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Clinical Review

Recent developments in Bell's palsy

BMJ 2004; 329 doi: (Published 02 September 2004) Cite this as: BMJ 2004;329:553

Rapid Response:

Corticosteroids are Not Proven for Treatment of Bell's Palsy

Editor—Holland and Eisner support the use of corticosteroids for treatment
of moderate to severe facial palsy based on two systematic reviews [1,2].
We believe that such a conclusion is not justified by the medical evidence
presented by the authors and that the two systematic reviews are fatally

In the Ramsey review, three studies met the authors’ criteria for
validity [3,4,5], but in Ramsey’s analysis the study by May et al.[3]-- a
valid study—-was excluded because it was an “outlier”, i.e., the results
were not consistent with the other two studies included in the review.
Excluding a study on the basis of results rather than methodology is
inappropriate. Results from non-valid studies should not be utilized in

May et al. reported that corticosteroids resulted in poorer facial
recovery than placebo. It should be noted that the quality index score of
the excluded (May) study was better than one of the studies included in
Ramsey’s review. If the May et al study is not excluded, the results do
not support the authors’ conclusion of benefit from corticosteroid

It should also be noted that a Cochrane systematic review [6]included
the May study as a valid study, but excluded the Austin study because 29
percent of subjects in the Austin study were lost to follow-up. Cochrane
also excluded the Shafshak study because it was a non-randomized study.

As pointed out by the Cochrane group, the Grogan “practice parameter”
is probably invalid because Grogan included the Shafshak and Austin
studies and that if these two trials were excluded from the pooled
estimate, the results were no longer in favor of steroids for the
treatment of Bell’s palsy.

1. Grogan PM, Gronseth GS. Practice parameter: steroids, acyclovir,
and surgery for Bell's palsy (an evidence-based review): report of the
Quality Standards Subcommittee of the American Academy of Neurology.
Neurology 2001;56: 830-6

2. Ramsey MJ, DerSimonian R, Holtel MR, Burgess LP. Corticosteroid
treatment for idiopathic facial nerve paralysis: a meta-analysis.
Laryngoscope 2000;110: 335-41

3.May M, Wette R, Hardin WB Jr, Sullivan J. The use of steroids in
Bell’s palsy: a prospective controlled study. Laryngoscope 1976;

4.Austin JR, Peskind SP, Austin SG, Rice DH. Idiopathic facial nerve
paralysis: a randomized double blind controlled study of placebo versus
prednisone. Laryngoscope 1993; 103:1326–1333.

5. Shafshak TS, Essa AY, Bakey FA. The possible contributing factors
for the success of steroid therapy in Bell’s palsy: a clinical and
electrophysiological study. J Laryngol Otol 1994; 108:940–943.

6. The Cochrane Database of Systematic Reviews
The Cochrane Library, Copyright 2003, The Cochrane Collaboration:
Corticosteroids for Bell's palsy (idiopathic facial paralysis) [Review]
Salinas, RA; Alvarez, G; Alvarez, MI; Ferreira, J Date of Most Recent
Update: 26-November-2001. Date of Most Recent Substantive Update: 15-

Competing interests:
None declared

Competing interests: No competing interests

07 September 2004
Michael E. Stuart
President, Delfini Group LLC, Clinical Assistant Professor, Univ. Washington, Dept. Family Medicine
Sheri A. Strite