Detection of Herpes Simplex and Varicella-Zoster Viruses in Patients with Bell's Palsy by the Polymerase Chain Reaction Technique

Predicting Early Treatment Effectiveness in Bell's Palsy Using Machine Learning: A Focus on Corticosteroids and Antivirals

Purpose

Facial nerve paralysis, particularly Bell's palsy, manifests as a rapid onset of unilateral facial weakness or paralysis. Despite most patients recovering within three to six months, a significant proportion experience poor recovery. This study utilized six machine learning models to investigate the effectiveness of early treatment in Bell's palsy.

Patients and Methods

We applied data from 17 hospitals in Scotland to predict treatment outcomes. Patients were randomized into four groups: Prednisolone (corticosteroids), Acyclovir (antivirals), both, and placebo. Outcomes, defined as full resolution of symptoms, were assessed using the House-Brackmann scale at 3 and 9 months post-treatment. We employed six different machine learning models to predict recovery outcomes and evaluated model performance using AUC, precision, recall, and F1-score.

Results

Among 493 patients, 72.6% recovered after three months and 89.5% after nine months. Logistic regression demonstrated the highest predictive performance for both 3-month (AUC = 0.751) and 9-month recovery (AUC = 0.720). Additionally, several models achieved Precision levels exceeding 0.9. We further employed the best-performing logistic regression for feature ranking, indicating that the patient's age and prednisolone administration are the most significant predictors of recovery.

Conclusion

The results highlight the potential of machine learning models in predicting the effectiveness of early treatment. This study conducted a comprehensive comparison of six different machine learning models, with the logistic regression showing the highest predictive performance for both 3-month and 9-month recovery. Additionally, feature ranking using logistic regression supported the importance of Prednisolone in treatment. Notably, our findings revealed the significance of age in prognosis evaluation for the first time. This suggests that future research should further develop age-specific prognostic models, enabling clinicians to tailor individualized treatment strategies more effectively. This previously unrecognized discovery provides a foundation for prognostic analysis in Bell's palsy patients.

Association of Influenza Vaccination With Risk of Bell Palsy Among Older Adults in Taiwan

Importance

Annual administration of the influenza vaccine (fluVc) is currently the most effective method of preventing the influenza virus in older adults. However, half of adults older than 65 years remain unvaccinated in Taiwan, possibly because of concern about adverse events, such as Bell palsy (BP). Currently, studies on the association between fluVc and risk of BP are inconsistent.

Objective

To determine whether the incidence of BP increases following fluVc in older adults.

Design, Setting, and Participants

A self-controlled case series study design was used. Days 1 through 7, days 8 through 14, days 15 through 30, and days 31 through 60 following fluVc were identified as risk intervals, and days 61 through 180 were considered the control interval. A total of 4367 vaccinated individuals aged 65 years or older who developed BP within 6 months following fluVc were enrolled. Population-based retrospective claims data were obtained between 2010 and 2017; data were analyzed from April 2022 through September 2022.

Exposure

Government-funded seasonal fluVc.

Main Outcomes and Measures

The outcome of interest was BP onset in risk intervals compared with control intervals. Three or more consecutive diagnoses of BP within 60 days following fluVc were used as the definition of a patient with BP. Poisson regression was used to analyze the incidence rate ratio (IRR) of risk intervals compared with control intervals.

Results

In total, 13 261 521 patients who received the fluVc were extracted from the National Health Insurance Research Database in Taiwan from January 1, 2010, to December 31, 2017. Of those, 7 581 205 patients older than 65 years old met the inclusion criteria. The number of patients with BP diagnosed within 6 months following fluVc enrolled for risk analysis was 4367 (mean [SD] age, 74.19 [5.97] years; 2349 [53.79%] female patients). The incidence rate of BP among all observed fluVc older adults was 57.87 per 100 000 person-years. The IRRs for BP on days 1 through 7, days 8 through 14, and days 15 through 30 were 4.18 (95% CI, 3.82-4.59), 2.73 (95% CI, 2.45-3.05), and 1.67 (95% CI, 1.52-1.84), respectively. However, there was no increase during days 31 through 60 (IRR, 1.06; 95% CI, 0.97-1.16). The postvaccination risk of BP was consistent across all subgroups stratified by sex, age group, and baseline conditions.

Conclusions and Relevance

The present self-controlled case series indicated that the risk of BP in individuals older than 65 years increased within the first month, especially within the first week, following fluVc. But overall, the adverse event rate of BP was low, and considering the morbidity and mortality of influenza infection, the benefits of fluVc still outweigh the risks.

Global Trends and Performances of Acupuncture Therapy on Bell's Palsy from 2000 to 2023: A Bibliometric Analysis

Purpose

Recent studies have shown that acupuncture may have great potential in the treatment of Bell's palsy. However, the bibliometric analysis of this field has not been summarized properly. Thus, the purpose of this study is to analyze the hotspot of acupuncture for Bell's Palsy.

Methods

The core collection database of Web of Science was searched for relevant publications from 2000 to 2023, and countries, institutions, authors, keywords, and literature were analyzed and visualized by bibliometric softwareCiteSpace 5.1.R6, Vosviewer, BICOMB, and gCLUTO to explore the scientific achievements, research collaboration networks, research hot spots, and research trends.

Results

229 publications were included in this study. The most cited journal is Journal of Otolaryngology-Head & Neck Surgery; the most prolific country is China; the most prolific author is Li Ying, moreover, the collaboration among scholars is poor; Kyung Hee University is the most prolific institution studying acupuncture for Bell's Palsy. Reference burst detection indicates that traditional Chinese Medicine philosophy, the role of acupuncture in the prognosis of facial palsy, mechanism of acupuncture to improve facial nerve function, and the use of electroacupuncture are starting to become new research hotspots.

