Corticosteroid and antiviral therapy for Bell's palsy: a network meta-analysis

Immune regulation and blood-brain barrier permeability in cerebral small vessel disease: study protocol of the INflammation and Small Vessel Disease (INSVD) study - a multicentre prospective cohort study

INTRODUCTION

The INflammation and Small Vessel Disease (INSVD) study aims to investigate whether peripheral inflammation, immune (dys)regulation and blood-brain barrier (BBB) permeability relate to disease progression in cerebral small vessel disease (SVD). This research aims to pinpoint specific components of the immune response in SVD relating to disease progression. This could identify biomarkers of SVD progression, as well as potential therapeutic targets to inform the development and repurposing of drugs to reduce or prevent SVD, cognitive decline and vascular dementia.

METHODS AND ANALYSIS

INSVD is a prospective observational multicentre cohort study in individuals with symptomatic SVD. This longitudinal study combines comprehensive immunophenotyping of the peripheral blood immune compartment with advanced neuroimaging markers of SVD and BBB permeability. The main SVD marker of interest is white matter microstructure as determined by diffusion tensor imaging, a valuable marker of disease progression owing to its sensitivity to early alterations to white matter integrity. The research is being conducted in two sites-in the UK (Cambridge) and the Netherlands (Nijmegen)-with each site recruiting 100 participants (total n=200). Participants undergo clinical and cognitive assessments, blood draws, and brain MRI at baseline and 2-year follow-up.

ETHICS AND DISSEMINATION

This study received ethical approval from the local ethics boards (UK: East of England-Cambridge Central Research Ethics Committee (REC) ref: 22/EE/00141, Integrated Research Application System (IRAS) ID: 312 747. Netherlands: Medical Research Ethics Committee (MREC) Oost-Nederland, ref: 2022-13623, NL-number: NL80258.091.22). Written informed consent was obtained from all subjects before the study. Any participant-derived benefits resulting from this research, such as new insights into disease mechanisms or possible novel therapies, will be disseminated to study participants, patient groups and members of the public.

TRIAL REGISTRATION NUMBER

NCT05746221.

Modification and Validation of a Diagnostic Questionnaire for Restless Legs Syndrome: Modified-Restless Legs Syndrome Diagnostic Questionnaire (m-RLS-DQ)

Background

Diagnostic questionnaire that are available for restless legs syndrome does not include items related to RLS mimics and, hence, increases chances of false positive cases. This study aimed at modification and validation of RLS-diagnostic Questionnaire.

Methods

During modification, additional items were identified, developed, and subjected to evaluation by experts. Experts were requested to validate the content of each item. Based on their responses, content validity indices (average and universal agreement) were calculated. It was then translated to Hindi and validated in a clinical population that included patients with RLS, somatic symptoms disorder, anxiety, other RLS mimics, and osteoarthritis. In addition, a group of healthy controls was also included. Face, concurrent, and discriminant validities were calculated.

Results

Among 209 subjects, nearly 40 subjects had clinical diagnosis of RLS, osteoarthritis, somatic-symptoms-disorder, and anxiety disorder, each. In addition, 16 patients had other RLS mimics (akathisia, varicose veins, BFS, leg-cramps, chronic insomnia) and 30 were healthy controls. After multiple revisions, content validity indices achieved a score of 1 for m-RLS-DQ. Sensitivity and specificity of m-RLS-DQ v. 1.4 for the diagnosis of RLS were 94.9% and 94.1%, respectively. For the diagnosis of RLS, PPV was 78.7%, and NPV was 98.7% with an accuracy of 94.3%. Less than one fourth of participants having chronic insomnia, somatic symptoms disorder, anxiety disorder, and knee osteoarthritis were found to be false positive on m-RLS-DQ; however, none of the healthy controls were found positive on m-RLS-DQ. Concurrent validity with clinical diagnosis of RLS was 0.83 (P < 0.001). Discriminant validity with somatic symptoms disorder was -0.14 (P = 0.03) and with osteoarthritis -0.24 (P < 0.001).

Conclusion

m-RLS-DQ is a valid instrument with acceptable psychometric properties, which can be used for the screening as well as diagnosis of RLS in clinical practice and research studies.

Validation and cross-cultural adaptation of the Multiple Sclerosis Intimacy and Sexuality Questionnaire-15 (MSISQ-15) into Spanish

Background

The Multiple Sclerosis Intimacy and Sexuality Questionnaire-15 (MSISQ-15) is a valid and reliable tool to assess the sexuality of people with multiple sclerosis. The objectives of this study were: 1) to cross-culturally adapt and examine the psychometric properties of the MSISQ-15 in the Spanish context and 2) to examine the association between sexual dysfunction and other related factors.

Methods

We conducted a instrumental study. People diagnosed with multiple sclerosis and members of multiple sclerosis associations in Spain were included. The linguistic adaptation of the questionnaire was performed through a translation-back translation procedure. For the psychometric validation, the confirmatory factor analysis was used while the internal consistency was examined by the ordinal alpha test. The construct validity was examined by correlating the results with the Male Sexual Function (FSH), Female Sexual Function-2 (FSM-2), Dyadic Adjustment Scale-13 (EAD-13) and Multiple Sclerosis International Quality of Life Questionnaire (MusiQoL) questionnaires.

Results

A total of 208 participants were included. Both the fit of the Spanish version of the MSISQ-15 to the original scale and the internal consistency were adequate (α = 0.89). The construct validity showed correlations with the FSH, FSM-2, and MusiQoL but not with the EAD-13.

Conclusions

The Spanish version of the MSISQ-15 is a valid and reliable tool to assess the sexuality of people with multiple sclerosis in the Spanish context.

Corticosteroids: A boon or bane for COVID-19 patients?

