Impact of clinical trial findings on Bell's palsy management in general practice in the UK 2001-2012: interrupted time series regression analysis

An ACS-NSQIP Data Analysis of 30-Day Outcomes Following Surgery for Bell's Palsy

BACKGROUND

There exists a paucity of large-scale, multi-institutional studies that investigate the outcomes of surgery for Bell's palsy (BP). Here, we utilize a large, multi-institutional database to study the risk factors and early-stage outcomes following surgical procedures in BP.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2008-2019) to identify patients who underwent surgery for the diagnosis of BP. We extracted data on comorbidities and preoperative blood values, and 30-day postoperative outcomes.

RESULTS

Two hundred fifty-seven patients who underwent surgery for BP symptoms over the 12-year review period were identified. Muscle grafts (n=50; 19%) and fascial grafts (n=48; 19%) accounted for the majority of procedures. The most common comorbidities were hypertension (n=89; 35%) and obesity (n=79; 31%). Complications occurred in 26 (10.1%) cases. Additionally, length of hospital stay was significantly associated with both surgical and medical complications (3.9±4.7 versus 1.5±2.0; P <0.01) and (3.2±3.8 versus 1.4±2.0; P <0.01), respectively. Preoperative creatinine, blood urea nitrogen, and alkaline phosphatase were identified as potential predictors of poor postoperative outcomes.

CONCLUSION

Based on multi-institutional analysis, complication rates following surgery for BP were found to be overall low and seen to correlate with length of hospital stay. Reoperations and readmissions were the most frequent complications after surgery for BP. The preoperative evaluation of routine laboratory values may help refine patient eligibility and risk stratification. In addition, our findings call for future large-scale prospective studies in the field of facial palsy surgery to further improve the quality of care and optimize perioperative protocols.

Surgery for patients with facial palsy in Germany: a diagnosis-related-groups-based nationwide analysis, 2005-2019

PURPOSE

Chronic flaccid paralysis of the facial nerve leads to permanent dysfunction of eye closure, problems with drinking and eating, and lack of emotional expression. Modern facial surgery can help those affected. An analysis of the development of facial surgery in Germany over time is presented.

METHODS

Nation-wide population-baes diagnosis-related case group (DRG) data of virtually all inpatients who underwent facial surgery for facial palsy between 2005 and 2019 were included. Binomial regression models for changes in surgery rates over time were calculated in relation to gender and treating specialty.

RESULTS

Between 2005 and 2019, there were 28,622 inpatient stays for facial surgery. Most surgeries were provided by otolaryngology (39%) and ophthalmology or dentistry, oral and maxillofacial surgery (20% each). The mean treatment rate was 2.33 ± 0.53 surgeries per 100,000 person-years. The surgery rate was highest for nerve reconstruction surgery (0.46 ± 0.15) and static sling surgery (0.44 ± 0.0.16). The greatest increase was seen in men for nerve surgery (3.9-fold; relative risk [RR] = 3.68; confidence interval [CI] = 3.18-4.26) and sling surgery (5.0-fold; RR = 4.25; CI = 3.38-5.33).

CONCLUSIONS

While nerve and sling surgery increased significantly over time, this was less true or not true at all for surgical techniques. Surgical rates and their change over time were greater in men, without explanation from the data.

Optimal Bell's Palsy Treatment: Steroids, Antivirals, and a Timely and Personalized Approach

IMPORTANCE

The optimal treatment approach for patients with Bell's palsy, a condition characterized by acute facial nerve palsy, remains unclear. The present study was designed to provide insights into the most effective treatment strategies, whether steroids alone or steroids plus antiviral agents, as well as the optimal timing of treatment initiation.

OBJECTIVE

To investigate the impact of treatment modalities and timing on the recovery rates of Bell's palsy patients and to assess the roles of individual factors.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective analysis included 1504 patients with Bell's palsy who visited Kyung Hee University Hospital. Patients were divided based on the treatment modality (steroid monotherapy vs. combined steroid and antiviral therapy) and the timing of treatment initiation (≤72 vs. >72 h).

MAIN OUTCOMES AND MEASURES

The primary outcome was the recovery rate, as assessed by the House-Brackmann (HB) grade. Secondary outcomes included factors such as age, electroneurography (ENoG) and electromyography (EMG) results, and comorbid conditions.

RESULTS

A combined comparison of patients treated with steroids plus antivirals and steroids alone, stratified by treatment start time, showed that recovery rates were highest in patients who received steroid monotherapy initiated within 72 h (OR 2.36; p < 0.05). Patients with severe Bell's palsy tended to benefit more from combined therapy when treatment was initiated within 72 h. The recovery rate was higher in patients who received steroid monotherapy than combined therapy (86.32% vs. 79.25%, p < 0.05). Initiating treatment beyond 72 h was associated with a higher recovery rate than starting treatment within 72 h (85.69% vs. 76.92%, p < 0.05). An evaluation of the factors affecting recovery showed that patients aged 20 to 39 years had a higher recovery rate than other age groups (OR 1.47; p < 0.05). Fairly predictive EMG results were associated with significantly higher recovery rates (OR 3.52; p < 0.05).

CONCLUSIONS

These findings underscore the importance of individualized treatment approaches in Bell's palsy management. Steroid monotherapy remains effective, although combined treatment may have potential advantages, especially in patients with more severe disease. The best treatment results were achieved when steroid treatment was administered within 72 h. Our results suggest that there may be more flexibility in the application of the 72 h treatment period if we consider the time of treatment initiation alone, but this should take into account patient behavior patterns and the limitations of retrospective analysis. Further research is warranted to validate these findings and refine treatment recommendations for patients with Bell's palsy.

The Use of Plantaris Muscle Flap for Facial Reanimation: A Comprehensive Anatomical Study

Background: Functional facial reanimation remains challenging and the quest for optimization continues. Objective: To characterize the anatomical conditions of the plantaris muscle for facial reanimation. Study Design and Methods: Forty-two plantaris muscle specimens were obtained from 23 post-mortem chemically fixed cadavers. The muscles were dissected, evaluated, and measured. Mock facial reanimation was performed on three cadaver heads. Results: The plantaris muscle was a consistently available muscle. Mean muscle belly length was 10.1 cm (standard deviation [SD] 1.4), and mean width was 1.7 cm (SD 0.4). The mean tendon length of 30.1 cm (SD 2.8) is unique in the human body. The main artery supplying the muscle had a mean length of 1.4 cm (SD 0.4). The mean nerve length was 2.2 cm (SD 0.7). Sixteen variations of vascular supply were identified. Mock facial reanimations demonstrated a good size match, and great versatility of the long tendon for oral fixation. Conclusions: The plantaris muscle as a free flap for facial reanimation could offer new possibilities in terms of oral fixation and volumetric aesthetic conditions.

