Friday, February 3, 2012

Forget about antivirals for Bell's palsy

RAGING HYPOTHETICAL:
--A guy comes in with a facial droop. You check for eyebrow raise and unequal smile and correctly identify this as a isolated peripheral VIIth nerve palsy. (Nice job not bothering the stoke fellow)



WHAT WILL YOU SEND THEM HOME WITH?

1) Eye protection
-patch to close at night and put some lacrilube in there. Artificial tears Q1 hour during the day

2) Antivirals?
-minimal extra efficacy when added to steroids vs. steroids alone, not statistically significant (looked at both valacyclovir and acyclovir)

-treating with antivirals alone was significantly worse than treating with steroid alone, and no better than placebo. (BMC Neuro 2011)

-consider adding antivirals in severe patients (only barely perceptible motion of face or complete paralysis)
3) Steroids
-Prednisolone (60 mg daily for five days, then tapered by 10 mg daily, for a total treatment length of 10 days) was studied in a large RCT.
-Patients treated with prednisolone in this RCT had a shorter return to recovery vs. those without steroid treatment.(Lancet 2008).
-An easy substitute would be Prednisone 60mg PO daily for 1 week.


10-SECOND RECAP:
--(whole) facial droop/paralysis, check eyebrows (upper face) & smile (lower face); if both involved, think 7th nerve/Bell's palsy
--eye protection/lube/tears
--antivirals not too useful, consider in severe palsy
--steroids hasten recovery; 7-10 day course prednisone.

Submitted by R. Morris.

Reference(s): Numthavaj, P. BMC Neurology 2011;  Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol. 2008 Nov;7(11):993-1000. Epub 2008 Oct 10; image

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