Conclusion

The field of acupuncture for Bell's Palsy has developed rapidly in recent years, and new research trends are mainly: combination with traditional Chinese medicine, the role of acupuncture in the prognosis of facial palsy, mechanism of acupuncture to improve facial nerve function, and the use of electroacupuncture. However, research in this field is still dominated by case reports and clinical trials, and there is a lack of large-scale, multicenter clinical trials and animal experiments there are still many problems in institutional cooperation and experimental design, which requires relevant researchers to strengthen cooperation and improve experimental design.

Comparing the Use of High-Dose to Standard-Dose Corticosteroids for the Treatment of Bell's Palsy in Adults-A Systematic Review and Meta-analysis

OBJECTIVE

Bell's palsy is typically treated with oral corticosteroids (40-60 mg daily). Concomitant antivirals are currently not recommended. The objective of this systematic review and meta-analysis was to examine the effect of high-dose versus standard-dose corticosteroids, without antivirals, in the management of Bell's palsy.

DATABASES REVIEWED

Embase, MEDLINE, PubMed, CINAHL, Cochrane Library.

METHODS

A systematic review and meta-analysis was performed according to PRISMA guidelines. Studies comparing high-dose (≥80 mg) or standard-dose (40-60 mg) corticosteroid therapy for Bell's palsy were included. Exclusion criteria were coexisting antiviral treatment, nonoral drug delivery, and facial palsy due to other causes. Risk of bias was assessed using ROBINS-I. A weighted estimate of treatment effects across trials as odds ratios (OR) using a Mantel-Haenzel random-effects model was calculated.

RESULTS

Three articles were included in the analysis, representing 485 patients. There was a significant decrease in nonrecovery with high-dose, compared with standard-dose, corticosteroids at 6 months follow-up (OR = 0.17, 95% confidence interval = 0.05-0.56, p = 0.004). Overall adverse events were 5.8% (n = 28), all reported in one study in the high-dose group (transient elevated liver enzymes and fecal occult blood).

CONCLUSIONS

Our analysis shows a favorable effect of high-dose corticosteroid in the treatment of Bell's palsy. It is the first to evaluate this effect without the use of antivirals in keeping with current treatment recommendations. As all included studies had a serious risk of bias, future research should focus on larger trials with more robust methodology. This will allow for more up-to-date and large-scale analyses where more valid conclusions can be drawn that may potentially influence treatment protocols.

Steroids with and Without Antivirals in the Treatment of Bell’s Palsy: Does It Make any Difference in Recovery? A Study at a Tertiary Care Center, Karachi, Pakistan

Objectives: To compare the pharmacological effects of steroids in comparison to steroids with antiviral drugs for the treatment of Bell’s Palsy. Methods: A total 60 patients were enrolled and segregated equally into two groups, where patients on prednisolone were labeled as group A (Control group), whereas patients on prednisolone + acyclovir were labeled as group B (study group). All patients had House Brackmann score. The control group started oral prednisolone 1 mg/kg for 10 days, whereas the study group started acyclovir 400 mg 4 times a day for 10 days along with prednisolone tablets. Patients were regularly observed till the study was completed. Primary outcome measure was facial nerve recovery. Health-related quality of life and facial appearance were considered secondary outcomes. Results: The primary outcomes assessed as complete recovery from Bell’s Palsy by Brackmann score at week 4 were found in 17/30 (57%) patients and 23/30 (77%) patients at week 8 in the control group. Complete recovery from Bell’s Palsy was also shown in the experimental group (Prednisolone + acyclovir) where 25/30 (83%) patients completed recovery at week 4, while 27/30 (90%) patients at week 8. Comparison of the two groups showed a significant improvement in the study group (prednisolone + acyclovir) (P = 0.047) at week 4 and (P = 0.02) at week 8. The secondary outcomes were assessed as improvement in the quality of life and facial appearance from Bell’s Palsy. Health utility score was 0.84 ± 0.01 in the control group (On prednisolone) with facial appearance score of (Derriford appearance scale 59) 61 ± 28. At week 4, the study group (on prednisolone+ acyclovir) showed 0.88 ± 0.12 score on Health utility index scale-3 and 46 ± 26 score on Derriford appearance scale. Comparison of the quality of life (Health quality index scale-3) and facial appearance among both control and study groups showed a significant improvement in the study group (P = 0.001 and P = 0.005, respectively). Moreover, when health utility score and Derriford appearance were compared among both groups, it showed a significant improvement in the study group (P = 0.001 and 0.016, respectively). Conclusions: The combination of prednisolone with acyclovir is found superior to prednisolone alone, and this combination treatment results in improvement in both recovery and quality of life.

Adjunctive Corticosteroids for Lyme Neuroborreliosis Peripheral Facial Palsy - a prospective study with historical controls

BACKGROUND

Lyme neuroborreliosis peripheral facial palsy (LNB PFP) and idiopathic peripheral facial palsy, Bell's palsy (BP), are the most common causes of facial palsy in borrelia-endemic areas and are clinically similar. Early treatment with corticosteroids has been shown to be effective in Bell's palsy and antibiotics improve outcome in LNB, but there is a lack of knowledge on how the addition of corticosteroids to standard antibiotic treatment affects outcome in LNB PFP.

METHODS

This prospective open trial with historical controls was conducted at two large hospitals in western Sweden between 2011 and 2018. Adults presenting with LNB PFP were included in the study group and were treated with oral doxycycline 200 mg b.i.d. for 10 days and prednisolone 60 mg o.d. for 5 days, then tapered over 5 days. The historical controls were adult patients with LNB PFP included in previous studies and treated with oral doxycycline. Both groups underwent a follow-up lumbar puncture and were followed until complete recovery or for 12 months.