Several drugs and antibodies have been repurposed to treat COVID-19. Since the outcome of the drugs and antibodies clinical studies have been mostly inconclusive or with lesser effects, therefore the need for alternative treatments has become unavoidable. However, corticosteroids, which have a history of therapeutic efficacy against coronaviruses (SARS and MERS), might emerge into one of the pandemic's heroic characters. Corticosteroids serve an immunomodulatory function in the post-viral hyper-inflammatory condition (the cytokine storm, or release syndrome), suppressing the excessive immunological response and preventing multi-organ failure and death. Therefore, corticosteroids have been used to treat COVID-19 patients for more than last two years. According to recent clinical trials and the results of observational studies, corticosteroids can be administered to patients with severe and critical COVID-19 symptoms with a favorable risk-benefit ratio. Corticosteroids like Hydrocortisone, dexamethasone, Prednisolone and Methylprednisolone has been reported to be effective against SARS-CoV-2 virus in comparison to that of non-steroid drugs, by using non-genomic and genomic effects to prevent and reduce inflammation in tissues and the circulation. Clinical trials also show that inhaled budesonide (a synthetic corticosteroid) increases time to recovery and has the potential to reduce hospitalizations or fatalities in persons with COVID-19. There is also a brief overview of the industrial preparation of common glucocorticoids.

Acute Peripheral Facial Nerve Palsy in Children and Adolescents: Clinical Aspects and Treatment Modalities

BACKGROUND

Peripheral facial nerve palsy is a relatively frequent, rather idiopathic, and isolated nonprogressive disorder with a tendency toward spontaneous recovery in children. It is primarily characterized by unilateral paresis or paralysis of the mimic musculature affecting verbal communication, social interactions, and quality of life.

OBJECTIVE

This study aimed to evaluate the clinical aspects and efficacy of different therapeutic modalities in the population of children and adolescents with acute peripheral facial nerve palsy, the quality and recovery rate in comparison to different therapy modalities and etiological factors as well as to determine parameters of recovery according to the age of patients.

METHODS

The retrospective study included children and adolescents (n=129) with an acute onset of peripheral facial nerve palsy, diagnosed and treated in the Clinic of Neurology and Psychiatry for Children and Youth in Belgrade (2000-2018). The mean age of the patients was 11.53 years (SD±4.41). Gender distribution: 56.6% female and 43.4% male patients.

RESULTS

There were 118 (91.5%) patients with partial and 11 (8.5%) patients with complete paralysis. Left-sided palsy occurred in 67 (51.9%) patients, right-sided in 58 (45.0%), while there were 4 (3.1%) bilateral paralyses. The most common etiological factor was idiopathic (Bell's palsy) - 74 (57.4%) patients followed by middle ear infections - 16 (12.4%). Regardless of etiology, age, and therapy protocols, there was a significant recovery in most of the patients (p<0.001), without significant differences in recovery rate. Comparison of inpatient and outpatient populations showed significant differences regarding the number of relapses, severity of clinical presentation, and recovery rate in relation to etiology.

CONCLUSION

Bell's palsy is shown to be the most common cause of peripheral facial nerve palsy in children and adolescents, regardless of gender. It is followed by mid-ear infections, respiratory infections, and exposure to cold. Most children and adolescents recovered in three weeks after initial presentation, regardless of etiology, age, and therapy.

Genotype-Phenotype Correlation in Progressive Supranuclear Palsy Syndromes: Clinical and Radiological Similarities and Specificities

The progressive supranuclear palsy (PSP) syndrome encompasses different entities. PSP disease of sporadic origin is the most frequent presentation, but different genetic mutations can lead either to monogenic variants of PSP disease, or to other conditions with a different pathophysiology that eventually may result in PSP phenotype. PSP syndrome of monogenic origin is poorly understood due to the low prevalence and variable expressivity of some mutations. Through this review, we describe how early age of onset, family history of early dementia, parkinsonism, dystonia, or motor neuron disease among other clinical features, as well as some neuroimaging signatures, may be the important clues to suspect PSP syndrome of monogenic origin. In addition, a diagnostic algorithm is proposed that may be useful to guide the genetic diagnosis once there is clinical suspicion of a monogenic PSP syndrome.

Neurological toll of COVID-19

The first case of coronavirus illness was discovered in Wuhan, China, in January 2020 and quickly spread worldwide within the next couple of months. The condition was initially only linked with respiratory disorders. After the evolution of various variants of the SARS-CoV-2, the critical impact of the virus spread to multiple organs and soon, neurological disorder manifestations started to appear in the infected patients. The review is focused on the manifestation of various neurological disorders linked with both the central nervous system and peripheral nervous system. Disorders such as cytokine release syndrome, encephalitis, acute stroke, and Bell's palsy are given specific attention and psychological manifestations are also investigated. For a clear conclusion, cognitive impairment, drug addiction disorders, mood and anxiety disorders, and post-traumatic stress disorder are all fully examined. The association of the SARS-CoV-2 with neurological disorders and pathway is yet to be clear. For better understanding, the explanation of the possible mechanism of viral infection influencing the nervous system is also attempted in the review. While several vaccines and drugs are already involved in treating the SARS-CoV-2 condition, the disease is still considered fatal and more likely to leave permanent neurological damage, which leads to an essential requirement for more research to explore the neurological toll of the COVID-19 disease.

Anti-Inflammatory Therapy of Infections

Anti-inflammatory treatment of infections is challenging due to the heterogeneity of etiologic agents and complex immune interactions. Nevertheless, anti-inflammatory medications are commonly used in infections to reduce unpleasant symptoms and to modify host response. They may play a fundamental role in managing infection with over-inflammation by decreasing inflammatory organ damage, e.g., COVID-19. However, by its inherent inhibition of immune functions, they might also contribute to the development of serious bacterial infections. Moreover, reducing a patient's symptoms and signs may provide a false sense of security and delay diagnosing threatening infections.

