HSC Section 3 - Trauma, Critical Care and Sleep Medicine

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Table 2 Summary of medical treatment of acute facial paralysis (Bell palsy)

Moderate Evidence

Strong Evidence

Low Evidence

Corticosteroids

Antiviral

Acupuncture Electrical stimulation (possibly harmful) Physical therapy (higher for chronic facial paralysis)

Corticosteroids Given the scientific evidence in support of neural inflammation and secondary ischemia resulting in neural blockade of the facial nerve that leads to FP, corticoste- roids are a mainstay in acute therapy. A recent Cochrane review 67 compared ste- roids with a placebo and showed high-quality evidence from randomized controlled trials in support of a beneficial effect of the use of corticosteroids. Moderate-quality evidence revealed less motor synkinesis and crocodile tears at 6-month follow-up versus the placebo group. Lower-quality evidence suggested that there was no difference in disabling persistent sequelae. No serious adverse ef- fects were noted. One study by Sullivan and colleagues, 68 with 496 patients, was a randomized double-blind, placebo-controlled trial that included patients within 72 hours of their paralysis. A total of 496 patients were included in 4 treatment arms. At follow-up at 3, 6, and 9-months, patients receiving prednisolone showed statistically significant improvement versus those receiving placebo (3 months: 83% vs 63.6%, 9 months: 94.4% vs 81.6%, P <.001) or antiviral (acyclovir) medica- tion alone (antiviral vs placebo, 3 months: 71.2% vs 75.7%, 9 months: 85.4% vs 90.8%). Combined therapy showed improvement of 79.7% and 92.7% (3 and 9 months, P <.001). Another large randomized placebo-controlled study by Engstrom and colleagues 69 compared prednisone and valacyclovir: 829 patients were placed into 4 treatment arms. Time to recovery was significantly shorter in those receiving steroid therapy ( P <.001). The typical prednisolone dosing in most studies was 60 mg per day for 5 days fol- lowed by a 5-day taper. 69,70 In children, weight-based dosing, such as prednisone 1 to 2 mg/kg per day for 10 days with a 3-day to 5-day taper is used 71 or prednisolone 0.5 to 1.0 mg/kg per day. 72 Although intravenous delivery is an option, this is not common. 73 Recent American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) clinical practice guidelines for BP recommend a 10-day course of oral corticosteroids with at least 5 days at a high dose (prednisolone 50 mg for 10 days or prednisone 60 mg for 5 days with a 5-day taper). Steroids should be started within 72 hours of the onset of symptoms. Although there are no high- quality data in support of steroid use in children, given that the disease process is similar and the low risk/benefit ratio of the drug, oral steroids should be considered for children. 74 Although steroids are associated with a range of possible side effects, this short- term dosing (10 days) is typically well tolerated. 67 During steroid therapy, patients should receive H 2 receptor blockade to prevent dyspepsia and gastric ulceration. Steroids should be prescribed with caution in patients with a medical history of dia- betes mellitus, gastric or duodenal ulcer, poorly controlled hypertension, renal or hepatic disease, glaucoma, pregnancy, recent head trauma, or psychiatric disease. A rare but devastating side effect of steroids is avascular necrosis of the femoral head.

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