For whom the bell tolls – steroids or antivirals for Bell palsy?

Sir Charles Bell first described the anatomy and function of the facial nerve in the 1800s. No wonder the eponymous Bell palsy bears his name (apparently we are no longer to refer to it as Bell’s palsy). The term Bell palsy is not synonymous with idiopathic facial palsy, as an etiology can usually be assigned to the former diagnosis. Reactivation of viruses in the herpes family is often to blame in the subsequent nerve dysfunction of Bell palsy.

Important in the differential of conditions associated with Bell palsy are both Lyme disease and HIV infection. As the CDC recommends routine HIV testing for all people ages 16 to 64, certainly a person presenting with Bell palsy should be offered HIV testing. Bell palsy is also more frequent in the third trimester of pregnancy, the immediate postpartum period, and in diabetes.

Because of the implication that both herpes virus infection and the subsequent inflammation of the facial nerve are involved in the pathogenesis of Bell palsy, both antivirals and steroids have been used in the treatment and amelioration of acute Bell palsy.

The American Academy of Neurology has recently published “Evidence-based guideline update: Steroids and antivirals for Bell palsy” in Neurology 2012;79:1-5.

The guidelines conclude and recommend as follows:

  • For patients with new-onset (within 72 hours) Bell palsy, steroids are highly likely to be effective and should be offered to increase the probability of recovery of facial nerve function.
  • For patients with new-onset Bell palsy, antiviral agents in combination with steroids do not increase the probability of facial function recovery by > 7%. Because of the possibility of a modest increase in recovery, patients may be offered antivirals (in addition to steroids). Patients offered antivirals should be counseled that a benefit for the medication has not been established and, if there is a benefit, it is likely to be modest at best.


Sir Charles Bell

A few famous people with Bell palsy:

  • Sylvester Stallone
  • Terrance Howard
  • Joe Mantegna

Marshall Kubota, MD

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