Impact of COVID-19 on vocal cord mobility: a case series study

Background

The World Health Organization (WHO) has declared the pandemic of COVID-19 infection in March 2020, most of cases presented with mild symptoms, and a significant number of cases showed variable neurological pictures. Vocal cord paralysis with no clear cause is termed as idiopathic vocal cord paralysis and supposed to be caused by viral infection. This is a case series study; data were collected prospectively from patients presented to the ENT clinic of Kasr Alainy (Cairo university) and Railway hospitals. Patients presented with defective vocal cord movement with concurrently or recently passed COVID-19 infection were reported from March 2020 to April 2021.

Results

Authors have reported 6 cases of vocal cord paralysis mainly unilateral due to COVID-19 infection as an only clear cause within 14 months. Age ranges from 39 to 69 years, 2 males and 4 females. Patients presented with different clinical scenarios. Follow-up of the cases showed spontaneous recovery in 5 cases and one case underwent cord medialization.

Conclusion

Viral infection could be an underlying cause of idiopathic laryngeal cord paralysis; in the new era of the COVID-19 pandemic, physicians all over the world noticed variable neurological pictures; in this study, we presented 6 cases of vocal cord paralysis mainly unilateral supposed to be due to COVID-19 infection; all cases showed spontaneous recovery apart from one case that needed medialization of the cord.

Bell's Palsy Associated with COVID-19 Infection: A Case Report

The COVID-19 has a wide range of symptoms. This novel infectious disease may also trigger a vast range of neurological involvements. The current report describes a case of COVID-19 complicated with Bell's palsy. A 64-year-old woman with diabetes was admitted due to abrupt left hemifacial weakness. On examination, her left hemifacial expression ability was impaired so that her face seemed asymmetrical during smiling, and numbness around the left nasolabial fold was detected. Furthermore, her ability to wink was impaired, and her eyebrow drooped. A brain computed tomography (CT) scan did not show any abnormalities. A lung CT scan was performed, which demonstrated bilateral ground-glass opacity (GGO), along with RT-PCR results indicative of COVID-19. A diagnosis of Bell's palsy in the setting of COVID-19 infection was made. She received antiviral agents and corticosteroids. At two-week follow-up, her symptoms had improved. During the COVID-19 epidemic, any newly occurred neurological involvement raises the suspicion of COVID-19 infection.

Recovery from Idiopathic Facial Paralysis (Bell’s Palsy) Using Photobiomodulation in Patients Non-Responsive to Standard Treatment: A Case Series Study

Diminished facial movement and marked facial asymmetry can lead to a consistent psychological burden. Bell′s palsy (BP) is one of the most common causes of facial nerve illness, which comes with unilateral acute facial paresis. Nowadays, no clear guidelines for treating BP are available. We carried out a case series study to test the efficacy of photobiomodulation (PBM) therapy in patients with BP non-responsive to standard treatment. The study was experimentally performed at the Department of Surgical and Diagnostic Sciences, University of Genoa (Genoa, Italy), in accordance with case report guidelines. Patients were referred to our department by colleagues for evaluation to be included in the case series because no consistent improvement was observed at least 3 months from the diagnosis of BP. All the patients interrupted their pharmacological therapy before the initiation of PBM therapy. PBM therapy (808 nm, 1 W irradiated in continuous-wave for 60 s on spot-size 1 cm2; 1 W/cm2; 60 J/cm2; and 60 J) was administered every 2 days until complete resolution. Evaluation of the House-Brackmann scale was performed before and after treatments. Fourteen patients were screened as eligible for the study. Patients were Caucasians (36% females and 64% males) with a mean age ± standard deviation of 56.07 ± 15.21 years. Eleven patients out of 14, who experienced BP a maximum of 6 months, completely recovered through PBM. The three patients that did not show improvement were those who had experienced BP for years. PBM could be a supportive therapy for the management of BP in patients non-responsive to standard treatment. However, randomized controlled trials are necessary to sustain our encouraging results, exclude bias, and better explain the boundary between the time from diagnosis and the recovery of BP through PBM therapy.

Pharmacological Treatments of Bell's Palsy in Adults: A Systematic Review and Network Meta-Analysis

OBJECTIVE

We aimed to simultaneously compare all available medical treatments for Bell's palsy using both direct and indirect data.

METHODS

The literature was searched from January 1, 1990, until March 1, 2020, with no language restrictions. Randomized clinical trials comparing pharmacological interventions were included in the current network meta-analysis. We estimated summary risk ratios (RRs), 95% credible interval (CrI), and the surface under the cumulative ranking curve (SUCRA) using network meta-analyses with random effects in a Bayesian framework. The primary outcomes were complete recovery in short-term (≤3 months) and intermediate/long-term (>3 months) after randomization. The secondary outcome was synkinesis.

RESULTS

In total, 21 trials comprising 2,839 participants were retrieved. In terms of good recovery, corticosteroids plus antivirals were the most effective treatment compared to placebo, with RRs ranging between 1.25 (95% CrI: 1.10, 1.43) for the short-term and 1.26 (95% CrI: 1.11, 1.45) for the intermediate/long-term recovery. For synkinesis, only corticosteroids plus antivirals (RR 0.35; 95% CrI: 0.19, 0.65) were associated with fewer synkinesis rates than placebo. The certainty of the evidence for good recovery and synkinesis was very low-low and moderate-high, respectively.

CONCLUSIONS

This network meta-analysis showed that combined therapy remains the best regimen for a good recovery outcome and the only efficacious regimen for synkinesis. More research is needed to confirm these findings. Laryngoscope, 131:1615-1625, 2021.

The effectiveness of low-level laser therapy combined with facial expression exercises in patients with moderate-to-severe Bell's palsy: A study protocol for a randomised controlled trial

BACKGROUND

Even though corticosteroid therapy and facial expression exercises were found to be effective, still 30% of participants with bell's palsy achieve incomplete recovery from the facial paralysis. The study objective was to evaluate the effectiveness of low-level laser therapy (LLLT) combined with progressive facial expression exercises in participants with moderate to severe bell's palsy.

