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

Abstract

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.

Fig 1 Flow diagram of the study selection process. The initial study numbers from each database do not represent the number of unique articles. Duplicate articles from different databases were removed in the first exclusion stage

Fig 2 Forest plot of the six included studies ordered according to Jadad score (highest quality to lowest) showing the odds ratio estimates and their 95% confidence intervals. The pooled estimate is based on a random effects model

Fig 3 Cumulative forest plot of the six included studies, ordered according to study quality (highest quality to lowest)

Fig 4 Forest plot of a one study removed analysis showing the odds ratio estimate and 95% confidence interval if the study specified in the “Study removed” column is not included

Fig 5 Funnel plot of the six included studies (solid circles) and two added studies (open circles) based on a trim and fill algorithm. The pooled odds ratio and 95% confidence interval based on the six included studies (solid diamond) and following the addition of the extra studies (open diamond) are shown