Retrospective study of peripheral facial paralysis in a tertiary hospital over 3 years

PURPOSE

To identify clinical and epidemiological characteristics of patients with peripheral facial palsy (PFP) at a tertiary care hospital.

METHOD

This is a retrospective observational study of patients with PFP treated at a tertiary medical center. We gathered demographic data, etiology, laterality, recurrence, recovery, clinical ophthalmology, severity according to the House-Brackmann (HB) scale, electrophysiological tests, medical services attended, medical and surgical treatment.

RESULTS

Two hundred and eighty-three PFP were included, 135 (48%) were men and 148 (52%) were women p = 0.47). All patients had unilateral involvement. The mean age was 54 ± 20 years. The main etiology was idiopathic in 215 (76%) patients. Median recovery time was 7 weeks. Recovery was complete in 190 (67%) patients. One hundred and seventy (84%) patients with idiopathic PFP had complete recovery, versus 30 (16%) patients with non-idiopathic PFP (p < 0.01). The 84% of patients with HB grade II, recovered completely, while with HB grade VI only 17% recovered (p = 0.003). Two hundred and twenty-nine patients (81%) had lagophthalmos. The majority received ocular surface care treatment in 271 (96%) patients and of these 249 (88%) patients received oral corticosteroid therapy. Thirteen patients (5%) required ophthalmologic surgery.

CONCLUSIONS

PFP affects all age ranges, without predilection for sex and unilateral. Its main cause is idiopathic. Recovery is complete in most cases, being more favorable in mild and idiopathic affections. Most only require medical treatment.

Association of Overweight and Obesity With Bell Palsy in Children

BACKGROUND

In the Division of Pediatric Neurology at the University Medical Center Göttingen we observed that many patients with Bell palsy are overweight or obese. To evaluate whether overweight and obesity are associated with increased risk of Bell palsy in children we conducted this single-centered retrospective study by performing a database search for International Classification of Diseases (ICD)-10 primary and secondary diagnosis of G51.0 (facial nerve palsy) between January 1, 2010, and December 31, 2020.

METHODS

For risk assessment, patients' body mass indices (BMIs) were compared with BMI data of controls from a nationwide child health survey.

RESULTS

In total, 202 patients with peripheral facial nerve palsies (pFPs) were included, of which nearly half were classified as Bell palsies; 38% and 24% of the patients with Bell palsy and pFP had a BMI above the 90th percentile, respectively. High BMI was associated with statistically increased odds of Bell palsy in the group of overweight and obese patients (BMI >90th percentile; odds ratio [OR], 2.42; 95% confidence interval [CI], 1.6 to 3.8; P < 0.001) and solely obese patients (BMI >97th percentile; OR, 2.43; 95% CI, 1.4 to 4.3; P = 0.003).

CONCLUSIONS

We could confirm our observation that overweight and obesity are associated with increased risk of Bell palsy in children.

Electroacupuncture combined with Qianzhengsan decoction for the treatment of peripheral facial paralysis: A retrospective study

This study retrospectively explored the effectiveness of electroacupuncture (EA) combined with Qianzhengsan decoction (QZSD) for the treatment of peripheral facial paralysis (PFP). This retrospective study included patients with PFP admitted to a single hospital between July 2018 and June 2020. Ninety patients were included and divided into treatment (n = 45) and control (n = 45) groups. All the patients in both groups received oral prednisone tablets and mecobalamin. In addition, patients in the treatment group received EA and QZSD. The outcomes were the overall response rate, facial nerve function, facial nerve electromyography, and adverse events. All outcome data were analyzed before and after treatment. Patients in the treatment group achieved better outcomes than those in the control group in improving overall response rate (P = .04), facial nerve function (P < .01), and facial nerve electromyography (P < .01). Patients in both groups reported adverse events. The results of this study showed that patients with PFP and QZSD received better outcomes than those who did not. Further studies are required to confirm these results.

Towards a Reliable and Rapid Automated Grading System in Facial Palsy Patients: Facial Palsy Surgery Meets Computer Science

Background: Reliable, time- and cost-effective, and clinician-friendly diagnostic tools are cornerstones in facial palsy (FP) patient management. Different automated FP grading systems have been developed but revealed persisting downsides such as insufficient accuracy and cost-intensive hardware. We aimed to overcome these barriers and programmed an automated grading system for FP patients utilizing the House and Brackmann scale (HBS). Methods: Image datasets of 86 patients seen at the Department of Plastic, Hand, and Reconstructive Surgery at the University Hospital Regensburg, Germany, between June 2017 and May 2021, were used to train the neural network and evaluate its accuracy. Nine facial poses per patient were analyzed by the algorithm. Results: The algorithm showed an accuracy of 100%. Oversampling did not result in altered outcomes, while the direct form displayed superior accuracy levels when compared to the modular classification form (n = 86; 100% vs. 99%). The Early Fusion technique was linked to improved accuracy outcomes in comparison to the Late Fusion and sequential method (n = 86; 100% vs. 96% vs. 97%). Conclusions: Our automated FP grading system combines high-level accuracy with cost- and time-effectiveness. Our algorithm may accelerate the grading process in FP patients and facilitate the FP surgeon’s workflow.

Multidisciplinary Care of Patients with Facial Palsy: Treatment of 1220 Patients in a German Facial Nerve Center

To determine treatment and outcome in a tertiary multidisciplinary facial nerve center, a retrospective observational study was performed of all patients referred between 2007 and 2018. Facial grading with the Stennert index, the Facial Clinimetric Evaluation (FaCE) scale, and the Facial Disability Index (FDI) were used for outcome evaluation; 1220 patients (58.4% female, median age: 50 years; chronic palsy: 42.8%) were included. Patients with acute and chronic facial palsy were treated in the center for a median of 3.6 months and 10.8 months, respectively. Dominant treatment in the acute phase was glucocorticoids ± acyclovir (47.2%), followed by a significant improvement of all outcome measures (p < 0.001). Facial EMG biofeedback training (21.3%) and botulinum toxin injections (11%) dominated the treatment in the chronic phase, all leading to highly significant improvements according to facial grading, FDI, and FaCE (p < 0.001). Upper eyelid weight (3.8%) and hypoglossal–facial-nerve jump suture (2.5%) were the leading surgical methods, followed by improvement of facial motor function (p < 0.001) and facial-specific quality of life (FDI, FaCE; p < 0.05). A standardized multidisciplinary team approach in a facial nerve center leads to improved facial and emotional function in patients with acute or chronic facial palsy.