METHODOLOGY

A total of 120 participants with idiopathic bell's palsy to be equally allocated in three groups. LLLT, electrical stimulation and corticosteroid/antiviral therapy will be performed respectively in the group I, group II and Group III and facial expression exercises as a common intervention. First two groups to be treated with respective interventions weekly 3 days for 6 consecutive weeks and third group will receive prescribed doses of medications and facial expression exercise for 6 weeks. The functional recovery will be assessed at baseline, 3 weeks, 6 weeks, and 12 weeks using the Facial Disability Index and House-Brackmann Scale. The overall within and between group differences in the clinical outcomes to be reported based on the Friedman Repeated Measures ANOVA and Kruskal-Wallis test. Whereas Wilcoxon Signed Rank and Mann-Whitney-U tests will be performed to report the within and between groups timeline differences.

DISCUSSION

Based on the dearth of evidence for the effective treatment of moderate to severe bell's palsy, we framed a most appropriate LLLT dosage along with facial expression exercises. Our study's intervention protocol designed with equal duration and number of interventions for all three groups. Even the comparator groups such as electrical muscle stimulation and Corticosteroids therapy will be receiving similar facial expression exercises. We believe that this intervention protocol would benefit by promoting the complete facial function recovery in patients with moderate to severe bell's palsy.

DISSEMINATION

We plan to publish this review in a peer-reviewed journal. We may also present this review at local and/or national conferences.

Photobiomodulation Therapy to Treat Facial Paralysis of 8 Years: Case Report

Background: Paralysis of the facial muscles produces functional and aesthetic disturbance that has a negative impact for the patient's quality of life. Objective: To evaluate the effects of a photobiomodulation (PBM) with low-level laser (LLL) on the treatment of a patient with 8 years of facial paralysis. Methods: PBM with two different wavelengths of LLL (660 and 808 nm), applied only on the affected side, three times a week for 8 consecutive weeks. Evaluations were performed before starting treatments, after the 12th session of treatment and after the 24th session, using the House-Brackmann scale and electroneuromyography. Results: The House-Brackmann and electroneuromyography tests showed improvements in the movement of the facial muscles when tested in the middle and at the end of the treatment with LLL. Conclusions: PBM with LLL at the wavelength of 660 and 808 nm with the parameters used in this case report was an effective and noninvasive treatment for facial paralysis in this long-standing, chronic case of 8 years.

Facial Palsy: A Retrospective Study of 416 Cases Based on Electrodiagnostic Consultation

Background:

Facial nerve palsy (FP) is a frequent neurological condition caused mostly by Bell´s Palsy (BP).

Objectives:

The main objective of this study is to describe electrophysiological parameters in a retrospective 28-year review of 416 cases of FP based on electrodiagnostic consultation.

Methods:

In total, 520 exams from 416 patients over a 28-year period were reviewed. Sex, age, etiology, comorbidities, and variables from electroneurography and needle electromyography were analyzed. Cases were grouped as BP (70.7%), injury (16.4%), iatrogenic (10.3%) and Ramsay Hunt syndrome (RHS) (2.6%).

Results:

The mean age was 41 years (3-82), 53.4% female. Diabetes was the most frequent comorbidity. Estimated Axon Loss (EAL), >90%, was found in 50% of the cases, mainly in the iatrogenic group. The amplitude drop of the Compound Muscle Action Potentials (CMAPs) was proportional in the Orbicularis Oculi, Orbicularis Oris and Nasalis muscles. The absence of CMAPs was more frequent in the iatrogenic group and less frequent in the BP one. Bell´s palsy associated with diabetes was more severe. The R1 latency (blink reflex) was significantly longer in the BP group (P>0.001). Synkinesis due to the misdirection of regenerating axons was much more frequent in the BP and RHS groups.

Conclusion:

Bell´s palsy was the most common cause. The EAL was equal in all facial branches. Facial nerve inexcitability was more frequent in the iatrogenic/injury groups. The R1 latency was found to be prolonged in the BP group and the only good prognosis indicator in a few cases. Misdirection reinnervation was more frequent in BP and RHS groups. There was no sex or side predominance.

Intratympanic Steroid Treatment of Bell's Palsy in Patients with Comorbid Disease: A Preliminary Report

OBJECTIVES

This study evaluated the efficacy of intratympanic steroid injection (ITSI)as initial treatment and therecovery speed for Bell's palsy (BP)inpatients with diabetes mellitus (DM)and/or hypertension (HT).

MATERIALS AND METHODS

In total,90 patients with comorbid diseases diagnosed with BP received either ITSI (study group, n=61) or systemic steroid treatment (SST) (control group, n=29).The facial nerve function was assessed using the House-Brackmann (HB) grading system for up to 6 months or until complete recovery from BP. To investigate a relationship with the complete recovery time from BP, hematologic and baseline characteristic parameters were analyzed.

RESULTS

The complete recovery rate of the ITSI and SST groups was 47.5% and 44.8% at the 1st month, 70.5% and 89.7% at the 3rd month, and 96.7% and 100% at the 6th month of the study, respectively. Lymphocyte and neutrophil values were significantly associated with the complete recovery time from BP. No major adverse events from ITSI itself were noticed during the procedure and during the follow-up of the treatment.

CONCLUSION

Both treatment types have no superiorities over each other in initial treatment for BP in patients with comorbid diseases. ITSI is effective and safe and may avoid the unwanted side effects associated with systemic steroids inthese patients.

Factors Associated With Fast Recovery of Bell Palsy in Children

The purpose of this study was to identify the clinical characteristics and factors affecting the prognosis of children with Bell palsy. We retrospectively reviewed the medical records of 53 pediatric patients diagnosed with Bell palsy. After a mean follow-up period of 30 days, 30 patients (56%) were completely recovered, 21 patients (40%) were partially recovered, and 2 patients (4%) had not recovered. The patients in the complete recovery group were significantly younger than those in the partial and nonrecovery groups (8.8 ± 4.2 years vs 12.2 ± 3.0 years, P = .003). Patients <8 years old had a higher complete recovery rate than was found in patients >8 years old (80% vs 47%, P = .031). Sex, affected side, and early or late treatment did not influence the recovery rate. These results suggest that younger age may be a good prognostic factor affecting the fast recovery of children with Bell palsy.

