Recent developments in Bell's palsy
http://www.100md.com
《英国医生杂志》
EDITOR—Holland and Weiner's clinical review on recent developments in Bell's palsy prompted 24 responses, 10 of them critical of the views on treatment.1 The authors were wrong to recommend early treatment with steroids or antiviral agents, or both, because the supporting evidence they offered was inconclusive and flawed; they ignored the best evidence (two systematic reviews) and selected other trials to support their own opinion; neither treatment is harmless, and antiviral agents are expensive; and they glossed other potentially useful treatments.
A physiotherapist thought the review a bit light on facial retraining for people with residual paralysis, and a surgeon from Seattle wanted more on the potential benefits of decompression surgery. A patient said that speech therapy had been the only useful treatment, while other responses emphasised that most patients get better without any treatment at all.
Criticism of Holland and Weiners' use and misuse of evidence led to more general criticism of the BMJ for allowing them the space to do it in public. The BMJ, they felt, should be more rigorous and "evidence based." Just to emphasise the point, one response reports an obvious inconsistency between Clinical Evidence—the BMJ Publishing Group's most systematic and evidence based publication—which says that steroids are an unproved treatment for Bell's palsy, and Holland and Weiners' article—a mostly unsystematic review also published by the BMJ Publishing Group—which says that steroids might work and you should prescribe them as soon as possible to most patients.
So which wing of the BMJ should readers believe? A large new clinical trial is under way that will hopefully provide the answers.
Holland and Weiner recommend early referral to a specialist as well as early treatment with steroids. Three general practitioners from the United Kingdom disagree. "Prompt treatment, support, and follow up can all be effectively delivered in general practice with the option to refer patients who fail to improve or have poor prognostic indicators," says the first. "In an NHS where resources are so scarce, advice to refer patients who will not benefit from outpatient attendance is wasteful of resources."
Nine responses touch on the causes of facial palsy. A paediatrician writes that high blood pressure could be responsible for up to 17% of cases in children. There may also be a link between Bell's palsy and high blood pressure in pregnant women, says another respondent, citing a study showing that about a fifth of pregnant women who present with Bell's palsy develop preeclampsia. A third respondent describes the case of a young man who had three episodes of Bell's palsy before someone thought to look for, and found, coeliac disease. A gluten free diet has so far prevented any further neurological problems.
Infectious aetiologies seem more controversial. Lyme disease may be an established cause of facial palsy, but who should you test for Lyme disease and how? One respondent says the serological testing advocated by Holland and Weiner is unreliable. And a community paediatrician from Sweden suggests lumbar puncture to look for pleocytosis before risking treatment with corticosteroids.
Finally, two patients give insight on the impact of Bell's palsy on their social and working lives. "As chairman and MD of a software development company the facial deformity and the apparently drunken speech were not only embarrassing but made work virtually impossible by making sensible communication difficult," writes one. "The comparative rarity of the condition (20/100 000) in the UK and consequent public lack of awareness helped to reinforce the negative view of the facially distorted slurring stranger."
Alison Tonks, freelance medical editor
Altrincham, Cheshire WA15 9AY
Competing interests: None declared.
References
Electronic responses. Recent developments in Bell's palsy. Bmj.com 2004. http://bmj.bmjjournals.com/cgi/eletters/329/7465/553 (accessed 14 Oct 2004).
A physiotherapist thought the review a bit light on facial retraining for people with residual paralysis, and a surgeon from Seattle wanted more on the potential benefits of decompression surgery. A patient said that speech therapy had been the only useful treatment, while other responses emphasised that most patients get better without any treatment at all.
Criticism of Holland and Weiners' use and misuse of evidence led to more general criticism of the BMJ for allowing them the space to do it in public. The BMJ, they felt, should be more rigorous and "evidence based." Just to emphasise the point, one response reports an obvious inconsistency between Clinical Evidence—the BMJ Publishing Group's most systematic and evidence based publication—which says that steroids are an unproved treatment for Bell's palsy, and Holland and Weiners' article—a mostly unsystematic review also published by the BMJ Publishing Group—which says that steroids might work and you should prescribe them as soon as possible to most patients.
So which wing of the BMJ should readers believe? A large new clinical trial is under way that will hopefully provide the answers.
Holland and Weiner recommend early referral to a specialist as well as early treatment with steroids. Three general practitioners from the United Kingdom disagree. "Prompt treatment, support, and follow up can all be effectively delivered in general practice with the option to refer patients who fail to improve or have poor prognostic indicators," says the first. "In an NHS where resources are so scarce, advice to refer patients who will not benefit from outpatient attendance is wasteful of resources."
Nine responses touch on the causes of facial palsy. A paediatrician writes that high blood pressure could be responsible for up to 17% of cases in children. There may also be a link between Bell's palsy and high blood pressure in pregnant women, says another respondent, citing a study showing that about a fifth of pregnant women who present with Bell's palsy develop preeclampsia. A third respondent describes the case of a young man who had three episodes of Bell's palsy before someone thought to look for, and found, coeliac disease. A gluten free diet has so far prevented any further neurological problems.
Infectious aetiologies seem more controversial. Lyme disease may be an established cause of facial palsy, but who should you test for Lyme disease and how? One respondent says the serological testing advocated by Holland and Weiner is unreliable. And a community paediatrician from Sweden suggests lumbar puncture to look for pleocytosis before risking treatment with corticosteroids.
Finally, two patients give insight on the impact of Bell's palsy on their social and working lives. "As chairman and MD of a software development company the facial deformity and the apparently drunken speech were not only embarrassing but made work virtually impossible by making sensible communication difficult," writes one. "The comparative rarity of the condition (20/100 000) in the UK and consequent public lack of awareness helped to reinforce the negative view of the facially distorted slurring stranger."
Alison Tonks, freelance medical editor
Altrincham, Cheshire WA15 9AY
Competing interests: None declared.
References
Electronic responses. Recent developments in Bell's palsy. Bmj.com 2004. http://bmj.bmjjournals.com/cgi/eletters/329/7465/553 (accessed 14 Oct 2004).