The efficacy and safety of acupoint catgut embedding for peripheral facial paralysis sequela: A protocol for systematic review and meta-analysis

BACKGROUND

Peripheral facial paralysis sequela (PFPS) is a group of sequence syndrome after the acute onset of peripheral facial paralysis. Nearly 70% of patients with peripheral facial paralysis recover completely, but nearly 30% of patients leave multiple sequelae, which have serious negative impacts on the physical and psychological health of patients. Without a high risk of side effect, acupoint catgut embedding (ACE), a common acupuncture therapy, is widely used to treat this disorder. And a number of studies have shown the efficacy of this therapy for PFPS. But in fact, the evidence of the overall effect of ACE in the treatment of PFPS is still insufficient. Therefore, the purpose of this study is to evaluate the efficiency and safety of ACE for PFPS.

METHODS

Two reviewers will collect randomized controlled trials (RCTs) on ACE for PFPS by searching the following databases, including The Cochrane Library, PubMed, Web of Science, EMBASE, China Biomedical Literature (CBM), China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP), and Wanfang database, from their initiation to May 2021. The searching of publications will include English and Chinese without any restriction of countries and regions. Besides, 2 reviewers will independently include in studies that meet the inclusion criteria and extract data we need, then use Cochrane Collaboration's Risk of Bias Tool to assess their methodological quality. The efficacy and safety of ACE as a treatment for PFPS will be assessed according to the synthetic risk ratio (RR), odds ratio (OR), or weighted mean difference (WMD), standardized mean difference (SMD) with consistent 95% confidence intervals (95% CI). And the Review Manager 5.3 software will be adopted to conduct the statistical analysis.

RESULTS

The protocol for meta-analysis will systematically evaluate the efficacy and safety of ACE for PFPS. And the final result of this search will provide sufficient evidence and an authentic assessment focusing on the problem.

CONCLUSION

This search will explore whether ACE could be used as an effective and non-drug external therapy of TCM for PFPS and offer supports for clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42021240004.

[Diagnostics and Therapy of Idiopathic Facial Palsy (Bell's Palsy)]

The purpose of this review is to report the knowledge for otolaryngologists on standard of care, latest advances, interesting new findings and controversies about the treatment of Bell's palsy. This review is focusing on the acute phase of the disease. The chronic phase, with incomplete, incorrect or no recovery of the palsy, is described briefly. Treatment with prednisolone alone within 72 hours after onset still is the cornerstone of the treatment. The role of antivirals still is unclear. Since 2009 no new and breakthrough clinical trials with influence on the treatment standards have been performed. A study to clarify the role of prednisolone treatment in children is ongoing. Patient-related outcome measures like the Facial Clinimetric Evaluation Scale and the Facial Disability Index are important tools to assess the subjective severity of the disease and psychosocial impact of Bell's palsy next to the motor deficits. Simplified subjective electronic grading systems like the eFACE and first automated image analysis systems have been introduced. Studies clarifying the role of antivirals for severe cases are urgently needed as well as studies on the role of salvage second line therapy after insufficient response to initial corticosteroid treatment. An international consensus on the outcome measures in diagnostics and follow-up is also needed.

The Potential Role of Human Papillomavirus Infection in Bell's Palsy: A Hypothesis-Generating Study Based on a Nationwide Cohort

Objective: Our purpose was to investigate whether people with a previous human papillomavirus (HPV) infection were associated with an increased risk of Bell's palsy (BP).

Methods: By using Taiwan population-based data, patients aged > 18 years with HPV infection (n = 22,260) from 2000 to 2012 were enrolled and compared with control subjects who had never been diagnosed with an HPV infection at a 1:4 ratio matched by sex, age, index date, and co-morbidities (n = 89,040). The index date was the first date of HPV diagnosis. All the patients were tracked until the occurrence of BP. Cox proportional hazards regression was applied to estimate the hazard ratios (HRs) for the development of BP in both groups.

Results: The HPV group had 1.25 [95% confidence interval (CI) = 1.03–1.51] times higher risk of BP compared with the non-HPV group after adjusting for sex, age, and co-morbidities. The association of HPV and BP was significant in the sensitivity analyses. In the subgroup analysis, the impact of HPV infection on the risk of BP was more pronounced in the elderly > 50 years [adjusted hazard ratio (aHR) =1.86; 95% CI = 1.37–2.52], hypertension (aHR = 1.65; 95% CI = 1.17–2.31), and chronic obstructive pulmonary disease (aHR = 2.14, 95% CI 1.333.43) subgroups.

Conclusions: Patients with HPV infection have a higher risk of subsequent BP compared with non-HPV patients. More rigorous studies are needed to confirm if and how specific HPV genotypes are associated with BP and the possible role of vaccines in disease prevention.

Can PIMS-TS lead to a facial nerve palsy?

Paediatric inflammatory multisystem syndrome—temporally associated with SARS-CoV-2 (PIMS-TS) is a recently described syndrome. We describe the case of a 17-year-old man presenting with a recent illness consistent with COVID-19 who presented with fever, chest pain and anterior uveitis. He was treated with aspirin, pulsed methylprednisolone and tocilizumab followed by oral steroids. On day 16 from initial presentation, he developed a facial nerve palsy. He was managed with ongoing steroids and the addition of valaciclovir. PIMS-TS is an under-recognised condition among adult physicians and may not be well known in adult neurology. It is important for adult physicians and neurologists to be aware of PIMS-TS and its possible sequelae.

The efficacy and safety of cupping therapy for treating of intractable peripheral facial paralysis: A protocol for systematic review and meta-analysis

BACKGROUND

Peripheral facial paralysis (PFP) is a common clinical neurological disease and the incidence of intractable peripheral facial paralysis is on the rise. Symptoms include crooked mouth and eyes, tearing and shallow nasolabial folds. The disease seriously affects the physical and mental health of patients. At present, a large number of clinical studies have shown that cupping is effective in treating intractable peripheral facial paralysis (IPFP). Therefore, the purpose of this review is to evaluate the effectiveness and safety of cupping in the treatment of refractory peripheral facial paralysis.

METHODS

We will conduct a comprehensive and systematic search of relevant documents in the following databases: Medline, PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, Chinese Biomedical Literatures Database, China National Knowledge Infrastructure (CNKI), Wang Fang Database, Chinese Scientific Journal Database from inception to February 2021 without any language restriction. The 2 reviewers will be independently completed select research, extract data, evaluate research quality and use the Cochrane risk of bias tool to assess methodological quality. Using revman5.4 software for statistical analysis. The degree of heterogeneity will be Determined through heterogeneity test, to definite whether to adopt a random effects model or a fixed-effects model.