RESULTS

Fifty-seven patients were included, 27 in the study group and 30 in the control group. Two patients (6%) in the study group and 6 patients (20%) in the control group suffered from sequelae at end follow up. There was no statistically significant difference between the groups, neither in the proportion of patients with sequelae, nor in the decline in CSF mononuclear cell count.

CONCLUSIONS

Adjunctive corticosteroids neither improve nor impair the outcome for patients with Lyme neuroborreliosis peripheral facial palsy treated with doxycycline.

Surgical interventions for the early management of Bell's palsy

BACKGROUND

Bell's palsy is an acute unilateral facial paralysis of unknown aetiology and should only be used as a diagnosis in the absence of any other pathology. As the proposed pathophysiology is swelling and entrapment of the nerve, some surgeons suggest surgical decompression of the nerve as a possible management option; this is ideally performed as soon as possible after onset. This is an update of a review first published in 2011, and last updated in 2013. This update includes evidence from one newly identified study.

OBJECTIVES

To assess the effects of surgery in the early management of Bell's palsy.

SEARCH METHODS

On 20 March 2020, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and WHO ICTRP. We handsearched selected conference abstracts for the original version of the review.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) or quasi-RCTs involving any surgical intervention for Bell's palsy. Trials compared surgical interventions to no treatment, later treatment (beyond three months), sham treatment, other surgical treatments or medical treatment.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. The primary outcome was complete recovery of facial palsy at 12 months. Secondary outcomes were complete recovery at three and six months, synkinesis and contracture at 12 months, psychosocial outcomes at 12 months, and side effects and complications of treatment.

MAIN RESULTS

Two trials with 65 participants met the inclusion criteria; one was newly identified at this update. The first study randomised 25 participants into surgical or non-surgical (no treatment) groups using statistical charts. One participant declined surgery, leaving 24 evaluable participants. The second study quasi-randomised 53 participants; however, only 41 were evaluable as 12 declined the intervention they were allocated. These 41 participants were then divided into early surgery, late surgery or non-surgical (no treatment) groups using alternation. There was no mention on how alternation was decided. Neither study mentioned if there was any attempt to conceal allocation. Neither participants nor outcome assessors were blinded to the interventions in either study. There were no losses to follow-up in the first study. The second study lost three participants to follow-up, and 17 did not contribute to the assessment of secondary outcomes. Both studies were at high risk of bias. Surgeons in both studies used a retro-auricular/transmastoid approach to decompress the facial nerve. For the outcome recovery of facial palsy at 12 months, the evidence was uncertain. The first study reported no differences between the surgical and no treatment groups. The second study fully reported numerical data, but included no statistical comparisons between groups for complete recovery. There was no evidence of a difference for the early surgery versus no treatment comparison (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.05 to 11.11; P = 0.84; 33 participants; very low-certainty evidence) and for the early surgery versus late surgery comparison (RR 0.47, 95% CI 0.03 to 6.60; P = 0.58; 26 participants; very low-certainty evidence). We considered the effects of surgery on facial nerve function at 12 months very uncertain (2 RCTs, 65 participants; very low-certainty evidence). Furthermore, the second study reported adverse effects with a statistically significant decrease in lacrimal control in the surgical group within two to three months of denervation. Four participants in the second study had 35 dB to 50 dB of sensorineural hearing loss at 4000 Hz, and three had tinnitus. Because of the small numbers and trial design we also considered the adverse effects evidence very uncertain (2 RCTs, 65 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is very low-certainty evidence from RCTs or quasi-RCTs on surgery for the early management of Bell's palsy, and this is insufficient to decide whether surgical intervention is beneficial or harmful. Further research into the role of surgical intervention is unlikely to be performed because spontaneous or medically supported recovery occurs in most cases.

Can Systemic Immune-Inflammation Index (SII) be a prognostic factor of Bell's palsy patients?

OBJECTIVE

Recent studies showed that the neutrophil-to-lymphocyte ratio (NLR) and that platelet-to-lymphocyte ratio (PLR) can be used as inflammatory markers in Bell's palsy. In this study, the aim is to investigate a novel inflammatory index, the Systemic Immune-Inflammation Index (SII), defined as SII = platelets × neutrophils/lymphocytes, in Bell's palsy patients.

STUDY DESIGN

Retrospective.

SETTING

Clinical research center.

PATIENTS

The study included 88 Bell's palsy patients and 50 healthy controls.

INTERVENTIONS

Patients diagnosed with Bell's palsy from 2010 to 2019 in a university hospital and an age- and sex-matched healthy control group were included in the study retrospectively. A complete blood count was performed for all participants. Magnetic resonance imaging was applied for Bell's palsy patients for the exclusion of other diagnoses.

MAIN OUTCOME MEASURES

The CBC parameters were analyzed and hemoglobin, erythrocytes, leukocytes, neutrophils, lymphocytes, and platelet counts were measured. The PLR, NLR, and SII values were calculated with the formula.

RESULTS

The patient group had higher neutrophil counts and higher SII and NLR values than the control group (p < 0.05). Also, SII value is a prognostic factor in Bell's palsy in our study.

CONCLUSIONS

Bell's palsy has an inflammatory component. The SII value can indicate an inflammatory condition in these patients. It may be used as a marker and prognostic indicator in Bell's palsy.

Evaluation on curative effects of combined acupuncture plus physical therapy for treating idiopathic facial paralysis: A protocol for a systematic review and meta-analysis

BACKGROUND

The present study primarily aims to evaluate how effective acupuncture combined with physical therapy for the treatment of idiopathic facial paralysis.

