Recent developments in Bell's palsy
http://www.100md.com
《英国医生杂志》
1 Department of Otolaryngology, Royal Devon and Exeter NHS Foundation Trust, Exeter EX2 5DW
Correspondence to: N J Holland njulianholland@hotmail.com
Introduction
We canvassed specialists with an interest in acute facial palsy and incorporated the latest consensus from key publications and systematic reviews. We performed a hierarchical literature search through Medline, CINAHL, SUMSearch, bmj.com, Lancet Neurology Network, Bandolier, Health Technology Assessment, Clinical Evidence, and the Cochrane Library. Both authors are otolaryngologists with an interest in neurotology and facial palsy.
Incidence and pathophysiology
The most alarming symptom of Bell's palsy is paresis; up to three quarters of affected patients think they have had a stroke or have an intracranial tumour. The palsy is often sudden in onset and evolves rapidly, with maximal facial weakness developing within two days. Associated symptoms may be hyperacusis, decreased production of tears, and altered taste (table 2).
Table 2 Polyneuropathy in Bell's palsy4
Patients may also mention otalgia or aural fullness and facial or retroauricular pain, which is typically mild and may precede the palsy. Severe pain suggests herpes zoster virus and may precede a vesicular eruption and progression to Ramsay Hunt syndrome. Features may be consistent with a mild polyneuropathy. A slow onset progressive palsy with other cranial nerve deficits or headache raises the possibility of a neoplasm.
Examination
Serum testing for rising antibody titres to herpes virus is not a reliable diagnostic tool for Bell's palsy. Salivary polymerase chain reaction for herpes simplex virus type 1 or herpes zoster virus is more likely to confirm virus during the replicating phase, but these tests remain research tools. Serological tests for Lyme disease (IgM, IgG) are essential to exclude this disease in endemic areas, and magnetic resonance imaging has revolutionised the detection of tumours. Typically, the hearing threshold is not affected in Bell's palsy, but stapedius reflexes may be reduced or absent. Topognostic tests and electroneurography may give useful prognostic information but remain research tools.8
Zoster sine herpete
Bell's palsy is a much less common cause of facial palsy in children under 10 years of age. These children therefore merit careful review to identify an alternative cause, including acute suppurative ear disease. Lyme disease may be responsible for as many as half the cases in endemic areas.
Outcomes
The main aims of treatment in the acute phase of Bell's palsy are to speed recovery and to prevent corneal complications. Treatment should begin immediately to inhibit viral replication and the effect on subsequent pathophysiological processes that affect the facial nerve. Psychological support is also essential, and for this reason patients may require regular follow up.
Eye care
Eye care of patients with Bell's palsy focuses on protecting the cornea from drying and abrasion due to problems with lid closure and the tearing mechanism. The patient is educated to report new findings such as pain, discharge, or change in vision. Lubricating drops should be applied hourly during the day and a simple eye ointment should be used at night.
Corticosteroids
Two recent systematic reviews concluded that Bell's palsy could be effectively treated with corticosteroids in the first seven days, providing up to a further 17% of patients with a good outcome in addition to the 80% that spontaneously improve (see also fig B on bmj.com).10 11 Other studies have shown the benefits of treatment with steroids; in one, patients with severe facial palsy showed a significant improvement after treatment within 24 hours.12 13 Recovery rates in patients treated within 72 hours were enhanced by the addition of aciclovir.14
A randomised controlled trial of patients treated with high dose parenteral steroids within 72 hours compared with placebo found a significant improvement in recovery rate and time to return to work but no statistical difference in final outcome.15 More randomised controlled trials are needed, but at least 200 patients would be required in each arm.16 17
Given the existing evidence (see bmj.com for description of grades (A) to (D)), we support the use of oral prednisone with aciclovir in patients presenting with moderate to severe facial palsy, ideally within 72 hours. Immunocompetent patients without specific contraindications are prescribed prednisone at 1 mg/kg/d (maximum 80 mg) for the first week, which is tapered over the second week.(B) Around a fifth of patients will progress from partial palsy, so these patients should also be treated.11(C)
Antiviral agents
Treatment with antivirals seems logical in Bell's palsy because of the probable involvement of herpes viruses. Aciclovir, a nucleotide analogue, interferes with herpes virus DNA polymerase and inhibits DNA replication. Because of aciclovir's relatively poor bioavailability (15% to 30%),18 newer drugs in its class are being trialled. Better bioavailability, dosing regimens, and clinical effectiveness in treating shingles have been shown with valaciclovir (prodrug of aciclovir), famciclovir (prodrug of penciclovir), and sorivudine.19
Box 2: Evolving treatments for Bell's palsy