RESULTS

The protocol for the meta-analysis will systematically evaluate the efficacy and safety of cupping therapy for intractable peripheral facial paralysis patients.

CONCLUSION

This study will explore whether or not cupping therapy can be used as one of the non-drug therapies to prevent or treat intractable peripheral facial paralysis.

Epidemiological trends of Bell's palsy treated with steroids in Korea between 2008 and 2018

INTRODUCTION

Contemporary epidemiological data on Bell's palsy are crucial to clarify disease burden and improve management strategies. We aimed to examine the epidemiology of, and factors associated with, Bell's palsy treated with steroids in Korea.

METHODS

Using the National Health Insurance claims data from 2008 to 2018, we determined the incidence, recurrence rate, and management trends of Bell's palsy treated with steroids. We defined Bell's palsy cases based on diagnostic codes and concurrent treatment with steroids.

RESULTS

The incidence of Bell's palsy showed an increasing trend (from 23.0 per 100 000 persons in 2008 to 30.8 per 100 000 persons in 2018). Age (60-69 y), sex (men), and month (January) were risk factors of Bell's palsy. The recurrence rate of Bell's palsy over the 11-y period was 1.5%. Male sex (hazard ratio [HR], 1.1; 95% confidence interval [CI], 1.0-1.2) and physiotherapy (HR, 0.9; 95% CI, 0.8-0.99) were independently associated with the recurrence of Bell's palsy. During the study period, the use of electrodiagnostic testing steadily increased, whereas that of physiotherapy steadily decreased, and antiviral therapy fluctuated,.

DISCUSSION

The incidence and recurrence rates presented in this study are comparable with those reported in earlier studies that included patients with Bell's palsy, regardless of the use of steroids, and documented an increase in the burden of Bell's palsy. Further randomized controlled trials are required to ascertain the long-term effects of physiotherapy on recurrent Bell's palsy.

Raising the Digital Profile of Facial Palsy: National Surveys of Patients' and Clinicians' Experiences of Changing UK Treatment Pathways and Views on the Future Role of Digital Technology

BACKGROUND

Facial nerve palsy leaves people unable to move muscles on the affected side of their face. Challenges exist in patients accessing facial neuromuscular retraining (NMR), a therapy used to strengthen muscle and improve nerve function. Access to therapy could potentially be improved through the use of digital technology. However, there is limited research available on patients' and clinicians' views about the potential benefits of such telerehabilitation based on their lived experiences of treatment pathways.

OBJECTIVE

This study aims to gather information about facial palsy treatment pathways in the United Kingdom, barriers to accessing NMR, factors influencing patient adherence, measures used to monitor recovery, and the potential value of emerging wearable digital technology.

METHODS

Separate surveys of patients with facial palsy and facial therapy specialists were conducted. Questionnaires explored treatment pathways and views on telerehabilitation, were co-designed with users, and followed a similar format to enable cross-referencing of responses. A follow-up survey of national specialists investigated methods used to monitor recovery in greater detail. Analysis of quantitative data was conducted allowing for data distribution. Open-text responses were analyzed using thematic content analysis.

RESULTS

A total of 216 patients with facial palsy and 25 specialist therapists completed the national surveys. Significant variations were observed in individual treatment pathways. Patients reported an average of 3.27 (SD 1.60) different treatments provided by various specialists, but multidisciplinary team reviews were rare. For patients diagnosed most recently, there was evidence of more rapid initial prescribing of corticosteroids (prednisolone) and earlier referral for NMR therapy. Barriers to NMR referral included difficulties accessing funding, shortage of specialist therapists, and limited awareness of NMR among general practitioners. Patients traveled long distances to reach an NMR specialist center; 9% (8/93) of adults reported traveling ≥115 miles. The thematic content analysis demonstrates positive attitudes to the introduction of digital technology, with similar incentives and barriers identified by both patients and clinicians. The follow-up survey of 28 specialists uncovered variations in the measures currently used to monitor recovery and no agreed definitions of a clinically significant change for any of these. The main barriers to NMR adherence identified by patients and therapists could all be addressed by using suitable real-time digital technology.

CONCLUSIONS

The study findings provide valuable information on facial palsy treatment pathways and views on the future introduction of digital technology. Possible ways in which emerging sensor-based digital technology can improve rehabilitation and provide more rigorous evidence on effectiveness are described. It is suggested that one legacy of the COVID-19 pandemic will be lower organizational barriers to this introduction of digital technology to assist NMR delivery, especially if cost-effectiveness can be demonstrated.

Cloud Computing Mobile Application for Remote Monitoring of Bell's Palsy

Mobile applications provide the healthcare industry with a means of connecting with patients in their own home utilizing their own personal mobile devices such as tablets and phones. This allows therapists to monitor the progress of people under their care from a remote location and all with the added benefit that patients are familiar with their own mobile devices; thereby reducing the time required to train patients with the new technology. There is also the added benefit to the health service that there is no additional cost required to purchase devices for use. The Facial Remote Activity Monitoring Eyewear (FRAME) mobile application and web service framework has been designed to work on the IOS and android platforms, the two most commonly used today. Results: The system utilizes secure cloud based data storage to collect, analyse and store data, this allows for near real time, secure access remotely by therapists to monitor their patients and intervene when required. The underlying framework has been designed to be secure, anonymous and flexible to ensure compliance with the data protection act and the latest General Data Protection Regulation (GDPR); this new standard came into effect in April 2018 and replaces the Data Protection Act in the UK and Europe.

The Diagnosis and Treatment of Idiopathic Facial Paresis (Bell's Palsy)

BACKGROUND

Peripheral facial nerve palsy is the most com- mon functional disturbance of a cranial nerve. 60-75% of cases are idiopathic.

METHODS

This review is based on a selective literature search proceeding from the current, updated German-language guideline on the diagnosis and treatment of idiopathic facial nerve palsy.

RESULTS

The recommended drug treatment consists of prednisolone 25 mg bid for 10 days, or 60 mg qd for 5 days followed by a taper to off in decrements of 10 mg per day. This promotes full recovery (number needed to treat [NNT] = 10; 95% confidence interval [6; 20]) and lessens the risk of late sequelae such as synkinesia, autonomic disturbances, and contractures. Virostatic drugs are optional in severe cases (intense pain or suspicion of herpes zoster sine herpete) and mandatory in cases of varicella-zoster virus (VZV) infection. Corneal protection with dexpanthenol ophthalmic ointment, artificial tears, and a nocturnal moisture- retaining eye shield has been found useful in practice. In cases of incomplete recovery with residual facial weakness, both static and microsurgical dynamic methods can be used to restore facial nerve function.