METHODS

The PubMed database was searched (1946 to September 2020), the EMBASE data were also searched (January 1946 to September 2020), moreover, the Cochrane Central Register of Controlled Trials was searched (all years), and finally, the China National Knowledge Infrastructure (CNKI) was also included in the searching of electronic databases. The searching of publications did not include any language constraints. The titles and abstracts were scrutinized by a pair of authors to identify relevant studies. The efficacy of the association in the combination of acupuncture and physical therapy as a method of treatment for idiopathic facial paralysis was evaluated according to the pooled risk ratio (RR), mean differences (MD), or standardized mean difference (SMD) with the corresponding 95% confidence intervals (95% CI). A pair of authors conducted an autonomous risk assessment of the bias that would be introduced when the Cochrane Risk of Bias Tool is used. A pair of authors autonomously extracted data with the aid of a customized data extraction form. The RevMan 5.3 statistical analysis software was utilized for conducting the statistical analysis.

RESULTS

The final results will be presented in a scientific journal that will be peer-reviewed.

CONCLUSION

It is expected that the proposed systematic review and meta-analysis of acupuncture combined with physical therapy for treating idiopathic facial paralysis will provide reliable evidence for clinical application.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/RPCSE (https://osf.io/rpcse/).

Revisión sistemática sobre la prevalencia de la serología infecciosa en la parálisis facial periférica

Introducción y objetivos. La parálisis facial periférica es una afección del Nervio Facial que suele cursar con dolor retroauricular, pródromos vitales y parálisis facial. Ante la falta de bibliografía sobre la etiología de dicha parálisis se propuso realizar una revisión sistemática orientada a conocer la prevalencia serológica de la parálisis facial periférica en los diferentes estudios publicados incluyendo el realizado en esta facultad el curso anterior. Materiales y métodos. Revisión sistemática y metanálisis de los estudios publicados sobre la confirmación de una parálisis facial periférica por serología positiva. Resultados. Un total de 628 pacientes fueron analizados, de los cuáles 76 tenían serología positiva (12,10%). El metanálisis muestra heterogeneidad entre los resultados y sesgo de publicación. Conclusiones. No se evidencia que haya una relación significativa entre una parálisis facial periférica y una serología positiva reciente por lo que no se obtendría beneficio con un tratamiento antiviral.

The presence of herpes simplex-1 and varicella zoster viruses is not related with clinical outcome of Bell's Palsy

Bell's Palsy is the most frequent acute neuropathy of cranial nerves; it has been associated in various reports to herpes viruses. In a prospective study we searched the presence of DNA from five herpes viruses (HSV-1 and 2, VZV, EBV and HHV-6) in 79 patients at the acute phase of Bell's Palsy. Results were related with various parameters; age, gender and clinical outcome. We found the significant presence (p˂0.001) of HSV-1 and VZV in 39% and 42% of patients. However, a large percentage of cases were negative. When comparisons were made between subgroups according to gender and age no differences were found with viral findings nor with clinical outcome of palsy, which was of clinical remission in most cases (78%). Our results suggest that herpes viruses might participate in the complex mechanisms of autoimmunity of Bell's Palsy but not as determinant etiological element.

Recurrent Bell's palsy: outcomes and correlation with clinical comorbidities

Recurrent Bell’s palsy (RBP) has been reported to range from 2.6 to 15.2% of primary Bell’s palsy (BP) and has been associated with systemic comorbidities such as diabetes and hypertension. A retrospective analysis of patients affected by BP and RBP were performed to define the signs and symptoms associated with recurrence and the outcomes. Clinical and subjective characteristics of 341 patients affected by facial palsy were analysed. Facial function was assessed via House-Brackmann and Sunnybrook grading system. Characteristics of the palsy and systemic comorbidities (diabetes, hypertension, herpetic infections, autoimmunity disorders, audio-vestibular symptoms) were analysed in BP and RBP patients applying Fisher exact and the Mann-Whitney U tests, while time to recovery was explored with univariate and multivariate analysis. Twenty-four patients presented two or more episodes of facial palsy, representing a recurrence rate of 7%. Associated symptoms (e.g. retroauricular pain, taste disorder, dry eye etc.) were similar between BP and RBP patients. RBP occurred at older age than primary episode (p = 0.03). Recurrence was a risk factor for delayed recovery (p = 0.02), although final facial function was similar between the two groups. In conclusion, no significant differences were found between primary BP patients and RBP patients in terms of symptoms, palsy severity and presence of comorbidities. Delayed facial nerve function recovery in RBP did not affect the final outcome. Treatment of facial nerve recurrences must be the same of the primary episode, although the presence of prodromal symptoms may alert the patient and early corticosteroid treatment may be commenced even before the onset of paresis.

Chinese Herbal Medicine and Acupuncture Reduced the Risk of Stroke After Bell's Palsy: A Population-Based Retrospective Cohort Study

Objectives: Patients with Bell's palsy are more likely to develop stroke than the general population. The therapeutic effect of Traditional Chinese Medicine (TCM) on the risk of stroke in patients with Bell's palsy is unknown. We investigated the risk of stroke according to TCM use in Bell's palsy patients. Design: Records obtained from Taiwan's National Health Insurance Research Database identified 9,863 patients with Bell's palsy, 238 of whom met study inclusion criteria and were categorized as TCM users (n = 119) or non-TCM users (n = 119). TCM treatment modalities and Chinese herbal medicine prescription patterns were analyzed. Cox proportional hazards regression analysis determined the risk of stroke. Results: TCM users were at lower risk of stroke compared with non-TCM users (adjusted hazard ratio [aHR] 0.19; 95% confidence interval [CI], 0.06-0.59; p < 0.004). In subgroup analyses, patients treated with both TCM and oral steroids were at significantly lower risk of stroke compared with those who used neither (aHR 0.05; 95% CI, 0.01-0.22; p < 0.001). The risk of stroke was also lower among those treated with TCM only (aHR 0.25; 95% CI, 0.11-0.59; p < 0.001) or oral steroids only (aHR 0.12; 95% CI, 0.03-0.39; p < 0.01), compared with patients using neither. Conclusion: TCM therapy may lower the risk of stroke after Bell's palsy. However, the retrospective nature of this study and characteristics of the database limit these observational findings. Our results deserve further verification in large-scale prospective studies.