Some evidence of effect
Methylcobalamin—an active form of vitamin B-12
Hyperbaric oxygen—may be useful in patients who show degeneration despite maximal therapy
Facial retraining—"mime therapy"
Botulinum toxin for synkinesis and hemifacial spasm
Uncertain effect
Transcutaneous electrical stimulation
Acupuncture
Current research
Multicentre, randomised, double blind, placebo controlled trials on steroid and antiviral therapy are being carried out in Sweden and France
New antivirals—for example, famciclovir, sorivudine
Vaccination against herpes zoster virus and herpes simplex virus types 1 and 2
Neurotrophic growth factors, neuroprotective agents—for example, nimodipine, glial cell derived neurotrophic factor
Additional educational resources
Book
Pensak ML. Controversies in otolaryngology. New York: Thieme, 2001: 218-31—three chapters presenting current perspectives on acute facial palsy
Key papers
Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different aetiologies. Acta Otolaryngol Suppl 2002;549: 4-30—key text on the epidemiology and outcomes of untreated Bell's palsy
Morrow MJ. Bell's palsy and herpes zoster oticus. Curr Treat Options Neurol 2000;2: 407-16—excellent review and evidence based treatment guidelines
Sweeney CJ, Gilden DH. Ramsay Hunt syndrome. J Neurol, Neurosurg Psychiatry 2001;71: 149—relevant publication from active researchers in this subject
Internet resources
emedicine.com—has several well structured articles on Bell's palsy
Information for patients
The official patient's sourcebook on Bell's palsy: a revised and updated directory for the internet age publisher. San Diego, CA: Icon Health, 2003—several books are available to patients, which tend to present the authors' viewpoints
Patient information. Bell's palsy. J Fam Pract Feb 2003;52: 160—useful information leaflet
Bell's palsy information site (www.bellspalsy.ws/links.htm)—a structured website with information about acute treatment and rehabilitation
Bell's palsy association (www.bellspalsy.org.uk/links.htm)—UK based site providing information and support for patients
Open directory project (http://dmoz.org/)—access to a huge number of links of variable quality
Aciclovir compared with prednisone
Aciclovir has been compared with prednisone.20 Prednisone has been shown to be more effective in producing good recovery at three or more months, but despite flaws in this study, we would not recommend using aciclovir (or any antiviral) without steroids unless steroids are contraindicated.19(B)
Aciclovir with prednisone
A recent systematic review found that patients treated with combined aciclovir and prednisone had a better outcome than those treated with prednisone alone.10 However, a Cochrane review at that time concluded that more studies were required.21 More recently, a study of patients with severe palsies found better recovery with combined aciclovir and prednisone than with prednisone alone. The main determinate of the difference was treatment within three days of the onset of palsy.14
A prospective case controlled study showed that patients treated with valaciclovir and prednisone (86% within 72 hours) had better recovery rates than patients treated with prednisone alone. A noticeable benefit was seen in elderly patients, a group that is often overlooked for maximal treatment.22 A study of systemic therapy found no difference between oral aciclovir with prednisone and intravenous aciclovir with prednisone.23 Systemic treatment should be considered in immunocompromised patients or for widespread zoster involving the central nervous system.
We support the use of oral aciclovir or valaciclovir with prednisone in patients presenting within a first week (ideally within 72 hours) with moderate to severe facial palsy.(B)
Treatment in children
Studies have found that children with complete facial palsies and major degeneration have poor outcomes as often as adults. However, no supportive evidence has been found for use of steroids or antivirals in children with Bell's palsy (see fig C on bmj.com).24(D)
Zoster sine herpete
Although 2000 mg/d of aciclovir would not be adequate for Ramsay Hunt syndrome with vesicles, it seems to be effective in patients with zoster sine herpete.14 On the basis of current evidence, in the absence of major pain or evidence of vesicles, this dose would be adequate with steroids for treating Bell's palsy associated with herpes zoster virus.(C)
Future research may indicate that patients with severe post auricular pain, dense palsy, or herpes zoster virus do better with higher dose antiviral therapy from the outset.(D)
Surgery
Surgical intervention decompresses the facial nerve.25 However, middle fossa craniotomy carries risks, including seizures, deafness, leakage of cerebrospinal fluid, and facial nerve injury. Hence decompression surgery for Bell's palsy is not routinely offered in the United Kingdom.(D)
Physical therapies
Several physical therapies, including massage and facial exercises, are recommended to patients, but there are few controlled clinical trials of their effectiveness.(D) Some recent evidence supports facial retraining (mime therapy) with biofeedback.26(C)
Follow up
Rowlands S, Hooper R, Hughes R, Burney P. The epidemiology and treatment of Bell's palsy in the UK. Eur J Neurol 2002;9: 63-7.
Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl 2002;549: 4-30.
Murakami S, Mizobuchi M, Nakashiro Y, Doi T, Hato N, Yanagihara N. Bell's palsy and herpes simplex virus: identification of viral DNA in endoneurial fluid and muscle. Ann Intern Med 1996;124: 27-30.
Adour KK. Current concepts in neurology: diagnosis and management of facial paralysis. N Engl J Med 82;307: 348-51.
House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93: 146-7.
Dresner SC. Ophthalmic management of facial nerve paralysis. Focal points. San Francisco: American Academy of Ophthalmology, Jan 2000.
Stanek G, Strle F. Lyme borreliosis. Lancet 2003;362: 1639-47.
Dobie RA. Tests of facial nerve function. In: Cummings CW et al, eds. Otolaryngology head and neck surgery. New York: Mosby, 1998: 2757-66.
Sweeney CJ, Gilden DH. Ramsay Hunt syndrome. J Neurol Neurosurg Psychiatr 2001;71: 149.
Grogan PM, Gronseth GS. Practice parameter: steroids, acyclovir, and surgery for Bell's palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001;56: 830-6.
Ramsey MJ, DerSimonian R, Holtel MR, Burgess LP. Corticosteroid treatment for idiopathic facial nerve paralysis: a meta-analysis. Laryngoscope 2000;110: 335-41.
Williamson IG, Whelan TR. The clinical problem of Bell's palsy: is treatment with steroids effective? Br J Gen Pract 1996;46: 743-7.
Shafshak TS, Essa AY, Bakey FA. The possible contributing factors for the success of steroid therapy in Bell's palsy: a clinical and electrophysiological study. J Laryngol Otol 1994;108: 940-3.
Hato N, Matsumoto S, Kisaki H, Takahashi H, Wakisaka H, Honda N, et al. Efficacy of early treatment of Bell's palsy with oral acyclovir and prednisolone. Otol Neurotol 2003;24: 948-51.
Lagalla G, Logullo F, Di Bella P, Provinciali L, Ceravolo MG. Influence of early high-dose steroid treatment on Bell's palsy evolution. Neurol Sci 2002;23: 107-12.
Salinas RA, Alvarez G, Alvarez MI, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2002;(1): CD001942.
Burgess LP, Yim DW, Lepore ML. Bell's palsy: the steroid controversy revisited. Laryngoscope 1984;94: 1472-6.
De Miranda P, Blum MR. Pharmacokinetics of acyclovir after intravenous and oral administration. J Antimicrob Chemother 1983;12(suppl B): 29-37.
Snoeck R, Andrei G, De Clercq E. Current pharmacological approaches to the therapy of varicella zoster virus infections: a guide to treatment. Drugs 1999;57: 187-206.
De Diego JI, Prim MP, De Sarria MJ, Madero R, Gavilan J. Idiopathic facial paralysis: a randomized, prospective, and controlled study using single-dose prednisone versus acyclovir three times daily. Laryngoscope 1998;108: 573-5.
Sipe J, Dunn L. Aciclovir for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2001;(4): CD001869.
Axelsson S, Lindberg S, Stjernquist-Desatnik A. Outcome of treatment with valacyclovir and prednisone in patients with Bell's palsy. Ann Oto, Rhinol Laryngol 2003;112: 197.
Murakami S, Hato N, Horiuchi J, Honda N, Gyo K, Yanagihara N. Treatment of Ramsay Hunt syndrome with acyclovir-prednisone: significance of early diagnosis and treatment. Ann Neurol 1997;41: 353-7.
Salman MS, MacGregor DL. Should children with Bell's palsy be treated with corticosteroids? A systematic review. J Child Neurol 2001;16: 565-8.
Fisch U. Surgery for Bell's palsy. Arch Otolaryngol 1981;107: 1-11.
