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CLINICIAN'S CORNER
Combined Corticosteroid and Antiviral Treatment for Bell PalsyA Systematic Review and Meta-analysis
John R. de Almeida, MD;
Murtadha Al Khabori, MD;
Gordon H. Guyatt, MD, MSc, FRCPC;
Ian J. Witterick, MD, MSc, FRCSC;
Vincent Y. W. Lin, MD, FRCSC;
Julian M. Nedzelski, MD, FRCSC;
Joseph M. Chen, MD, FRCSC
JAMA. 2009;302(9):985-993.
Context New evidence has emerged regarding the use of corticosteroids and antiviral agents in Bell palsy.
Objective To estimate the association of corticosteroids and antiviral agents with the risk of unsatisfactory facial recovery in patients with Bell palsy.
Data Sources The search included MEDLINE, EMBASE, CENTRAL, PsychInfo, CINAHL, Web of Science, PAPERSFIRST, PROCEEDINGSFIRST, and PROQUEST to identify studies up to March 1, 2009.
Study Selection and Data Extraction Eligible studies were randomized controlled trials comparing treatment with either corticosteroids or antiviral agents with a control and measuring at least 1 of the following outcomes: unsatisfactory facial recovery ( 4 months), unsatisfactory short-term recovery (6 weeks to <4 months), synkinesis and autonomic dysfunction, or adverse effects. Two reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus.
Results Eighteen trials involving 2786 patients were eligible. Regression analysis identified a synergistic effect when corticosteroids and antiviral agents were administered in combination compared with alone (odds ratio for interaction term, 0.54 [95% confidence interval {CI}, 0.35-0.83]; P = .004). Meta-analysis using a random-effects model showed corticosteroids alone were associated with a reduced risk of unsatisfactory recovery (relative risk [RR], 0.69 [95% CI, 0.55-0.87]; P = .001) (number needed to treat to benefit 1 person, 11 [95% CI, 8-25]), a reduced risk of synkinesis and autonomic dysfunction (RR, 0.48 [95% CI, 0.36-0.65]; P < .001) (number needed to treat to benefit 1 person, 7 [95% CI, 6-10]), and no increase in adverse effects. Antiviral agents alone were not associated with a reduced risk of unsatisfactory recovery (RR, 1.14 [95% CI, 0.80-1.62]; P = .48). When combined with antiviral agents, corticosteroids were associated with greater benefit (RR, 0.48 [95% CI, 0.29-0.79]; P = .004) than antiviral agents alone. When combined with corticosteroids, antiviral agents were associated with greater risk reduction of borderline significance compared with corticosteroids alone (RR, 0.75 [95% CI, 0.56-1.00]; P = .05).
Conclusions In Bell palsy, corticosteroids are associated with a reduced risk of unsatisfactory recovery. Antiviral agents, when administered with corticosteroids, may be associated with additional benefit.
Author Affiliations: Department of Otolaryngology– Head and Neck Surgery, Sunnybrook Hospital (Drs de Almeida, Lin, Nedzelski, and Chen), Department of Medical Oncology and Hematology, Princess Margaret Hospital (Dr Al Khabori), and Department of Otolaryngology–Head and Neck Surgery, Mount Sinai Hospital (Dr Witterick), University of Toronto, Toronto, Ontario, Canada; and Departments of Clinical Epidemiology and Biostatistics (Drs de Almeida, Al Khabori, and Guyatt) and Medicine (Dr Guyatt), CLARITY Research Group (Dr Guyatt), McMaster University, Hamilton, Ontario, Canada.
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