Compare the efficacy of acupuncture with drugs in the treatment of Bell's palsy: A systematic review and meta-analysis of RCTs

BACKGROUND

Bell's palsy or idiopathic facial paralysis is an acute facial paralysis caused by the inflammation of facial nerve. Several previous studies showed that acupuncture was beneficial in the treatment of facial paralysis. However, its effectiveness is still controversial compared with drug therapy. Therefore, this systematic review and meta-analysis was performed to assess the efficacy of acupuncture for Bell's palsy.

METHODS

This is a systematic review and meta-analysis of clinical studies among patients with Bell's palsy. We did a systematic literature search in PubMed, Embase, and the Cochrane Register of Controlled Trials to identify studies comparing the efficacy of acupuncture and drug treatment in treating facial paralysis. The search was last updated on July 2018.

RESULTS

The study included 11 randomized controlled trials with an overall sample of 1258 individuals. Acupuncture treatment was associated with an increased cure rate [relative risk (RR) = 1.77, 95% confidence interval (CI): 1.41-2.21], with significant heterogeneity in the pooled results (I = 67%, P = .0008). There was a significant difference in total effective rate in acupuncture and drug treatment for Bell's palsy (RR = 1.18,95% CI: 1.07-1.31), with substantial heterogeneity (I = 90%, P < .00001).

CONCLUSION

Although there was not enough evidence to prove its safety, acupuncture seems to be an effective therapy for Bell's palsy. Results of the present meta-analysis showed that acupuncture was associated with increased cure rate and total effective rate of the treatment of Bell's palsy in comparison with drugs. However, the results should be interpreted cautiously, because of the poor quality and heterogeneity of the included studies. In the future, more and more high quality randomized controlled trials (RCT) are needed to prove the safety and effectiveness of acupuncture.

Thiol/disulphide homeostasis in Bell's palsy as a novel pathogenetic marker

OBJECTIVES

The aim of this study was to investigate the relationship between Bell's palsy and a novel oxidative stress parameter, thiol/disulphide homeostasis.

DESIGN

A prospective study evaluating oxidative stress in Bell's palsy.

SETTING

This research took place in the department of Otorhinolaryngology, Ataturk Training and Research Hospital.

PARTICIPANTS

Totally, 77 patients with Bell's palsy and 38 healthy controls were included in this study.

MAIN OUTCOME MEASURES

The blood levels of total and native thiol and disulphide activity were assessed, and their levels were compared in the patients and controls.

RESULTS

There were statistically significant differences between the patients and controls regarding thiol/disulphide parameters. The mean native thiol and total thiol were significantly lower and disulphide levels were higher in the Bell's palsy than controls. On binary logistic regression analysis, the created model showed 45.3% variation. The cut-off value was 18.95 for disulphides.

CONCLUSION

Native and total thiol levels were low in the Bell's palsy. This metabolic disturbance may have a role in the pathogenesis of Bell's palsy.

Effects of Wind Chill Factor, Temperature and Other Meteorological Parameters on the Incidence of Bell's Palsy: Results Based on a Retrospective, 7-Year Long, Greek Population Study

BACKGROUND

The etiology of Bell's palsy (BP), the most common type of dysfunction of the facial nerve, remains unclear despite vigorous research. Data concerning the effects of meteorological factors (MFs) on its appearance are inconclusive. The aim of our study was to examine the demographics of a convenience sample of patients with BP and to determine the effects of several MFs in the recorded number of cases per month (cpm).

METHODS

We retrospectively reviewed 568 files of BP patients and concomitant data of MFs during an 84-month observation period. Information collected included age, gender, diabetic status, number of cpm (months further categorized as winter or summer), mean daily and monthly temperatures and wind speeds and monthly values of wind chill factor (WCF), a measure dependent on both temperature and wind speed. Potential correlations were estimated by univariate analyses (p = 0.05).

RESULTS

Demographics were in line with previous research regarding age and diabetic status, but indicative of slight male preponderance. Summer months and mean monthly temperatures showed significant negative correlations with cpm (p = 0.002 and <0.000, respectively) and strong positive correlation with WCF (p < 0.000).

CONCLUSIONS

MFs can substantially influence the possibility for BP appearance. We propose WCF as a novel, reliable estimator of the overall MF-derived risk.

Efficacy of Acupuncture for Bell's Palsy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Acupuncture has emerged as an alternative therapy for Bell’s palsy in both adults and children. However, the use of acupuncture is controversial. We conducted a systematic review and meta-analysis to assess the efficacy of acupuncture for Bell’s palsy. We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials, irrespective of any language restrictions. Randomized controlled trials comparing acupuncture with other therapies for Bell’s palsy in adults or children were included. Fourteen randomized controlled trials involving 1541 individuals were included in this meta-analysis. Significant association was observed in acupuncture with a higher effective response rate for Bell’s palsy (relative risk, 1.14; 95% confidence interval, 1.04–1.25; P = 0.005) but there was a heterogeneity among the studies (I² = 87%). An assessment of the included studies revealed a high risk of bias in methodological quality. An evaluation of the incidence of complications was not available, owing to incomplete data. Acupuncture seems to be an effective therapy for Bell’s palsy, but there was insufficient evidence to support the efficacy and safety of acupuncture. However, the results should be interpreted cautiously, because of the poor quality and heterogeneity of the included studies.