CONCLUSION

Because 25-40% of cases of facial nerve palsy are not idiopathic, differential diagnosis is very important; key diagnostic methods include a clinical neurological examin- ation, otoscopy, and a lumbar puncture for cerebrospinal fluid examination. High-level evidence supports corticosteroid treatment for the idiopathic form of the disorder.

Prognostic factors for the outcome of Bells' palsy: A cohort register-based study

OBJECTIVES

There is a lack of data on patients' and diagnostic factors for prognostication of complete recovery in patients with Bell's palsy.

DESIGN AND SETTING

Cohort register-based study of 368 patients with Bell's palsy and uniform diagnostics and standardised treatment in a university hospital from 2007 to 2017 (49% female, median age: 51 years).

MAIN OUTCOME MEASURES

Clinical data, facial grading, electrodiagnostics, motor function tests, non-motor function tests and onset of prednisolone therapy were assessed for their impact on the probability of complete recovery using univariable and multivariable statistics.

RESULTS

Median onset of treatment was 1.5 days. 46% of patients had a House-Brackmann scale at baseline of ≥ III. The median recovery time was 2.6 months (95% confidence interval [CI] = 2.1-3.0). 54.9% achieved a complete recovery. If prednisolone therapy started later than 96 hours after onset, the recovery rate decreased significantly. Beyond less severe palsy, no abnormal electroneurography side difference, no pathological spontaneous activity in electromyography and normal stapedius reflex testing were the most powerful tool for prognostication of recovery after Bell's palsy.

CONCLUSION

Beyond severity of the palsy, facial electrodiagnostics and stapedius reflex testing are the most powerful tool for prognostication of recovery time after Bell's palsy. Prednisolone therapy should have started at best within a time window of 96 hours after onset to reach the highest probability of complete recovery.

The impact of misdiagnosing Bell's palsy as acute stroke

Idiopathic Bell's palsy can lead to a serious and, sometimes permanently, disfiguring and emotionally challenging facial palsy. Early diagnosis and treatment with corticosteroids are important, as they significantly improve recovery rates. Bell's palsy is a benign condition that should be diagnosed and managed in primary care. Patients who self-present to the emergency department should be managed and discharged without needing admission. We reviewed all patients referred urgently to our hospital with facial weakness and discharged with a diagnosis of Bell's palsy, to explore whether clinicians were confident in making this diagnosis at initial assessment and, if not, how often they sought a specialist opinion. Furthermore, we assessed the impact of its over-investigation and mistreatment on healthcare resources and the patients.

Antiviral treatment for Bell's palsy (idiopathic facial paralysis)

BACKGROUND

Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. This review was first published in 2001 and most recently updated in 2015. Since a significant benefit of corticosteroids for the early management of Bell's palsy has been demonstrated, the main focus of this update, as in the previous version, was to determine the effect of adding antivirals to corticosteroid treatment. We undertook this update to integrate additional evidence and to better assess the robustness of findings, taking risk of bias fully into account.

OBJECTIVES

To assess the effects of antiviral treatments alone or in combination with any other therapy for Bell's palsy.

SEARCH METHODS

We searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS in July 2019. We reviewed the bibliographies of the identified trials and contacted trial authors to identify additional published or unpublished data. We searched clinical trials registries for ongoing studies.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) or quasi-RCTs of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy. We excluded trials that followed-up participants for less than three months.

DATA COLLECTION AND ANALYSIS

We independently assessed trials for relevance, eligibility, and risk of bias, using standard Cochrane procedures. We performed sensitivity analyses excluding trials at high or unclear risk of bias in at least five domains, and reported these data as the primary analyses.

MAIN RESULTS

Fourteen trials, including 2488 participants, met the inclusion criteria. Most were small, and most were at high or unclear risk of bias in multiple domains. We included four new studies at this update.Incomplete recoveryA combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in people with Bell's palsy compared to corticosteroids alone (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.38 to 1.74; 3 trials, N = 766; random-effects; low-certainty evidence). We excluded 10 trials that were at high or unclear risk of bias in several domains from this analysis and limited all analyses to studies at lower risk of bias. Recovery rates were better in participants receiving corticosteroids alone than antivirals alone (RR 2.69, 95% CI 0.73 to 10.01; 2 trials, N = 667; random-effects), but the result was imprecise and allowed for the possibility of no effect. The rate of incomplete recovery was lower with antivirals plus corticosteroids than with placebo or no treatment (RR 0.56, 95% CI 0.42 to 0.76; 2 trials, N = 658; random-effects). Antivirals alone had no clear effect on incomplete recovery rates compared with placebo, but the result was imprecise (RR 1.10, 95% CI 0.87 to 1.40; 2 trials, N = 658; fixed-effect). For people with severe Bell's palsy (House-Brackmann score of 5 and 6, or equivalent on other scales), we found that the combination of antivirals and corticosteroids had no clear effect on incomplete recovery at month six compared to corticosteroids alone, although the result was again imprecise (RR 0.82, 95% CI 0.57 to 1.17; 2 trials, N = 98; random-effects).Motor synkinesis or crocodile tearsAntivirals plus corticosteroids reduced the proportion of participants who experienced these long-term sequelae from Bell's palsy compared to placebo plus corticosteroids (RR 0.56, 95% CI 0.36 to 0.87; 2 trials, N = 469; fixed-effect; moderate-certainty evidence). Antivirals plus corticosteroids reduced long-term sequelae compared to placebo but there was no clear difference in this outcome with antivirals alone compared to placebo.Adverse events Adverse event data were available in four studies providing data on 1592 participants. None of the four comparisons showed clear differences in adverse events between treatment and comparison arms (very low-certainty evidence); for the comparison of antivirals plus corticosteroids and corticosteroids alone in studies at lower risk of bias, the RR was 1.17 (95% CI 0.81 to 1.69; 2 trials, N = 656; fixed-effect; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in comparison to corticosteroids alone in Bell's palsy of various degrees of severity, or in people with severe Bell's palsy, but the results were very imprecise. Corticosteroids alone were probably more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no clear benefit from antivirals alone over placebo.The combination of antivirals and corticosteroids probably reduced the late sequelae of Bell's palsy compared with corticosteroids alone. Studies also showed fewer episodes of long-term sequelae in corticosteroid-treated participants than antiviral-treated participants.We found no clear difference in adverse events from the use of antivirals compared with either placebo or corticosteroids, but the evidence is too uncertain for us to draw conclusions.An adequately powered RCT in people with Bell's palsy that compares different antiviral agents may be indicated.