Beurskens CH, Heymans PG. Positive effects of mime therapy on sequelae of facial paralysis: stiffness, lip mobility, and social and physical aspects of facial disability. Otol Neurol 2003;24: 677-81.(N Julian Holland, special)
Correspondence to: N J Holland njulianholland@hotmail.com
Introduction
We canvassed specialists with an interest in acute facial palsy and incorporated the latest consensus from key publications and systematic reviews. We performed a hierarchical literature search through Medline, CINAHL, SUMSearch, bmj.com, Lancet Neurology Network, Bandolier, Health Technology Assessment, Clinical Evidence, and the Cochrane Library. Both authors are otolaryngologists with an interest in neurotology and facial palsy.
Incidence and pathophysiology
The most alarming symptom of Bell's palsy is paresis; up to three quarters of affected patients think they have had a stroke or have an intracranial tumour. The palsy is often sudden in onset and evolves rapidly, with maximal facial weakness developing within two days. Associated symptoms may be hyperacusis, decreased production of tears, and altered taste (table 2).
Table 2 Polyneuropathy in Bell's palsy4
Patients may also mention otalgia or aural fullness and facial or retroauricular pain, which is typically mild and may precede the palsy. Severe pain suggests herpes zoster virus and may precede a vesicular eruption and progression to Ramsay Hunt syndrome. Features may be consistent with a mild polyneuropathy. A slow onset progressive palsy with other cranial nerve deficits or headache raises the possibility of a neoplasm.
Examination
Serum testing for rising antibody titres to herpes virus is not a reliable diagnostic tool for Bell's palsy. Salivary polymerase chain reaction for herpes simplex virus type 1 or herpes zoster virus is more likely to confirm virus during the replicating phase, but these tests remain research tools. Serological tests for Lyme disease (IgM, IgG) are essential to exclude this disease in endemic areas, and magnetic resonance imaging has revolutionised the detection of tumours. Typically, the hearing threshold is not affected in Bell's palsy, but stapedius reflexes may be reduced or absent. Topognostic tests and electroneurography may give useful prognostic information but remain research tools.8
Zoster sine herpete
Bell's palsy is a much less common cause of facial palsy in children under 10 years of age. These children therefore merit careful review to identify an alternative cause, including acute suppurative ear disease. Lyme disease may be responsible for as many as half the cases in endemic areas.
Outcomes
The main aims of treatment in the acute phase of Bell's palsy are to speed recovery and to prevent corneal complications. Treatment should begin immediately to inhibit viral replication and the effect on subsequent pathophysiological processes that affect the facial nerve. Psychological support is also essential, and for this reason patients may require regular follow up.
Eye care
Eye care of patients with Bell's palsy focuses on protecting the cornea from drying and abrasion due to problems with lid closure and the tearing mechanism. The patient is educated to report new findings such as pain, discharge, or change in vision. Lubricating drops should be applied hourly during the day and a simple eye ointment should be used at night.
Corticosteroids
Two recent systematic reviews concluded that Bell's palsy could be effectively treated with corticosteroids in the first seven days, providing up to a further 17% of patients with a good outcome in addition to the 80% that spontaneously improve (see also fig B on bmj.com).10 11 Other studies have shown the benefits of treatment with steroids; in one, patients with severe facial palsy showed a significant improvement after treatment within 24 hours.12 13 Recovery rates in patients treated within 72 hours were enhanced by the addition of aciclovir.14
A randomised controlled trial of patients treated with high dose parenteral steroids within 72 hours compared with placebo found a significant improvement in recovery rate and time to return to work but no statistical difference in final outcome.15 More randomised controlled trials are needed, but at least 200 patients would be required in each arm.16 17
Given the existing evidence (see bmj.com for description of grades (A) to (D)), we support the use of oral prednisone with aciclovir in patients presenting with moderate to severe facial palsy, ideally within 72 hours. Immunocompetent patients without specific contraindications are prescribed prednisone at 1 mg/kg/d (maximum 80 mg) for the first week, which is tapered over the second week.(B) Around a fifth of patients will progress from partial palsy, so these patients should also be treated.11(C)
Antiviral agents
Treatment with antivirals seems logical in Bell's palsy because of the probable involvement of herpes viruses. Aciclovir, a nucleotide analogue, interferes with herpes virus DNA polymerase and inhibits DNA replication. Because of aciclovir's relatively poor bioavailability (15% to 30%),18 newer drugs in its class are being trialled. Better bioavailability, dosing regimens, and clinical effectiveness in treating shingles have been shown with valaciclovir (prodrug of aciclovir), famciclovir (prodrug of penciclovir), and sorivudine.19
