Bell's palsy--is glucocorticoid treatment enough?

Approximately a third of cases of acute peripheral facial weakness are caused by trauma, diabetes mellitus, hypertension, eclampsia, the Ramsay Hunt syndrome (facial palsy with zoster oticus caused by varicella–zoster virus), Lyme disease, sarcoidosis, Sjögren’s syndrome, parotid gland tumors, and amyloidosis and may even be a complication of intranasal influenza vaccine.1 The remaining two thirds of cases are idiopathic (Bell’s palsy). Bell’s palsy occurs in 20 to 32 persons per 100,000 per year2,3 and affects both sexes and all ages. Fortunately, most patients with Bell’s palsy recover completely, but 20 to 30% may have permanent, disfiguring facial weakness or paralysis.3,4 Besides the asymmetry evident from limited retraction of the muscles around the angle of the mouth on one side and an inability to close the eye (Fig. 1), there may be other permanent sequelae, such as synkinesia, hyperacusis, a loss of taste, and an inability to produce tears. It is this substantial minority of patients with Bell’s palsy on whom early treatment is focused. The rationale for early and aggressive treatment is based on long-standing observations by surgeons who have reported the presence of facialnerve swelling during decompression operations in patients with Bell’s palsy.5 Edema may be secondary to ischemia6 or inflammation, as evidenced by contrast enhancement of the facial nerve seen on magnetic resonance imaging 9 to 23 days after the onset of Bell’s palsy.7 For years, physicians have treated patients with Bell’s palsy as early as possible with glucocorticoids. In addition, the detection of herpes simplex virus in the endoneurial fluid of patients with Bell’s palsy8 has led to the widespread use of antiviral agents along with glucocorticoids in the past decade, although the exact role of the virus in disease pathogenesis is unknown. Most, but not all, of the numerous studies that have compared glucocorticoid treatment with placebo in patients with Bell’s palsy have shown significant improvement with glucocorticoids.9 Glucocorticoids also appear to confer a greater benefit than acyclovir in these patients.10 Although the collective data suggest that glucocorticoids decrease the incidence of permanent facial paralysis, whether antiviral therapy confers additional benefits has not been known. In this issue of the Journal, Sullivan et al.11 report on a large study involving the treatment of