Inpatient treatment of patients with acute idiopathic peripheral facial palsy: A population-based healthcare research study

OBJECTIVES

To determine the inpatient management for patients with acute idiopathic facial palsy (IFP) in Thuringia, Germany.

DESIGN

Population-based study.

SETTING

All inpatients with IFP in all hospitals with departments of otolaryngology and neurology in 2012, in the German federal state, Thuringia.

MAIN OUTCOME MEASURES

Patients' characteristics and treatment were compared between departments, and the probability of recovery was tested.

RESULTS

A total of 291 patients were mainly treated in departments of otolaryngology (55%) and neurology (36%). Corticosteroid treatment was the predominant therapy (84.5%). The probability to receive a facial nerve grading (odds ratio [OR=12.939; 95% confidence interval [CI]=3.599 to 46.516), gustatory testing (OR=6.878; CI=1.064 to 44.474) and audiometry (OR=32.505; CI=1.485 to 711.257) was significantly higher in otolaryngology departments, but lower for cranial CT (OR=0.192; CI=0.061 to 0.602), cerebrospinal fluid examination (OR=0.024; CI=0.006 to 0.102). A total of 131 patients (45%) showed a recovery to House-Brackmann grade≤II. A pathological stapedial reflex test (Hazard ratio [HR]=0.416; CI=0.180 to 0.959) was the only independent diagnostic predictor of worse outcome. Prednisolone dose >500 mg (HR=0.579; CI 0.400 to 0.838) and no adjuvant physiotherapy (HR=0.568; CI=0.407 to 0.794) were treatment-related predictors of worse outcome.

CONCLUSIONS

Inpatient treatment of IFP seems to be highly variable in daily practice, partly depending on the treating discipline and despite the availability of evidence-based guidelines. The population-based recovery rate was worse than reported in clinical trials.

Causes and management of facial nerve palsy

Facial nerve palsy causes disfigurement with cosmetic, functional and psychological repercussions. The facial nerve can be affected anywhere along its course. A comprehensive assessment considering all differential diagnoses is critical to optimal management, as prompt, appropriate therapy leads to better outcomes.

Bell's Palsy in Children (BellPIC): protocol for a multicentre, placebo-controlled randomized trial

BACKGROUND

Bell's palsy or acute idiopathic lower motor neurone facial paralysis is characterized by sudden onset paralysis or weakness of the muscles to one side of the face controlled by the facial nerve. While there is high level evidence in adults demonstrating an improvement in the rate of complete recovery of facial nerve function when treated with steroids compared with placebo, similar high level studies on the use of steroids in Bell's palsy in children are not available. The aim of this study is to assess the utility of steroids in Bell's palsy in children in a randomised placebo-controlled trial.

METHODS/DESIGN

We are conducting a randomised, triple-blinded, placebo controlled trial of the use of prednisolone to improve recovery from Bell's palsy at 1 month. Study sites are 10 hospitals within the Australian and New Zealand PREDICT (Paediatric Research in Emergency Departments International Collaborative) research network. 540 participants will be enrolled. To be eligible patients need to be aged 6 months to < 18 years and present within 72 hours of onset of clinician diagnosed Bell's palsy to one of the participating hospital emergency departments. Patients will be excluded in case of current use of or contraindications to steroids or if there is an alternative diagnosis. Participants will receive either prednisolone 1 mg/kg/day to a maximum of 50 mg/day or taste matched placebo for 10 days. The primary outcome is complete recovery by House-Brackmann scale at 1 month. Secondary outcomes include assessment of recovery using the Sunnybrook scale, the emotional and functional wellbeing of the participants using the Pediatric Quality of Life Inventory and Child Health Utility 9D Scale, pain using Faces Pain Scale Revised or visual analogue scales, synkinesis using a synkinesis assessment questionnaire and health utilisation costs at 1, 3 and 6 months. Participants will be tracked to 12 months if not recovered earlier. Data analysis will be by intention to treat with primary outcome presented as differences in proportions and an odds ratio adjusted for site and age.

DISCUSSION

This large multicenter randomised trial will allow the definitive assessment of the efficacy of prednisolone compared with placebo in the treatment of Bell's palsy in children.

TRIAL REGISTRATION

The study is registered with the Australian New Zealand Clinical Trials Registry ACTRN12615000563561 (1 June 2015).

Corticosteroids for Bell's palsy (idiopathic facial paralysis)

BACKGROUND

Inflammation and oedema of the facial nerve are implicated in causing Bell's palsy. Corticosteroids have a potent anti-inflammatory action that should minimise nerve damage. This is an update of a review first published in 2002 and last updated in 2010.

OBJECTIVES

To determine the effectiveness and safety of corticosteroid therapy in people with Bell's palsy.

SEARCH METHODS

On 4 March 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and LILACS. We reviewed the bibliographies of the randomised trials and contacted known experts in the field to identify additional published or unpublished trials. We also searched clinical trials registries for ongoing trials.

SELECTION CRITERIA

Randomised trials and quasi-randomised trials comparing different routes of administration and dosage schemes of corticosteroid or adrenocorticotrophic hormone therapy versus a control group receiving no therapy considered effective for this condition, unless the same therapy was given in a similar way to the experimental group.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. The main outcome of interest was incomplete recovery of facial motor function (i.e. residual facial weakness). Secondary outcomes were cosmetically disabling persistent sequelae, development of motor synkinesis or autonomic dysfunction (i.e. hemifacial spasm, crocodile tears) and adverse effects of corticosteroid therapy manifested during follow-up.

MAIN RESULTS

We identified seven trials, with 895 evaluable participants for this review. All provided data suitable for the primary outcome meta-analysis. One of the trials was new since the last version of this Cochrane systematic review. Risk of bias in the older, smaller studies included some unclear- or high-risk assessments, whereas we deemed the larger studies at low risk of bias. Overall, 79/452 (17%) participants allocated to corticosteroids had incomplete recovery of facial motor function six months or more after randomisation; significantly fewer than the 125/447 (28%) in the control group (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.50 to 0.80, seven trials, n = 895). The number of people who need to be treated with corticosteroids to avoid one incomplete recovery was 10 (95% CI 6 to 20). The reduction in the proportion of participants with cosmetically disabling sequelae six months after randomisation was very similar in the corticosteroid and placebo groups (RR 0.96, 95% CI 0.40 to 2.29, two trials, n = 75, low-quality evidence). However, there was a significant reduction in motor synkinesis during follow-up in participants receiving corticosteroids (RR 0.64, 95% CI 0.45 to 0.91, three trials, n = 485, moderate-quality evidence). Three studies explicitly recorded the absence of adverse effects attributable to corticosteroids. One trial reported that three participants receiving prednisolone had temporary sleep disturbances and two trials gave a detailed account of adverse effects occurring in 93 participants, all non-serious; the combined analysis of data from these three trials found no significant difference in adverse effect rates between people receiving corticosteroids and people receiving placebo (RR 1.04, 95% CI 0.71 to 1.51, n = 715).