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.

Bell Palsy and the Risk of Cardio-Cerebrovascular Disease: A Population-Based Follow-Up Study

OBJECTIVE

To evaluate the risk of cardio-cerebrovascular disease (CCVD), such as ischemic stroke and acute myocardial infarction (AMI), in patients diagnosed with Bell palsy STUDY DESIGN: Population-based follow-up study.

METHODS

We used the National Sample Cohort 2002 to 2013 data from the Korea National Health Insurance Service. The Bell palsy group comprised all patients diagnosed with Bell palsy (n = 730). The comparison group comprised patients selected randomly using propensity score matching (n = 1,460). The Kaplan-Meier survival analysis, log-rank test, and Cox proportional-hazards regression models were used to calculate the disease-free survival rate and hazard ratio (HR) of CCVD for each group.

RESULTS

Of the total study population, ischemic stroke developed in 15.7% of patients with Bell palsy and 9% of patients in the comparison group during the 12-year follow-up period. After adjusting for other factors, the HR of ischemic stroke during the 12-year follow-up period was 1.84 times greater in the Bell palsy group than in the comparison group (95% confidence interval [CI], 1.43-2.36). However, the adjusted HR of developing ischemic stroke for patients with Bell palsy treated concurrently with antiviral agents and steroids was 1.12 (95% CI, 0.62.-2.04). There was no significant relationship between Bell palsy and risk of AMI development (HR, 1.13; 95% CI, 0.71-1.82).

CONCLUSION

Bell palsy is linked with an increased incidence of ischemic stroke. Our data suggest that Bell palsy may be used as an indicator of increased stroke risk, and concurrent treatment with antiviral agents and steroids may be effective in preventing ischemic stroke.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2371-2377, 2019.

Association between Upper Respiratory Infection and Idiopathic Unilateral Vocal Fold Paralysis

INTRODUCTION

Unilateral vocal fold paralysis (UVFP) without an identifiable cause is termed idiopathic unilateral vocal fold paralysis (IUVFP). Some authors have postulated that select cases of IUVFP have a viral etiology, but the causality has not been established. We set out to review institutional cases of IUVFP and determine if there is a correlation between upper respiratory infection symptoms and presentation of IUVFP.

METHODS

Cases of IUVFP were reviewed over a 10-year period (2002-2012). The history was investigated to review presenting symptoms. We specifically reviewed for symptoms of upper respiratory infection at the onset of UVFP and tallied the frequency. Symptoms included sore throat, laryngitis, cough, influenza, bronchitis, pneumonia, otalgia, and sinusitis. The seasonal onset (if possible) was determined based on the history provided from the initial consultation.

STUDY DESIGN

Case series.

RESULTS

Overall, 107 patients presented with IUVFP; 35.5% of patients reported symptoms of upper respiratory infection at the onset of UVFP. Among these individuals, pharyngitis/laryngitis was the most common presenting symptom; 34.2% reported cough. In total, 40.0% of patients with IUVFP reported an onset of symptoms between December and February.

CONCLUSIONS

This study suggests that symptoms of upper respiratory infection frequently occur with the presentation of IUVFP. The onset of symptoms tended to occur between December and February. The mechanism of viral-mediated UVFP has not been established. Future studies to explore this pathophysiology are needed.

A Patient-Specific Three-Dimensional Hemodynamic Model of the Circle of Willis

Circle of Willis (CoW) is one of the most important cerebral arteries in the human body and various attempts have been made to study the hemodynamic of blood flow in this vital part of the brain. In the present study, blood flow in a patient specific CoW is numerically modeled to predict disease-prone regions of the CoW. Medical images and computer aided design software are used to construct a realistic three-dimensional model of the CoW for this particular case. The arteries are considered as elastic conduits and the interactions between arterial walls and the blood flow are taken into account. Mooney-Rivlin hyperelastic model is used to describe the behavior of arterial walls and blood is considered as a non-Newtonian fluid obeying the Carreau model. An available experimental-based pulsatile velocity profile is used at the entrance of the CoW. The finite element-based commercial software, ADINA, is used to solve the governing equations. Blood pressure and velocity and arterial wall shear stress are calculated in different regions of the CoW. A simplified form of the model is also compared with the available published data. Results affirmed that the proposed computational model has the potential to capture the hemodynamic characteristics of the CoW. The computational results can be used to determine disease-prone locations for a given CoW.

Prevalence of Dementia, Depression, and Mild Cognitive Impairment in a Rural Area of the Island of Crete, Greece

The studies on the prevalence of dementia, depression, and mild cognitive impairment (MCI) in Greece are sparse and show major variations of prevalence depending on geographical areas, nutritional habits, and the way of living. The aim of this door-to-door study was to find the prevalence of dementia, depression, and MCI in a rural Greek population. Four hundred and forty-three individuals older than 61years following the application of specific criteria were diagnosed with: normal cognition, depression, MCI with and without depression, and dementia with and without depression. Four diagnostic methods were used, 2 of which included Mungas correction for age and education. After Mungas adjustment, the results were as follows-depression: 33.9%; MCI: 15.3%; MCI with depression: 8.6%; dementia: 2.0%; and dementia with depression: 7.2%. Dementia is less prevalent compared to global data and other Greek areas. Mild cognitive impairment is more prevalent than dementia. High percentages of depression may be related to low education.

