42%) compared with only 6% of specialist registrars (p = 0.009). Geographical variability was evident; Glasgow neurologists advised steroids more readily, with 95%, 74%, and 21% giving them at 24 hours, three days, and seven days, respectively. This compared with 42% (p = 0.002), 42% (p = 0.065), and 17% (p = 0.34) at Edinburgh. There was also a trend for Glasgow physicians to prescribe more acyclovir (21% v 11% (p = 0.37)).
COMMENT
Although many neurologists advise steroids and some would recommend acyclovir, the uncertainty regarding the treatment of Bell’s palsy is reflected in our questionnaire responses.
The majority of responders indicated that their advice was not based on local guidelines and many commented on the lack of evidence. Some felt it was imperative to discuss the uncertainty with the patient; others that better randomised controlled trials are needed.
A new Scotland based randomised controlled trial will start later this year (Morrison J, personal communication). This study, coordinated by primary care physicians and ear, nose and throat surgeons, will compare four treatment arms (comprising steroids, acyclovir, placebo) within 48 to 72 hours of onset. Assessment of treatment effect will include photographs and questionnaires about objective and subjective outcomes. The aim is to recruit up to 720 patients, of whom 480 will have begun treatment within 48 hours of onset. Given the annual incidence of Bell’s palsy in Scotland, the researchers estimate that this will take up to 18 months. Uncertainty in managing this condition can only be resolved by well conducted randomised controlled trials.
APPENDIX
Bell’s palsy questionnaire
How frequently in the last 3 months have you
Do you arrange to see the patient before giving advice? Yes/No
If you are satisfied with the clinical diagnosis:
Would you advise steroids
within 24 hours? Yes/No
within 3 days? Yes/No
within 7 days? Yes/No
in pregnancy? Yes/No
with Ramsay Hunt syndrome? Yes/No
with complete facial palsy (loss of taste/hyperacusis)? Yes/No
with partial facial palsy? Yes/No
If steroids are advised, what regime would you suggest? ________________
Is the advice you give on steroids based on local guidelines? Yes/No
Would you advise acyclovir? Yes/No
If yes:
Is the advice you give on acyclovir based on local guidelines? Yes/No
Any additional comments:
References
Martyn CN, Hughes RAC. Epidemiology of peripheral neuropathy. J Neurol Neurosurg Psychiatry 1997;62:310–18.
Peitersen E. The natural history of Bell’s palsy. Am J Otol 1982;4:107–11.
Cochrane review. Acyclovir for Bell’s palsy (idiopathic facial paralysis). 2003;3.
Cochrane review. Corticosteroids for Bell’s palsy (idiopathic facial paralysis). 2003;3.(M Shaw1, F Nazir2 and I B)