AUTHORS' CONCLUSIONS

The available moderate- to high-quality evidence from randomised controlled trials showed significant benefit from treating Bell's palsy with corticosteroids.

Antiviral treatment for Bell's palsy (idiopathic facial paralysis)

BACKGROUND

Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. Significant morbidity can be associated with severe cases of Bell's palsy. This review was first published in 2001 and revised several times, most recently in 2009. This version replaces an update of the review in Issue 7 of the Cochrane Library subsequently withdrawn because of an ongoing investigation into the reliability of data from an included study.

OBJECTIVES

To assess the effects of antiviral treatments alone or in combination with any other therapy for Bell's palsy.

SEARCH METHODS

On 7 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, DARE, NHS EED, and HTA. We also reviewed the bibliographies of the identified trials and contacted trial authors and known experts in the field and relevant drug companies to identify additional published or unpublished data. We searched clinical trials registries for ongoing studies.

SELECTION CRITERIA

We considered randomised controlled trials or quasi-randomised controlled trials of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy. We excluded trials that had a high risk of bias in several domains.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently assessed trials for relevance, eligibility, and risk of bias, using standard Cochrane procedures.

MAIN RESULTS

Ten trials, including 2280 participants, met the inclusion criteria and are included in the final analysis. Some of the trials were small, and a number were at high or unclear risk of bias. Other trials did not meet current best standards in allocation concealment and blinding. Incomplete recoveryWe found a significant benefit from adding antivirals to corticosteroids in comparison with corticosteroids alone for people with Bell's palsy (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.39 to 0.97, n = 1315). For people with severe Bell's palsy (House-Brackmann scores of 5 and 6 or the equivalent in other scales), we found a reduction in the rate of incomplete recovery at month six when antivirals plus corticosteroids were used, compared to corticosteroids alone (RR 0.64, 95% CI 0.41 to 0.99, n = 478). The outcome for the participants receiving corticosteroids alone was significantly better than for those receiving antivirals alone (RR 2.82, 95% CI 1.09 to 7.32, n = 768). The treatment effect of placebo was significantly lower than that of antivirals plus corticosteroids (RR 0.56, 95% CI 0.41 to 0.76, n = 658). Antivirals alone produced no benefit compared with placebo (RR 1.10, 95% CI 0.87 to 1.40, n = 658). Motor synkinesis or crocodile tearsIn two trials comparing antivirals and corticosteroids with corticosteroids and placebo that assessed this outcome, we found a significant difference in long-term sequelae in favour of antivirals plus corticosteroids (RR 0.56, 95% CI 0.36 to 0.87, n = 469). Two trials comparing antivirals alone with corticosteroids alone investigating this outcome showed fewer sequelae with corticosteroids (RR 1.52, 95% CI 1.08 to 2.12, n = 472). We found no data on long-term sequelae for other comparisons. Adverse events Adverse event data were available in three studies giving comparison data on 1528 participants. None of the four comparisons (antivirals plus corticosteroids versus corticosteroids plus placebo or no treatment; antivirals versus corticosteroids; antivirals plus corticosteroids versus placebo; antivirals versus placebo) showed significant differences in adverse events between treatment and control arms. We could find no correlation with specific treatment within these results.

AUTHORS' CONCLUSIONS

Low-quality evidence from randomised controlled trials showed a benefit from the combination of antivirals with corticosteroids compared to corticosteroids alone for the treatment of Bell's palsy of various degrees of severity. Low-quality evidence showed a benefit of combination therapy compared with corticosteroids alone in severe Bell's palsy. Corticosteroids alone were more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no benefit from antivirals alone over placebo.Moderate-quality evidence indicated that the combination of antivirals and corticosteroids reduced sequelae of Bell's palsy compared with corticosteroids alone.We found no significant increase in adverse events from the use of antivirals compared with either placebo or corticosteroids, based on low-quality evidence.

Antiviral treatment for Bell's palsy (idiopathic facial paralysis)

BACKGROUND

Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. Significant morbidity can be associated with severe cases of Bell's palsy.

OBJECTIVES

To assess the effects of antiviral treatments alone or in combination with any other therapy for Bell's palsy.

SEARCH METHODS

On 7 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, DARE, NHS EED, and HTA. We also reviewed the bibliographies of the identified trials and contacted trial authors and known experts in the field and relevant drug companies to identify additional published or unpublished data. We searched clinical trials registries for ongoing studies.

SELECTION CRITERIA

We considered randomised controlled trials or quasi-randomised controlled trials of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy. We excluded trials that had a high risk of bias in several domains.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently assessed trials for relevance, eligibility, and risk of bias, using standard Cochrane procedures.

MAIN RESULTS

Eleven trials, including 2883 participants, met the inclusion criteria and are included in the final analysis. We added four studies to the previous review for this update. Some of the trials were small, and a number were at high or unclear risk of bias. Other trials did not meet current best standards in allocation concealment and blinding. Incomplete recoveryWe found no significant benefit from adding antivirals to corticosteroids in comparison with corticosteroids alone for people with Bell's palsy (risk ratio (RR) 0.69, 95% confidence interval (CI) 0.47 to 1.02, n = 1715). For people with severe Bell's palsy (House-Brackmann scores of 5 and 6 or the equivalent in other scales), we found a reduction in the rate of incomplete recovery at month six when antivirals plus corticosteroids were used (RR 0.64, 95% CI 0.41 to 0.99, n = 478). The outcome for the participants receiving corticosteroids alone was significantly better than for those receiving antivirals alone (RR 2.09, 95% CI 1.36 to 3.20, n = 1169). The treatment effect of placebo was significantly lower than that of antivirals plus corticosteroids (RR 0.56, 95% CI 0.41 to 0.76, n = 658). Antivirals alone had a non-significant detrimental effect on the outcome compared with placebo (RR 1.10, 95% CI 0.87 to 1.40, n = 658). Motor synkinesis or crocodile tearsIn three trials comparing antivirals and corticosteroids with corticosteroids and placebo that assessed this outcome, we found a significant difference in long-term sequelae in favour of antivirals plus corticosteroids (RR 0.73, 95% CI 0.54 to 0.99, n = 869). Three trials comparing antivirals alone with corticosteroids alone investigating this outcome showed fewer sequelae with corticosteroids (RR 1.44, 95% CI 1.11 to 1.85, n = 873). We found no data on long-term sequelae for other comparisons. Adverse events Adverse event data were available in three studies giving comparison data on 1528 participants. None of the four comparisons (antivirals plus corticosteroids versus corticosteroids plus placebo or no treatment; antivirals versus corticosteroids; antivirals plus corticosteroids versus placebo; antivirals versus placebo) showed significant differences in adverse events between treatment and control arms. We could find no correlation with specific treatment within these results.

