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The benefits of steroids versus steroids plus antivirals for treatment of Bell’s palsy: a meta-analysis

BMJ 2009; 339 doi: (Published 07 September 2009) Cite this as: BMJ 2009;339:b3354

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  1. Eudocia C Quant, neuro-oncology fellow12,
  2. Shafali S Jeste, neurologist32,
  3. Rajeev H Muni, ophthalmologist4,
  4. Alison V Cape, maternal fetal medicine fellow52,
  5. Manveen K Bhussar, clinical research assistant6,
  6. Anton Y Peleg, research fellow and infectious diseases physician267
  1. 1Department of Neurology, Massachusetts General Hospital, Boston, MA 02114
  2. 2Harvard Medical School, Boston, MA 02115
  3. 3Division of Neurology, Children’s Hospital Boston, Boston, MA 02115
  4. 4Department of Ophthalmology and Vision Sciences, University of Toronto, St Michael’s Hospital, Toronto, Ontario M5B 1W8, Canada
  5. 5Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, MA 02115
  6. 6Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA 02215
  7. 7Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114
  1. Correspondence to: A Y Peleg apeleg{at}
  • Accepted 29 May 2009


Objective To determine whether steroids plus antivirals provide a better degree of facial muscle recovery in patients with Bell’s palsy than steroids alone.

Design Meta-analysis.

Data sources PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for studies published in all languages from 1984 to January 2009. Additional studies were identified from cited references.

Selection criteria Randomised controlled trials that compared steroids with the combination of steroids and antivirals for the treatment of Bell’s palsy were included in this study. At least one month of follow-up and a primary end point of at least partial facial muscle recovery, as defined by a House-Brackmann grade of at least 2 (complete palsy is designated a grade of 6) or an equivalent score on an alternative recognised scoring system, were required.

Review methods Two authors independently reviewed studies for methodological quality, treatment regimens, duration of symptoms before treatment, length of follow-up, and outcomes. Odds ratios with 95% confidence intervals were calculated and pooled using a random effects model.

Results Six trials were included, a total of 1145 patients; 574 patients received steroids alone and 571 patients received steroids and antivirals. The pooled odds ratio for facial muscle recovery showed no benefit of steroids plus antivirals compared with steroids alone (odds ratio 1.50, 95% confidence interval 0.83 to 2.69; P=0.18). A one study removed analysis showed that the highest quality studies had the greatest effect on the lack of difference between study arms shown by the odds ratio. Subgroup analyses assessing causes of heterogeneity defined a priori (time from symptom onset to treatment, length of follow-up, and type of antiviral studied) showed no benefit of antivirals in addition to that provided by steroids.

Conclusions Antivirals did not provide an added benefit in achieving at least partial facial muscle recovery compared with steroids alone in patients with Bell’s palsy. This study does not, therefore, support the routine use of antivirals in Bell’s palsy. Future studies should use improved herpes virus diagnostics and newer antivirals to assess whether combination therapy benefits patients with more severe facial paralysis at study entry.


  • We thank Michael Stoto for his invaluable assistance with statistical analyses and for his thoughtful comments. We also thank Frank Sullivan, Martina Minnerop, and Kedar Adour for providing unpublished raw data; Roy Alcalay for obtaining an article; and Barbara Voetsch for translating an article.

  • Contributors: AYP was responsible for the conception of this study and ECQ, SSJ, RHM, AVC, and AYP were responsible for design. SSJ and AYP searched for and retrieved articles, and AVC and ECQ extracted the data. RHM acted as a third independent reviewer for disagreements in data extraction. Data analysis and interpretation were performed by ECQ, RHM, SSJ, AVC, MKB, and AYP. AYP wrote the manuscript, and ECQ, SSJ, RHM, AVC, and MKB revised it. ECQ and SSJ constructed the figures. ECQ, RHM, AVC, SSJ, and AYP are guarantors.

  • Funding: No specific funding was received for this study. However, ECQ was funded by an American National Cancer Institute Paul Calabresi Award for Clinical Oncology (K12CA090354), SSJ was funded by an American Academy of Neurology Clinical Research Training fellowship, RHM by an EA Baker Fellowship from the Canadian National Institute for the Blind, and AYP by a University of Queensland postgraduate fellowship. All researchers are independent of the funding body.

  • Competing interests: AYP has acted as an adviser for Abbott Molecular. All other authors have no competing interests.

  • All authors had full access to all of the data in this study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

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