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Combination Therapy for Bell's Palsy

      To the Editor:
      Treatment of Bell's palsy with antivirals constitutes an ongoing discussion. Lee et al
      • Lee H.Y.
      • Byun J.Y.
      • Park M.S.
      • Yeo S.G.
      Steroid-antiviral treatment improves the recovery rate in patients with severe Bell's palsy.
      were the first to perform a study in the relevant population domain (ie, patients with a severe palsy). Their manuscript confirms the results of a previous retrospective study.
      • Hato N.
      • Matsumoto S.
      • Kisaki H.
      • et al.
      Efficacy of early treatment of Bell's palsy with oral acyclovir and prednisolone.
      The authors are to be congratulated with the outcome: they offer clear proof of the effectiveness of combination therapy—corticosteroids and antivirals—enhancing recovery in patients with a severe palsy.
      Lee suggests that we performed a study in which we gave patients the choice for treatment. However, we merely stated that based on our review, the prescription of antivirals should be discussed with individual patients.
      • Lee H.Y.
      • Byun J.Y.
      • Park M.S.
      • Yeo S.G.
      Steroid-antiviral treatment improves the recovery rate in patients with severe Bell's palsy.
      • Van der Veen E.L.
      • Rovers M.M.
      • De Ru J.A.
      • Van der Heijden G.J.
      A small effect of adding antiviral agents in treating patients with severe bell palsy.
      In their fourth Table, Lee referenced studies by Engstrom and Axelsson.
      • Lee H.Y.
      • Byun J.Y.
      • Park M.S.
      • Yeo S.G.
      Steroid-antiviral treatment improves the recovery rate in patients with severe Bell's palsy.
      • Engstrom M.
      • Berg T.
      • Stjernquist-Desatnik A.
      • et al.
      Prednisolone and valaciclovir in Bell's palsy: a randomized, double-blind, placebo-controlled, multicenter trial.
      • Axelsson S.
      • Berg T.
      • Jonsson L.
      • Engstrom M.
      • Kanerva M.
      • Stjernquist-Desatnik A.
      Bell's palsy – the effect of prednisolone and/or valaciclovir versus placebo in relation to baseline severity in a randomised controlled trial.
      However, these studies are both based on the same patients. Although the articles were published in different journals, it is the same salami sliced differently. Therefore, Engstrom can be deleted, which results in an even higher pooled odds ratio.
      Since our review, only one other study has been published with a subgroup analysis based on the severity of palsy.
      • Ryu E.W.
      • Lee H.Y.
      • Lee S.Y.
      • Park M.S.
      • Yeo S.G.
      Clinical manifestations and prognosis of patients with Ramsay Hunt syndrome.
      The severe cases fared better when treated with combination therapy. Unfortunately, the authors (including Lee) concluded negatively about antivirals for Bell's palsy.
      In a reaction to our “rapid response,” the BMJ published a correction to the meta-analysis by Quant et al.

      De Ru JA, Martens EP, Van der veen EL. Antivirals for a possible viral cause. Rapid response to Quant et al., BMJ. 2009;339:doi:10.1136/bmj.b3354. BMJ. 2011. Available at: http://www.bmj.com/rapid-response/2011/11/03/antivirals-possible-viral-cause. Accessed August 5, 2013.

      Their pooled odds ratio became positive as well, even though studies including all grades of severity were analyzed.
      Furthermore, synkinesis, as shown by Axelsson, occurs more often in patients with corticosteroids monotherapy.
      • Axelsson S.
      • Berg T.
      • Jonsson L.
      • Engstrom M.
      • Kanerva M.
      • Stjernquist-Desatnik A.
      Bell's palsy – the effect of prednisolone and/or valaciclovir versus placebo in relation to baseline severity in a randomised controlled trial.
      Recovery not beyond the House-Brackmann grade V occurs only in the monotherapy group.
      • Lee H.Y.
      • Byun J.Y.
      • Park M.S.
      • Yeo S.G.
      Steroid-antiviral treatment improves the recovery rate in patients with severe Bell's palsy.
      The conclusion from the above is simple: in case of Bell's palsy, combination therapy of corticosteroids and antivirals is preferable. Trying to optimize treatment (dose, timing, type of antiviral, and for whom) is necessary. Not prescribing in case of severe palsy amounts to malpractice.

      References

        • Lee H.Y.
        • Byun J.Y.
        • Park M.S.
        • Yeo S.G.
        Steroid-antiviral treatment improves the recovery rate in patients with severe Bell's palsy.
        Am J Med. 2013; 126: 336-341
        • Hato N.
        • Matsumoto S.
        • Kisaki H.
        • et al.
        Efficacy of early treatment of Bell's palsy with oral acyclovir and prednisolone.
        Otol Neurotol. 2003; 24: 948-951
        • Van der Veen E.L.
        • Rovers M.M.
        • De Ru J.A.
        • Van der Heijden G.J.
        A small effect of adding antiviral agents in treating patients with severe bell palsy.
        Otolaryngol Head Neck Surg. 2012; 146: 353-357
        • Engstrom M.
        • Berg T.
        • Stjernquist-Desatnik A.
        • et al.
        Prednisolone and valaciclovir in Bell's palsy: a randomized, double-blind, placebo-controlled, multicenter trial.
        Lancet Neurol. 2008; 7: 993-1000
        • Axelsson S.
        • Berg T.
        • Jonsson L.
        • Engstrom M.
        • Kanerva M.
        • Stjernquist-Desatnik A.
        Bell's palsy – the effect of prednisolone and/or valaciclovir versus placebo in relation to baseline severity in a randomised controlled trial.
        Clin Otolaryngol. 2012; 37: 283-290
        • Ryu E.W.
        • Lee H.Y.
        • Lee S.Y.
        • Park M.S.
        • Yeo S.G.
        Clinical manifestations and prognosis of patients with Ramsay Hunt syndrome.
        Am J Otolaryngol. 2012; 33: 313-318
      1. De Ru JA, Martens EP, Van der veen EL. Antivirals for a possible viral cause. Rapid response to Quant et al., BMJ. 2009;339:doi:10.1136/bmj.b3354. BMJ. 2011. Available at: http://www.bmj.com/rapid-response/2011/11/03/antivirals-possible-viral-cause. Accessed August 5, 2013.

      Linked Article

      • Steroid-antiviral Treatment Improves the Recovery Rate in Patients with Severe Bell's Palsy
        The American Journal of MedicineVol. 126Issue 4
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          The extent of facial nerve damage is expected to be more severe in higher grades of facial palsy, and the outcome after applying different treatment methods may reveal obvious differences between severe Bell's palsy and mild to moderate palsy. This study aimed to systematically evaluate the effects of different treatment methods and related prognostic factors in severe to complete Bell's palsy.
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      • The Reply
        The American Journal of MedicineVol. 126Issue 12
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          We found that treatment with steroids and antiviral agents was more effective than steroids alone in treating severe to complete Bell's palsy. This type of combination therapy is not novel, with many researchers mentioning its advantages.1
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