Bidirectional association between Bell's palsy and anxiety disorders: A nationwide population-based retrospective cohort study

OBJECTIVE

Bell's palsy and anxiety disorders share numerous risk factors (e.g., immune response, ischemia, and psychological stress). However, there have been no studies on the bidirectional temporal association between the two illnesses. In this study, we used the Taiwan National Health Insurance Research Database (NHIRD) to test the bidirectional association between Bell's palsy and anxiety disorders. We hypothesized that patients with Bell's palsy would have an increased risk of subsequent anxiety disorders later in life and that, conversely, those with anxiety disorders would have an increased likelihood of developing Bell's palsy later in life.

METHODS

We conducted two retrospective cohort studies using Taiwan's National Health Insurance Research Database (NHIRD). Study 1 included 8070 patients diagnosed with anxiety disorders and 32,280 controls without anxiety disorders who were matched with sex, age, and enrollment date to analyze the following risk of Bell's palsy among both groups. Study 2 included 4980 patients with Bell's palsy and 19,920 controls without Bell's palsy who were matched with sex, age, and enrollment date to analyze the following risk of anxiety disorders among both groups. The patient records selected for the studies were dated between January 1, 2000, and December 31, 2004. All subjects were observed until their outcomes of interest, death or December 31, 2009.

RESULTS

After adjustment for age, sex, comorbidities, urbanization, and income, the hazard ratio (HR) for patients with anxiety disorders to contract Bell's palsy was 1.53 (95% CI, 1.21-1.94, P<.001), and the HR for patients with Bell's palsy to develop an anxiety disorder was 1.59 (95% CI, 1.23-2.06, P<.001).

CONCLUSION

This study found a bidirectional temporal association between Bell's palsy and anxiety disorders. After one of these conditions develops, the morbidity rate for the other significantly increases. Additional studies are required to determine whether these two conditions share the same pathogenic mechanisms, and whether successfully treating one will reduce the morbidity rate for the other.

Facial Palsy, a Disorder Belonging to Influential Neurological Dynasty: Review of Literature

Facial paralysis is one of the common problem leading to facial deformation. Bell's palsy (BP) is defined as a lower motor neuron palsy of acute onset and idiopathic origin. BP is regarded as a benign common neurological disorder of unknown cause. It has an acute onset and is almost always a mononeuritis. The facial nerve is a mixed cranial nerve with a predominant motor component, which supplies all muscles concerned with unilateral facial expression. Knowledge of its course is vital for anatomic localization and clinical correlation. BP accounts for approximately 72% of facial palsies. Almost a century later, the management and etiology of BP is still a subject of controversy. Here, we present a review of literature on this neurologically significant entity.

Antiviral agents convey added benefit over steroids alone in Bell's palsy; decompression should be considered in patients who are not recovering

BACKGROUND

The management of Bell's palsy has been the subject of much debate, with corticosteroids being the preferred medication. However, evidence also supports the use of antiviral drugs for severe cases and even decompression surgery in patients who, despite medical treatment, are not recovering.

METHOD

A literature review was conducted on the management of Bell's palsy.

RESULTS

This paper describes the background, statistical evidence, study results and pathophysiological theories that support more aggressive treatment for patients with severe palsy and those who have inadequate recovery.

CONCLUSION

Combination therapy including antiviral medication significantly improves outcomes in patients with severe Bell's palsy. Decompression should be considered in patients who have not recovered with drug treatment.

Facial nerve paralysis in children

Facial nerve palsy is a condition with several implications, particularly when occurring in childhood. It represents a serious clinical problem as it causes significant concerns in doctors because of its etiology, its treatment options and its outcome, as well as in little patients and their parents, because of functional and aesthetic outcomes. There are several described causes of facial nerve paralysis in children, as it can be congenital (due to delivery traumas and genetic or malformative diseases) or acquired (due to infective, inflammatory, neoplastic, traumatic or iatrogenic causes). Nonetheless, in approximately 40%-75% of the cases, the cause of unilateral facial paralysis still remains idiopathic. A careful diagnostic workout and differential diagnosis are particularly recommended in case of pediatric facial nerve palsy, in order to establish the most appropriate treatment, as the therapeutic approach differs in relation to the etiology.

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.

Comparison of Risk of Carpal Tunnel Syndrome in Patients with Distal Radius Fractures After 7 Treatments

Background

To compare risk of carpal tunnel syndrome (CTS) in distal radius fracture (DRF) patients after 7 treatments using bridging external fixation (BrEF), non-bridging external fixation (non-BrEF), plaster fixation, K-wire fixation, dorsal plating fixation, volar plating fixation, and dorsal and volar plating by performing a network meta-analysis.

Material/Methods

An exhaustive search of electronic databases identified randomized controlled trails (RCTs) closely related to our study topic. The published articles were screened, based on predefined inclusion and exclusion criteria, to select high-quality studies for the present network meta-analysis. Data extracted from the selected studies were analyzed using STATA version 12.0 software.

Results

The literature search and selection process identified 12 eligible RCTs that contained a total of 1370 DRF patients (394 patients with BrEF, 377 patients with non-BrEF, 89 patients with K-wire fixation, 192 patients with plaster fixation, 42 patients with dorsal plating fixation, 152 patients with volar plating fixation, and 124 patients with dorsal and volar plating fixation). Our network meta-analysis results demonstrated no significant differences in CTS risk among the 7 treatments (P>0.05). The value of surface under the cumulative ranking curve (SUCRA), however, suggested that dorsal plating fixation is the optimal treatment, with the lowest risk of CTS in DRF patients (dorsal plating fixation: 89.2%; dorsal and volar plating: 57.8%; plaster fixation: 50.9%; non-BrEF: 50.6%; volar plating fixation: 39.6%; BrEF: 38.4%; K-wire fixation: 23.6%).

Conclusions

Our network meta-analysis provides evidence that dorsal plating fixation significantly decreases the risk of CTS and could be the method of choice in DRF 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. 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.