Box 2: Evolving treatments for Bell's palsy
Some evidence of effect
Methylcobalamin—an active form of vitamin B-12
Hyperbaric oxygen—may be useful in patients who show degeneration despite maximal therapy
Facial retraining—"mime therapy"
Botulinum toxin for synkinesis and hemifacial spasm
Uncertain effect
Transcutaneous electrical stimulation
Acupuncture
Current research
Multicentre, randomised, double blind, placebo controlled trials on steroid and antiviral therapy are being carried out in Sweden and France
New antivirals—for example, famciclovir, sorivudine
Vaccination against herpes zoster virus and herpes simplex virus types 1 and 2
Neurotrophic growth factors, neuroprotective agents—for example, nimodipine, glial cell derived neurotrophic factor
Additional educational resources
Book
Pensak ML. Controversies in otolaryngology. New York: Thieme, 2001: 218-31—three chapters presenting current perspectives on acute facial palsy
Key papers
Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different aetiologies. Acta Otolaryngol Suppl 2002;549: 4-30—key text on the epidemiology and outcomes of untreated Bell's palsy
Morrow MJ. Bell's palsy and herpes zoster oticus. Curr Treat Options Neurol 2000;2: 407-16—excellent review and evidence based treatment guidelines
Sweeney CJ, Gilden DH. Ramsay Hunt syndrome. J Neurol, Neurosurg Psychiatry 2001;71: 149—relevant publication from active researchers in this subject
Internet resources
emedicine.com—has several well structured articles on Bell's palsy
Information for patients
The official patient's sourcebook on Bell's palsy: a revised and updated directory for the internet age publisher. San Diego, CA: Icon Health, 2003—several books are available to patients, which tend to present the authors' viewpoints
Patient information. Bell's palsy. J Fam Pract Feb 2003;52: 160—useful information leaflet
Bell's palsy information site (www.bellspalsy.ws/links.htm)—a structured website with information about acute treatment and rehabilitation
Bell's palsy association (www.bellspalsy.org.uk/links.htm)—UK based site providing information and support for patients
Open directory project (http://dmoz.org/)—access to a huge number of links of variable quality
Aciclovir compared with prednisone
Aciclovir has been compared with prednisone.20 Prednisone has been shown to be more effective in producing good recovery at three or more months, but despite flaws in this study, we would not recommend using aciclovir (or any antiviral) without steroids unless steroids are contraindicated.19(B)
Aciclovir with prednisone
A recent systematic review found that patients treated with combined aciclovir and prednisone had a better outcome than those treated with prednisone alone.10 However, a Cochrane review at that time concluded that more studies were required.21 More recently, a study of patients with severe palsies found better recovery with combined aciclovir and prednisone than with prednisone alone. The main determinate of the difference was treatment within three days of the onset of palsy.14
A prospective case controlled study showed that patients treated with valaciclovir and prednisone (86% within 72 hours) had better recovery rates than patients treated with prednisone alone. A noticeable benefit was seen in elderly patients, a group that is often overlooked for maximal treatment.22 A study of systemic therapy found no difference between oral aciclovir with prednisone and intravenous aciclovir with prednisone.23 Systemic treatment should be considered in immunocompromised patients or for widespread zoster involving the central nervous system.
We support the use of oral aciclovir or valaciclovir with prednisone in patients presenting within a first week (ideally within 72 hours) with moderate to severe facial palsy.(B)
Treatment in children
Studies have found that children with complete facial palsies and major degeneration have poor outcomes as often as adults. However, no supportive evidence has been found for use of steroids or antivirals in children with Bell's palsy (see fig C on bmj.com).24(D)
Zoster sine herpete
Although 2000 mg/d of aciclovir would not be adequate for Ramsay Hunt syndrome with vesicles, it seems to be effective in patients with zoster sine herpete.14 On the basis of current evidence, in the absence of major pain or evidence of vesicles, this dose would be adequate with steroids for treating Bell's palsy associated with herpes zoster virus.(C)
Future research may indicate that patients with severe post auricular pain, dense palsy, or herpes zoster virus do better with higher dose antiviral therapy from the outset.(D)
Surgery
Surgical intervention decompresses the facial nerve.25 However, middle fossa craniotomy carries risks, including seizures, deafness, leakage of cerebrospinal fluid, and facial nerve injury. Hence decompression surgery for Bell's palsy is not routinely offered in the United Kingdom.(D)
Physical therapies
Several physical therapies, including massage and facial exercises, are recommended to patients, but there are few controlled clinical trials of their effectiveness.(D) Some recent evidence supports facial retraining (mime therapy) with biofeedback.26(C)
Follow up
Rowlands S, Hooper R, Hughes R, Burney P. The epidemiology and treatment of Bell's palsy in the UK. Eur J Neurol 2002;9: 63-7.
Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl 2002;549: 4-30.
Murakami S, Mizobuchi M, Nakashiro Y, Doi T, Hato N, Yanagihara N. Bell's palsy and herpes simplex virus: identification of viral DNA in endoneurial fluid and muscle. Ann Intern Med 1996;124: 27-30.
Adour KK. Current concepts in neurology: diagnosis and management of facial paralysis. N Engl J Med 82;307: 348-51.
House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93: 146-7.
Dresner SC. Ophthalmic management of facial nerve paralysis. Focal points. San Francisco: American Academy of Ophthalmology, Jan 2000.
Stanek G, Strle F. Lyme borreliosis. Lancet 2003;362: 1639-47.
Dobie RA. Tests of facial nerve function. In: Cummings CW et al, eds. Otolaryngology head and neck surgery. New York: Mosby, 1998: 2757-66.
Sweeney CJ, Gilden DH. Ramsay Hunt syndrome. J Neurol Neurosurg Psychiatr 2001;71: 149.
Grogan PM, Gronseth GS. Practice parameter: steroids, acyclovir, and surgery for Bell's palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001;56: 830-6.
Ramsey MJ, DerSimonian R, Holtel MR, Burgess LP. Corticosteroid treatment for idiopathic facial nerve paralysis: a meta-analysis. Laryngoscope 2000;110: 335-41.
Williamson IG, Whelan TR. The clinical problem of Bell's palsy: is treatment with steroids effective? Br J Gen Pract 1996;46: 743-7.
Shafshak TS, Essa AY, Bakey FA. The possible contributing factors for the success of steroid therapy in Bell's palsy: a clinical and electrophysiological study. J Laryngol Otol 1994;108: 940-3.
Hato N, Matsumoto S, Kisaki H, Takahashi H, Wakisaka H, Honda N, et al. Efficacy of early treatment of Bell's palsy with oral acyclovir and prednisolone. Otol Neurotol 2003;24: 948-51.
Lagalla G, Logullo F, Di Bella P, Provinciali L, Ceravolo MG. Influence of early high-dose steroid treatment on Bell's palsy evolution. Neurol Sci 2002;23: 107-12.
Salinas RA, Alvarez G, Alvarez MI, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2002;(1): CD001942.
Burgess LP, Yim DW, Lepore ML. Bell's palsy: the steroid controversy revisited. Laryngoscope 1984;94: 1472-6.
De Miranda P, Blum MR. Pharmacokinetics of acyclovir after intravenous and oral administration. J Antimicrob Chemother 1983;12(suppl B): 29-37.
Snoeck R, Andrei G, De Clercq E. Current pharmacological approaches to the therapy of varicella zoster virus infections: a guide to treatment. Drugs 1999;57: 187-206.
De Diego JI, Prim MP, De Sarria MJ, Madero R, Gavilan J. Idiopathic facial paralysis: a randomized, prospective, and controlled study using single-dose prednisone versus acyclovir three times daily. Laryngoscope 1998;108: 573-5.
Sipe J, Dunn L. Aciclovir for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2001;(4): CD001869.
Axelsson S, Lindberg S, Stjernquist-Desatnik A. Outcome of treatment with valacyclovir and prednisone in patients with Bell's palsy. Ann Oto, Rhinol Laryngol 2003;112: 197.
Murakami S, Hato N, Horiuchi J, Honda N, Gyo K, Yanagihara N. Treatment of Ramsay Hunt syndrome with acyclovir-prednisone: significance of early diagnosis and treatment. Ann Neurol 1997;41: 353-7.
Salman MS, MacGregor DL. Should children with Bell's palsy be treated with corticosteroids? A systematic review. J Child Neurol 2001;16: 565-8.
Fisch U. Surgery for Bell's palsy. Arch Otolaryngol 1981;107: 1-11.
Beurskens CH, Heymans PG. Positive effects of mime therapy on sequelae of facial paralysis: stiffness, lip mobility, and social and physical aspects of facial disability. Otol Neurol 2003;24: 677-81.(N Julian Holland, special)