AUTHORS' CONCLUSIONS

Moderate-quality evidence from randomised controlled trials showed no additional benefit from the combination of antivirals with corticosteroids compared to corticosteroids alone for the treatment of Bell's palsy of various degrees of severity. Moderate-quality evidence showed a small but just significant benefit of combination therapy compared with corticosteroids alone in severe Bell's palsy. Corticosteroids alone were more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no benefit from antivirals alone over placebo.Moderate-quality evidence indicated that the combination of antivirals and corticosteroids reduced sequelae of Bell's palsy compared with corticosteroids alone.We found no significant increase in adverse events from the use of antivirals compared with either placebo or corticosteroids, based on moderate-quality evidence.

WITHDRAWN. Antiviral treatment for Bell's palsy (idiopathic facial paralysis)

BACKGROUND

Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. Significant morbidity can be associated with severe cases of Bell's palsy.

OBJECTIVES

To assess the effects of antiviral treatments alone or in combination with any other therapy for Bell's palsy.

SEARCH METHODS

On 7 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, DARE, NHS EED, and HTA. We also reviewed the bibliographies of the identified trials and contacted trial authors and known experts in the field and relevant drug companies to identify additional published or unpublished data. We searched clinical trials registries for ongoing studies.

SELECTION CRITERIA

We considered randomised controlled trials or quasi-randomised controlled trials of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy. We excluded trials that had a high risk of bias in several domains.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently assessed trials for relevance, eligibility, and risk of bias, using standard Cochrane procedures.

MAIN RESULTS

Eleven trials, including 2883 participants, met the inclusion criteria and are included in the final analysis. We added four studies to the previous review for this update. Some of the trials were small, and a number were at high or unclear risk of bias. Other trials did not meet current best standards in allocation concealment and blinding. Incomplete recoveryWe found no significant benefit from adding antivirals to corticosteroids in comparison with corticosteroids alone for people with Bell's palsy (risk ratio (RR) 0.69, 95% confidence interval (CI) 0.47 to 1.02, n = 1715). For people with severe Bell's palsy (House-Brackmann scores of 5 and 6 or the equivalent in other scales), we found a reduction in the rate of incomplete recovery at month six when antivirals plus corticosteroids were used (RR 0.64, 95% CI 0.41 to 0.99, n = 478). The outcome for the participants receiving corticosteroids alone was significantly better than for those receiving antivirals alone (RR 2.09, 95% CI 1.36 to 3.20, n = 1169). The treatment effect of placebo was significantly lower than that of antivirals plus corticosteroids (RR 0.56, 95% CI 0.41 to 0.76, n = 658). Antivirals alone had a non-significant detrimental effect on the outcome compared with placebo (RR 1.10, 95% CI 0.87 to 1.40, n = 658). Motor synkinesis or crocodile tearsIn three trials comparing antivirals and corticosteroids with corticosteroids and placebo that assessed this outcome, we found a significant difference in long-term sequelae in favour or antivirals plus corticosteroids (RR 0.73, 95% CI 0.54 to 0.99, n = 869). Three trials comparing antivirals alone with corticosteroids alone investigating this outcome showed fewer sequelae with corticosteroids (RR 1.44, 95% CI 1.11 to 1.85, n = 873). We found no data on long-term sequelae for other comparisons. Adverse events Adverse event data were available in three studies giving comparison data on 1528 participants. None of the four comparisons (antivirals plus corticosteroids versus corticosteroids plus placebo or no treatment; antivirals versus corticosteroids; antivirals plus corticosteroids versus placebo; antivirals versus placebo) showed significant differences in adverse events between treatment and control arms. We could find no correlation with specific treatment within these results.

AUTHORS' CONCLUSIONS

Moderate-quality evidence from randomised controlled trials showed no additional benefit from the combination of antivirals with corticosteroids compared to corticosteroids alone or with placebo, and no benefit from antivirals alone compared to placebo, for the treatment of Bell's palsy. Moderate-quality evidence showed a small but just significant benefit of combination therapy compared with corticosteroids alone in severe Bell's palsy. We found no significant increase in adverse events from the use of antivirals compared with either placebo or corticosteroids.

Addressing the evidence to practice gap for complex interventions in primary care: a systematic review of reviews protocol

INTRODUCTION

Getting the results of research implemented into routine healthcare is often a challenge. The disconnect between the development and implementation of evidence into practice is called the 'second translational gap' and is particularly apparent in primary care. To address this gap, we plan to identify, summarise and synthesise currently available evidence by undertaking a systematic review of reviews to: (1) explore barriers and facilitators of implementation of research evidence or complex interventions, and (2) assess the effectiveness of strategies in facilitating implementation of complex interventions in primary care.

METHODS AND ANALYSIS

This is a protocol for a systematic review of reviews. We will search MEDLINE, EMBASE, the Cochrane Library, CINAHL and PsycINFO up until December 2013. We will check reference lists of included studies for further studies. Two authors will independently screen the titles and abstracts identified from the search; any discrepancies will be resolved by discussion and consensus. Full-text papers will be obtained and relevant reviews will be selected against inclusion criteria. Eligible reviews have to be based on predominantly primary care in developed countries and examine either factors to implementation or, the effectiveness of strategies to optimise implementation. Data from eligible reviews will be extracted using standardised data abstraction forms. For barriers and facilitators, data will be synthesised using an interpretative meta-synthesis approach. For implementation strategies, findings will be summarised and described narratively and synthesised using a framework approach. All findings will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required. The review findings will inform the work of the design and implementation of future studies and will be of interest to a wide audience including health professionals, researchers, health service or commissioning managers and policymakers.

TRIAL REGISTRATION NUMBER

Protocol registration number (PROSPERO CRD42014009410).