Workplace cluster of Bell's palsy in Lima, Peru

Background

We report on a workplace cluster of Bell’s palsy that occurred within a four-month period in 2011 among employees of a three-story office building in Lima, Peru and our investigation to determine the etiology and associated risk factors.

Findings

An outbreak investigation was conducted to identify possible common infectious or environmental exposures and included patient interviews, reviews of medical records, an epidemiologic survey, serological analysis for IgM and IgG antibodies to putative Bell’s palsy-inducing pathogens, and an environmental exposure assessment of the office building. Three cases of Bell’s palsy were reported among 65 at-risk employees, attack rate 4.6%. Although two patients had underlying risk factors, there was no clear association or common identifiable risk factor among all cases. Serologic analysis showed no evidence of recent infections, and air and water sample measures of all known chemical or neurotoxins were below maximum allowable concentrations for exposure.

Conclusions

An infection spread among workplace employees could not be excluded as a potential cause of this cluster; however, it was unlikely a pathogen commonly associated with individual cases of Bell’s palsy. Although a specific etiology was not identified among all cases, we believe this methodology will aid future outbreak investigations of Bell’s palsy and a better understanding of its etiology. While environmental assessments may be useful in their ability to ascertain the cause of clusters of Bell’s palsy, future investigations should prioritize focus on common infectious etiology.

Evidence based management of Bell's palsy

Bell's palsy (idiopathic facial paralysis) is caused by the acute onset of lower motor neurone weakness of the facial nerve with no detectable cause. With a lifetime risk of 1 in 60 and an annual incidence of 11-40/100,000 population, the condition resolves completely in around 71% of untreated cases. In the remainder facial nerve function will be impaired in the long term. We summarise current published articles regarding early management strategies to maximise recovery of facial nerve function and minimise long-term sequelae in the condition.

Surgical interventions for the early management of Bell's palsy

BACKGROUND

Bell's palsy is an acute paralysis of one side of the face of unknown aetiology. Bell's palsy should only be used as a diagnosis in the absence of all other pathology. As the proposed pathophysiology is swelling and entrapment of the nerve, some surgeons suggest surgical decompression of the nerve as a possible management option. This is an update of a review first published in 2011.

OBJECTIVES

To assess the effects of surgery in the management of Bell's palsy.

SEARCH METHODS

On 29 October 2012, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL (2012, Issue 10), MEDLINE (January 1966 to October 2012) and EMBASE (January 1980 to October 2012). We also handsearched selected conference abstracts for the original version of the review.

SELECTION CRITERIA

We included all randomised or quasi-randomised controlled trials involving any surgical intervention for Bell's palsy. We compared surgical interventions to no treatment, sham treatment, other surgical treatments or medical treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether trials identified from the searches were eligible for inclusion. Two review authors independently assessed the risk of bias and extracted data.

MAIN RESULTS

Two trials with a total of 69 participants met the inclusion criteria. The first study considered the treatment of 403 people but only included 44 participants in the surgical trial, who were randomised into surgical and non-surgical groups. However, the report did not provide information on the method of randomisation. The second study randomly allocated 25 participants into surgical or control groups using statistical charts. There was no attempt in either study to conceal allocation. Neither participants nor outcome assessors were blind to the interventions, in either study. The first study lost seven participants to follow-up and there were no losses to follow-up in the second study.Surgeons in both studies decompressed the nerves of all the surgical group participants using a retroauricular approach. The primary outcome was recovery of facial palsy at 12 months. The first study showed that the operated group and the non-operated group (who received oral prednisolone) had comparable facial nerve recovery at nine months. This study did not statistically compare the groups but the scores and size of the groups suggested that statistically significant differences are unlikely. The second study reported no statistically significant differences between the operated and control (no treatment) groups. One operated participant in the first study had 20 dB sensorineural hearing loss and persistent vertigo. We identified no new studies when we updated the searches in October 2012.

AUTHORS' CONCLUSIONS

There is only very low quality evidence from randomised controlled trials and this is insufficient to decide whether surgical intervention is beneficial or harmful in the management of Bell's palsy.Further research into the role of surgical intervention is unlikely to be performed because spontaneous recovery occurs in most cases.

Zoster sine herpete causing facial palsy

OBJECTIVES

The aims of this study were to verify the characteristics of zoster sine herpete (ZSH) causing facial palsy and the effects of different treatments and to confirm the difference from other etiologies.

METHODS

From March 2010 to March 2011, a prospective study was performed on patients with ZSH with facial palsy. Patients were divided into a steroid-treated group and a steroid-antiviral combination group, and then the effects according to regimen of treatment were prospectively analyzed. Last, the difference between the ZSH group and patients diagnosed with Bell palsy and Ramsay Hunt syndrome in the same study period was confirmed retrospectively.

RESULTS

Forty-five patients were diagnosed as having ZSH. Significant improvement was not observed in the ZSH group regardless of the treatment regimen during a 3-week period (P < .05). In patients with ZSH with accompanying typical pain, significant continuous improvement after 6 weeks was observed in patients with combination therapy (P < .05). Compared with patients with Bell palsy and Ramsay Hunt syndrome, there was a significant difference in recovery rate between patients with ZSH (accompanying pain) and those with Bell palsy (89.9%) (P < .05).

CONCLUSION

The initiation of recovery in ZSH started later than that in other peripheral palsies, and slower recovery was shown in patients with ZSH with pain compared with those with Bell palsy. Steroid-antiviral combination therapy was a more effective regimen for treatment compared with steroid-only treatment. To improve the accuracy of ZSH diagnosis, confirming the presence of accompanying typical pain is necessary.

