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PV card: Bell's Palsy Treatment

Posted Feb 21 2013 12:00am

Valid for practice

True to literature

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Bell's Palsy is an idiopathic unilateral facial nerve paralysis. Above is a video clip that I found on YouTube demonstrating the facial nerve paralysis.

Since the 2009 Cochrane review  showing that antivirals added no benefit to corticosteroids in Bell's Palsy, I stopped prescribing them. The site  has concluded the same. Looking at the literature a little more, the recommendations are a little murkier. Some groups are still advocating for antivirals for severe cases, because there may be a very small but questionably positive benefit.

  • 2012 American Academy of Neurology guidelines : "Because of the possibility of a modest increase in recovery, patients might be offered antivirals (in addition to steroids) (Level C). Patients offered antivirals should be counseled that a benefit from antivirals has not been established, and, if there is a benefit, it is likely that it is modest at best"
  • UpToDate: "For the subgroup of patients with severe facial palsy at presentation, defined as House-Brackmann grade IV or higher, we suggest early combined therapy with prednisone (60 to 80 mg per day) plus valacyclovir (1000 mg three times daily) for one week rather than glucocorticoids alone (Grade 2B)."
  • 2012 Otolaryng Head Neck Surg journal article : "The authors conclude that although a strong recommendation for adding antiviral agents to corticosteroids to further improve the recovery of patients with severe Bell palsy is precluded by the lack of robust evidence, it should be discussed with the patient."
  • 2009 JAMA meta-analysis : "Antiviral agents, when administered with corticosteroids, may be associated with additional benefit."

What's your practice? 
Do you add an antiviral agent for Bell's Palsy? 

Feel free to download this card and print on a 4'' x 6'' index card.
[ MS Word ] [ PDF ] See  other Paucis Verbis cards .
Thanks to Dr. Kristin Berona (UCSF-SFGH EM resident) for the idea and notes!


  • de Almeida JR, Al Khabori M, Guyatt GH, Witterick IJ, Lin VY, Nedzelski JM, Chen JM. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA. 2009 Sep 2;302(9):985-93. PMID:  19724046
  • Lockhart P, Daly F, Pitkethly M, Comerford N, Sullivan F. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001869. PMID: 19821283  ; Summary
  • Gronseth GS, Paduga R; American Academy of Neurology. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2012 Nov 27;79(22):2209-13. PMID: 23136264  
  • Lampert L, Wong YJ. Combined antiviral-corticosteroid therapy for Bell palsy yields inconclusive benefit. J Am Dent Assoc. 2012 Jan;143(1):57-8. PMID:  22207669
  • Mattar S. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Treatment of Bell's palsy: should antiviral agents be added to prednisolone? Emerg Med J. 2012 Apr;29(4):340-2. PMID: 22420001
  • van der Veen EL, Rovers MM, de Ru JA, van der Heijden GJ. A small effect of adding antiviral agents in treating patients with severe Bell palsy. Otolaryngol Head Neck Surg. 2012 Mar;146(3):353-7. PMID: 22217913  
  • Vrabec JT, Backous DD, Djalilian HR, Gidley PW, Leonetti JP, Marzo SJ, Morrison D, Ng M, Ramsey MJ, Schaitkin BM, Smouha E, Toh EH, Wax MK, Williamson RA, Smith EO; Facial Nerve Disorders Committee. Facial Nerve Grading System 2.0. Otolaryngol Head Neck Surg. 2009 Apr;140(4):445-50. PMID: 19328328  
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