Steroid plus antiviral treatment for Bell's palsy

OBJECTIVES

The effectiveness of antiviral agents for the treatment of Bell's palsy is uncertain. We evaluated whether a steroid with an antiviral agent (S + A group) provided better recovery outcomes than a steroid alone (S group) in patients with Bell's palsy.

SUBJECTS AND DESIGN

A total of 1342 patients diagnosed with Bell's palsy who visited the Kyung Hee Medical Center in Seoul, Korea, from 2002 to 2012 were included in this study. Patients in the S + A group were treated with prednisolone and antiviral agents (n = 569) and those in the S group with prednisolone alone (n = 773). Outcomes were measured using the House-Brackmann (HB) scale according to age, initial disease severity, electroneurography (ENoG) findings and underlying comorbidities.

RESULTS

The rate of recovery (HB grades I and II) with initially severe Bell's palsy (HB grades V and VI) was higher in the S + A than in the S group (P = 0.001). However, the rates of recovery were similar with initially moderate palsy (HB grades II-IV) (P = 0.502). In patients classified according to age and ENoG-determined severity of palsy, the overall recovery rate was higher in the S + A than in the S group, but the differences were not statistically significant (P > 0.05 for both). The recovery rate without diabetes mellitus (DM) and hypertension (HTN) was higher in the S + A group than in the S group (P = 0.031). But in the patients with HTN and DM, the difference in recovery rates between the S + A and S groups was not statistically significant (P = 0.805).

CONCLUSIONS

Treatment with a steroid plus antiviral agent resulted in significantly higher recovery rates than steroid therapy alone in patients with initially severe Bell's palsy and without either HTN or DM, and a nonsignificant trend towards higher recovery rates in all patients with Bell's palsy in this study. Antiviral agents may therefore help in the treatment of Bell's palsy.

Peripheral facial nerve palsy after therapeutic endoscopy

Peripheral facial nerve palsy (FNP) is a mononeuropathy that affects the peripheral part of the facial nerve. Primary causes of peripheral FNP remain largely unknown, but detectable causes include systemic infections (viral and others), trauma, ischemia, tumor, and extrinsic compression. Peripheral FNP in relation to extrinsic compression has rarely been described in case reports. Here, we report a case of a 71-year-old man who was diagnosed with peripheral FNP following endoscopic submucosal dissection. This case is the first report of the development of peripheral FNP in a patient undergoing therapeutic endoscopy. We emphasize the fact that physicians should be attentive to the development of peripheral FNP following therapeutic endoscopy.

Advances in diagnosis and non-surgical treatment of Bell's palsy

Bell's palsy is a commonly seen cranial nerve disease and can result in compromised facial appearance and functions. Its etiology, prognosis and treatment are still being debated. This paper is a review of recent development in the understanding of etiology, diagnosis and non-surgical treatment of Bell's palsy.

Steroid-antivirals treatment versus steroids alone for the treatment of Bell's palsy: a meta-analysis

BACKGROUND

To illustrate whether the steroid-antivirals treatment could acquire a better recovery in patients with Bell's palsy than the steroids alone treatment.

MATERIALS AND METHODS

We conducted an exhaustive search over Pub med/Medline, Ovid, Elsevier search engines and the Cochrane library thereby collecting the randomized controlled trials in the treatment of patients with Bell's palsy with steroid-antivirals and steroids. The qualities of relevant articles were assessed by GRADE, which was used to present the overall quality of evidence as recommended by the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Two investigators evaluated these papers independently, and resolved the disagreements by discussion. At last 8 eligible papers (1816 patients included: 896 treated with steroid-antivirals and 920 treated with steroids alone) match the criteria. Owing to the result (chi(2) = 12.57, P = 0.08, I(2) = 44%) presented by the formal test for heterogeneity, the fixed effect meta-analysis model was chosen. The facial muscle recovery between the steroids-antivirals group and the steroids alone group show significant differences (OR = 1.52, 95% CI: 1.20-1.94), while the statistical outcome of adverse effect shows no statistical significance (OR = 1.28, 95% CI: 0.71-2.31).

CONCLUSIONS

The present meta-analysis indicates that the steroid-antivirals treatment could improve the recovery rate in patients with Bell's palsy when comparing with the steroid alone treatment.

CLINICAL SIGNIFICANCE

This meta-analysis showed that the steroid-antivirals treatment achieved the better outcomes in patients with Bell's palsy. Clinicians should consider that steroid-antivirals therapy is an alternative choice for the patients with Bell's palsy.

Prosthodontic Rehabilitation of Patients with Bell's Palsy: Our Experience

Bell's palsy is an idiopathic unilateral lower motor neuron paresis or paralysis of the facial nerve of sudden onset. It involves loss of muscular control on the affected side of the face. This paper reports the prosthodontic management of patients with Bell's palsy and also describes a technique to stabilize the jaw movements in complete denture patients using interim dentures. A 65-year-old male edentulous patient and a 55-year-old female edentulous patient reported to the department of prosthodontics to get their missing teeth replaced. They both gave history of facial paralysis and were diagnosed for Bell's palsy. Interim training dentures with flat occlusal tables were fabricated first to correct and stabilize their mandibular movements. During initial 4 weeks, there was poor functioning of the interim dentures. Gradually by 8(th) week the patients started stabilizing the interim dentures and were functional. After observing the improvement when the patients had no pain and could stabilize and use the treatment dentures successfully, definitive complete dentures were fabricated. This case report presents a systematic approach to successively rehabilitate edentulous patients with Bell's palsy.

Comparison of the Efficacy of Combination Therapy of Prednisolone - Acyclovir with Prednisolone Alone in Bell's Palsy

OBJECTIVE

Bell's palsy is a rapid onset, usually, unilateral paralysis of the facial nerve that causes significant changes in an individual's life such as a decline in personal, social, and educational performance. This study compared efficacy of combined prednisolone and acyclovir therapy with prednisolone alone.