Safety of zoster vaccine in adults from a large managed-care cohort: a Vaccine Safety Datalink study

OBJECTIVES

The aim of this study was to examine a large cohort of adults who received the zoster vaccine for evidence of an increased risk of prespecified adverse events requiring medical attention.

DESIGN

Two self-comparison approaches, including a case-centred approach and a self-controlled case series (SCCS) analysis were used.

SETTING

Eight managed-care organizations participating in the Vaccine Safety Datalink project in the United States.

SUBJECTS

A total of 193 083 adults aged 50 and older receiving a zoster vaccine from 1 January 2007 to 31 December 2008 were included.

MAIN OUTCOME MEASURES

Prespecified adverse events were identified by aggregated International Classification of Diseases, Ninth Revision (ICD-9) codes in automated health plan datasets.

RESULTS

The risk of allergic reaction was significantly increased within 1-7 days of vaccination [relative risk = 2.13, 95% confidence interval (CI): 1.87-2.40 by case-centred method and relative rate = 2.32, 95% CI: 1.85-2.91 by SCCS]. No increased risk was found for the following adverse event groupings: cerebrovascular events; cardiovascular events; meningitis; encephalitis; and encephalopathy; and Ramsay-Hunt syndrome and Bell's palsy.

CONCLUSIONS

The results of this study support the findings from the prelicensure clinical trials, providing reassurance that the zoster vaccine is generally safe and well-tolerated with a small increased risk of allergic reactions in 1-7 days after vaccination.

Surgical interventions for the early management of Bell's palsy

BACKGROUND

Bell's palsy is an acute paralysis of one side of the face of unknown aetiology. Bell's palsy should only be used as a diagnosis in the absence of all other pathology. As the proposed pathophysiology is swelling and entrapment of the nerve, some surgeons suggest surgical decompression of the nerve as a possible management option.

OBJECTIVES

The objective of this review was to assess the effectiveness of surgery in the management of Bell's palsy and to compare this to outcomes of medical management.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Specialized Register (23 November 2010). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) (23 November in The Cochrane Library, Issue 4 2010). We adapted this strategy to search MEDLINE (January 1966 to November 2010) and EMBASE (January 1980 to November 2010).

SELECTION CRITERIA

We included all randomised or quasi-randomised controlled trials involving any surgical intervention for Bell's palsy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether trials identified from the search strategy were eligible for inclusion. Two review authors assessed trial quality and extracted data independently.

MAIN RESULTS

Two trials with a total of 69 participants met the inclusion criteria. The first study considered the treatment of 403 patients but only included 44 in their surgical study. These were randomised into a surgical and non surgical group. The second study had 25 participants which they randomly allocated into surgical or control groups.The nerves of all the surgical group participants in both studies were decompressed using a retroauricular approach. The primary outcome was recovery of facial palsy at 12 months. The first study showed that both the operated and non operated groups had comparable facial nerve recovery at nine months. This study did not statistically compare the groups but the scores and size of the groups suggested that statistically significant differences are unlikely. The second study reported no statistically significant differences between their operated and control groups. One operated patient in the first study had 20 dB sensorineural hearing loss and persistent vertigo.

AUTHORS' CONCLUSIONS

There is only very low quality evidence from randomised controlled trials and this is insufficient to decide whether surgical intervention is beneficial or harmful in the management of Bell's palsy.Further research into the role of surgical intervention is unlikely to be performed because spontaneous recovery occurs in most cases.

Role of Kabat physical rehabilitation in Bell's palsy: a randomized trial

CONCLUSION

When applied at an early stage, Kabat's rehabilitation was shown to provide a better and faster recovery rate in comparison with non-rehabilitated patients.

OBJECTIVE

To assess the validity of an early rehabilitative approach to Bell's palsy patients.

PATIENTS AND METHODS

A randomized study involved 20 consecutive patients (10 males, 10 females; aged 35-42 years) affected by Bell's palsy, classified according to the House-Brackmann (HB) grading system and grouped on the basis of undergoing or not early physical rehabilitation according to Kabat, i.e. a proprioceptive neuromuscular rehabilitation. The evaluation was carried out by measuring the amplitude of the compound motor action potential (CMAP), as well as by observing the initial and final HB grade, at days 4, 7 and 15 after onset of facial palsy.

RESULTS

Patients belonging to the rehabilitation group clearly showed an overall improvement of clinical stage at the planned final observation, i.e. 15 days after onset of facial palsy, without presenting greater values of CMAP.

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

BACKGROUND

Antiviral agents against herpes simplex virus are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but their effectiveness is uncertain. Significant morbidity can be associated with severe cases.

OBJECTIVES

This review addresses the effect of antiviral therapy on Bell's palsy.

SEARCH STRATEGY

We updated the search of the Cochrane Neuromuscular Disease Group Trials Register (December 2008), MEDLINE (from January 1966 to December 8 2008), EMBASE (from January 1980 to December 8 2008) and LILACS (from January 1982 to December 2008).

SELECTION CRITERIA

Randomized trials of antivirals with and without corticosteroids versus control therapies for the treatment of Bell's palsy.

DATA COLLECTION AND ANALYSIS

Twenty-three papers were selected for consideration.