MATERIALS & METHODS

This study is a randomized controlled trial conducted on 43 Children (2-18 years old) with Bell's palsy. The first group of 23 patients was treated with prednisolone and the remaining patients were treated with a combination of prednisolone and acyclovir. The required data were extracted, using an informational form based on the House-Brackmann Scale, which grades facial nerve paralysis. The data were analyzed with Mann-Whitney test using SPSS version 16.

RESULTS

The mean age of the first and second group were 8.65 ± 5.07 and 8.35 ± 4.92 years, respectively, (p=0.84). Sixty one percent and 39% of patients in the first group, and 45% and 55% of patients in the second group were male and female, respectively. No significant differences exist between the groups in terms of age and gender. The rate of complete recovery was 65.2% in group I and 90% in the group II (p=0.04).

CONCLUSION

The results of this study showed that the combined prednisolone and acyclovir therapy of patients with Bell's palsy is far more effective than treatment with prednisolone alone. Actually, age and gender had no impact on the rate of recovery.

The neurologist's dilemma: a comprehensive clinical review of Bell's palsy, with emphasis on current management trends

Background

Recent advances in Bell’s palsy (BP) were reviewed to assess the current trends in its management and prognosis.

Material/Methods

We retrieved the literature on BP using the Cochrane Database of Systematic Reviews, PubMed, and Google Scholar. Key words and phrases used during the search included ‘Bell’s palsy’, ‘Bell’s phenomenon’, ‘facial palsy’, and ‘idiopathic facial paralysis’. Emphasis was placed on articles and randomized controlled trails (RCTs) published within the last 5 years.

Results

BP is currently considered the leading disorder affecting the facial nerve. The literature is replete with theories of its etiology, but the reactivation of herpes simplex virus isoform 1 (HSV-1) and/or herpes zoster virus (HZV) from the geniculate ganglia is now the most strongly suspected cause. Despite the advancements in neuroimaging techniques, the diagnosis of BP remains one of exclusion. In addition, most patients with BP recover spontaneously within 3 weeks.

Conclusions

Corticosteroids are currently the drug of choice when medical therapy is needed. Antivirals, in contrast, are not superior to placebo according to most reliable studies. At the time of publication, there is no consensus as to the benefit of acupuncture or surgical decompression of the facial nerve. Long-term therapeutic agents and adjuvant medications for BP are necessary due to recurrence and intractable cases. In the future, large RCTs will be required to determine whether BP is associated with an increased risk of stroke.

Clinical practice guideline: Bell's palsy

OBJECTIVE

Bell's palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mono-neuropathy, or disorder affecting a single nerve, and is the most common diagnosis associated with facial nerve weakness/paralysis. Bell's palsy is a rapid unilateral facial nerve paresis (weakness) or paralysis (complete loss of movement) of unknown cause. The condition leads to the partial or complete inability to voluntarily move facial muscles on the affected side of the face. Although typically self-limited, the facial paresis/paralysis that occurs in Bell's palsy may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential eye injury. Additional long-term poor outcomes do occur and can be devastating to the patient. Treatments are generally designed to improve facial function and facilitate recovery. There are myriad treatment options for Bell's palsy, and some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, numerous diagnostic tests available are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy.

PURPOSE

The primary purpose of this guideline is to improve the accuracy of diagnosis for Bell's palsy, to improve the quality of care and outcomes for patients with Bell's palsy, and to decrease harmful variations in the evaluation and management of Bell's palsy. This guideline addresses these needs by encouraging accurate and efficient diagnosis and treatment and, when applicable, facilitating patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell's palsy. The target population is inclusive of both adults and children presenting with Bell's palsy. ACTION STATEMENTS: The development group made a strong recommendation that (a) clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute-onset unilateral facial paresis or paralysis, (b) clinicians should prescribe oral steroids within 72 hours of symptom onset for Bell's palsy patients 16 years and older, (c) clinicians should not prescribe oral antiviral therapy alone for patients with new-onset Bell's palsy, and (d) clinicians should implement eye protection for Bell's palsy patients with impaired eye closure. The panel made recommendations that (a) clinicians should not obtain routine laboratory testing in patients with new-onset Bell's palsy, (b) clinicians should not routinely perform diagnostic imaging for patients with new-onset Bell's palsy, (c) clinicians should not perform electrodiagnostic testing in Bell's palsy patients with incomplete facial paralysis, and (d) clinicians should reassess or refer to a facial nerve specialist those Bell's palsy patients with (1) new or worsening neurologic findings at any point, (2) ocular symptoms developing at any point, or (3) incomplete facial recovery 3 months after initial symptom onset. The development group provided the following options: (a) clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell's palsy, and (b) clinicians may offer electrodiagnostic testing to Bell's palsy patients with complete facial paralysis. The development group offered the following no recommendations: (a) no recommendation can be made regarding surgical decompression for patients with Bell's palsy, (b) no recommendation can be made regarding the effect of acupuncture in patients with Bell's palsy, and (c) no recommendation can be made regarding the effect of physical therapy in patients with Bell's palsy.

Antivirals for Bell's palsy?

Each year in the UK around 1 in 5,000 people develop Bell's palsy-idiopathic unilateral lower motor neurone facial weakness of rapid onset. Although about 70% recover spontaneously, the remaining 30% are at risk of complications;(1) 13% have residual slight weakness and about 16% have persistent moderate to severe weakness if not treated.(2) As we have discussed in two previous articles there has been longstanding controversy about the best form of treatment.(2,3) In 2006 we concluded that published trials on the efficacy of drug treatments have been poor and no firm conclusions can be drawn about the benefit of any single drug;(2) in 2008 we noted that evidence suggests oral prednisolone started within 72 hours of symptom onset makes recovery more likely and that there was little good evidence that an antiviral drug helps.(3) The place of antivirals in the management of Bell's palsy remains a controversial issue. In this article we review the evidence for antiviral therapy alone or in conjunction with corticosteroid treatment.