MAIN RESULTS

Seven trials including 1987 participants met the inclusion criteria, adding five studies to the two in the previous review.Incomplete recovery at one year. There was no significant benefit in the rate of incomplete recovery from antivirals compared with placebo (n = 1886, RR 0.88, 95% CI 0.65 to 1.18). In meta-analyses with some unexplained heterogeneity, the outcome with antivirals was significantly worse than with corticosteroids (n = 768, RR 2.82, 95% CI 1.09 to 7.32) and the outcome with antivirals plus corticosteroids was significantly better than with placebo (n = 658, RR 0.56, 95% CI 0.41 to 0.76).Motor synkinesis or crocodile tears at one year. In single trials, there was no significant difference in long term sequelae comparing antivirals and corticosteroids with corticosteroids alone (n = 99, RR 0.39, 95% CI 0.14 to 1.07) or antivirals with corticosteroids (n = 101, RR 1.03, 95% CI 0.51 to 2.07).Adverse events.There was no significant difference in rates of adverse events between antivirals and placebo (n = 1544, RR 1.06, 95% CI 0.81 to 1.38), between antivirals and corticosteroids (n = 667, RR 0.96, 95% CI 0.65 to 1.41) or between the antiviral-corticosteroid combination and placebo (n = 658, RR 1.15, 95% CI 0.79 to 1.66).

AUTHORS' CONCLUSIONS

High quality evidence showed no significant benefit from anti-herpes simplex antivirals compared with placebo in producing complete recovery from Bell's palsy. Moderate quality evidence showed that antivirals were significantly less likely than corticosteroids to produce complete recovery.

Viral etiology for inner ear diseases: proven, unproven, unlikely

This is a revision article that deals with the broad field of inner ear disease caused by viral infections. Some of these entities have been proven to have a viral etiology. Others have strong evidence in favor of a viral causation but still cannot be considered as a viral disease. Finally, other entities are suggestive of a viral etiology but when the whole body of evidence is considered one concludes that a viral etiology is indeed unlikely. We review the literature and add our own experience in this subject. Clearly, the most important evidence about this subject came from the study of temporal bone histopathology. Certainly, we can learn much more if we continue to collect and study temporal bone specimens histopathologically.

Early treatment with prednisolone or acyclovir in Bell's palsy

BACKGROUND

Corticosteroids and antiviral agents are widely used to treat the early stages of idiopathic facial paralysis (i.e., Bell's palsy), but their effectiveness is uncertain.

METHODS

We conducted a double-blind, placebo-controlled, randomized, factorial trial involving patients with Bell's palsy who were recruited within 72 hours after the onset of symptoms. Patients were randomly assigned to receive 10 days of treatment with prednisolone, acyclovir, both agents, or placebo. The primary outcome was recovery of facial function, as rated on the House-Brackmann scale. Secondary outcomes included quality of life, appearance, and pain.

RESULTS

Final outcomes were assessed for 496 of 551 patients who underwent randomization. At 3 months, the proportions of patients who had recovered facial function were 83.0% in the prednisolone group as compared with 63.6% among patients who did not receive prednisolone (P<0.001) and 71.2% in the acyclovir group as compared with 75.7% among patients who did not receive acyclovir (adjusted P=0.50). After 9 months, these proportions were 94.4% for prednisolone and 81.6% for no prednisolone (P<0.001) and 85.4% for acyclovir and 90.8% for no acyclovir (adjusted P=0.10). For patients treated with both drugs, the proportions were 79.7% at 3 months (P<0.001) and 92.7% at 9 months (P<0.001). There were no clinically significant differences between the treatment groups in secondary outcomes. There were no serious adverse events in any group.

CONCLUSIONS

In patients with Bell's palsy, early treatment with prednisolone significantly improves the chances of complete recovery at 3 and 9 months. There is no evidence of a benefit of acyclovir given alone or an additional benefit of acyclovir in combination with prednisolone. (Current Controlled Trials number, ISRCTN71548196 [controlled-trials.com].).

Search for Herpesviruses in cerebrospinal fluid of facial palsy patients by PCR

CONCLUSIONS

Herpes simplex virus 1 (HSV-1) and varicella-zoster virus (VZV) DNA were not detected in the cerebrospinal fluid (CSF) of patients with acute idiopathic peripheral facial palsy (Bell's palsy). Our results indicate either the absence of these viruses or the presence of technical shortcomings. The role of human herpesvirus 6 (HHV-6) in this disorder and the significance of a positive HHV-6 DNA finding in the central nervous system need further investigation.

OBJECTIVE

Our goal was to determine whether DNA of HSV-1, VZV, or HHV-6 can be found by polymerase chain reaction (PCR) in the CSF of peripheral facial palsy patients.

MATERIALS AND METHODS

We used PCR to detect the presence of HSV-1, VZV, and HHV-6 DNA in CSF. This was a retrospective case control study with 33 peripheral facial palsy patients (34 CSF samples) in the study group (26 with Bell's palsy, 5 with simultaneously diagnosed herpesvirus infection, 1 with puerperal facial palsy, 1 with Melkersson-Rosenthal syndrome). The control group included 36 patients, most with diagnosed or suspected Borreliosis and facial palsy or sudden deafness.

RESULTS

One patient with Bell's palsy had HHV-6 DNA in CSF. Neither HSV-1 nor VZV DNA was detected in patients or controls.

Recommendations for the management of herpes zoster

The objective of this article is to provide evidence-based recommendations for the management of patients with herpes zoster (HZ) that take into account clinical efficacy, adverse effects, impact on quality of life, and costs of treatment. Systematic literature reviews, published randomized clinical trials, existing guidelines, and the authors' clinical and research experience relevant to the management of patients with HZ were reviewed at a consensus meeting. The results of controlled trials and the clinical experience of the authors support the use of acyclovir, brivudin (where available), famciclovir, and valacyclovir as first-line antiviral therapy for the treatment of patients with HZ. Specific recommendations for the use of these medications are provided. In addition, suggestions are made for treatments that, when used in combination with antiviral therapy, may further reduce pain and other complications of HZ.