Bell's Palsy
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In his Clinical Practice article on Bell's palsy, Gilden (Sept. 23 issue)1 recommends treatment of the patient in the vignette with oral prednisone. The Cochrane Collaboration2 has pointed out that the statement of the American Academy of Neurology — that early treatment with corticosteroids is "probably effective"3 — is most likely invalid because their evidence synthesis (i.e., their summary of the best available evidence) included a trial with a high rate of loss to follow-up4 and a nonrandomized trial5 — trials that both had serious threats to validity.
Without these studies, the pooled results are no longer in favor of corticosteroids.2 We concur with the Cochrane Collaboration and believe corticosteroids have not been shown to be effective in Bell's palsy. Cause-and-effect conclusions cannot be drawn from observational studies.
Michael E. Stuart, M.D.
Delfini Group
Seattle, WA 98115
mstuart@delfini.org
Sheri A. Strite
University of California, San Diego
San Diego, CA 92103
References
Gilden D. Bell's palsy. N Engl J Med 2004;351:1232-1231.
Salinas R, Alvarez G, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2004;4:CD001942-CD001942.
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;56:830-836.
Austin JR, Peskind SP, Austin SG, Rice DH. Idiopathic facial nerve paralysis: a randomized double blind controlled study of placebo versus prednisone. Laryngoscope 1993;103:1326-1333.
Adour KK, Wingerd J, Bell DN, Manning JJ, Hurley JP. Prednisone treatment for idiopathic facial paralysis (Bell's palsy). N Engl J Med 1972;287:1268-1272.
To the Editor: In the northeastern United States, it is appropriate to consider facial palsy to be a sign of Lyme disease, until proven otherwise, in a child or adult. In one study in southeastern Connecticut, 11 percent of children presenting with early disseminated Lyme disease had a facial palsy.1 The risks associated with untreated Lyme disease make serologic testing imperative. There are no data proving that recovery is faster or that long-term neurologic outcomes are better with early recognition and treatment of Bell's palsy due to Lyme disease, but the improved response to antimicrobial therapy provided early, rather than late, in the course of Lyme disease supports vigilance at the initial evaluation for this condition. Hence, I strongly disagree with the author's recommendation that "no tests are indicated" and recommend routine testing for Lyme disease in regions where it is endemic, especially when the palsy is bilateral.
John A. Magaldi, M.D.
Yale University School of Medicine
New Haven, CT 06520
magaldimd@aol.com
References
Gerber MA, Shapiro ED, Burke GS, Parcells VJ, Bell GL. Lyme disease in children in southeastern Connecticut. N Engl J Med 1996;335:1270-1274.
To the Editor: Gilden suggests that there is controversy regarding surgical decompression of the facial nerve in Bell's palsy. Among neurologists, the evidence of the benefit of surgical decompression is compelling. Previously, there has been controversy regarding the segment of the facial nerve that needs decompression and the timing of surgery. The site of conduction block of the facial nerve in Bell's palsy is proximal to the geniculate ganglion in 94 percent of patients.1 Therefore, the results of earlier studies, in which other segments of the facial nerve were decompressed, cannot be compared with data on the current technique — decompression of the labyrinthine portion of the facial nerve by the middle cranial fossa approach. A randomized, multicenter clinical trial2 showed that eligible patients who underwent middle fossa decompression before the 14th day of paralysis were more than twice as likely to have normal or near-normal facial-nerve function as those receiving medical treatment alone. This finding underscores the importance of prompt referral of patients for electroneurography and possible decompression. After the 14-day time point, the option of decompression surgery does not exist for those who may otherwise have poor outcomes.
Hamid R. Djalilian, M.D.
Charles Drew University of Medicine and Science
Los Angeles, CA 90059
hadjalil@cdrewu.edu
References
Gantz BJ, Gmur A, Fisch U. Intraoperative evoked electromyography in Bell's palsy. Am J Otolaryngol 1982;3:273-278.
Gantz BJ, Rubinstein JT, Gidley P, Woodworth GG. Surgical management of Bell's palsy. Laryngoscope 1999;109:1177-1188.
Dr. Gilden replies: Dr. Stuart and Ms. Strite correctly point out the limitations of the available data from studies assessing the effects of corticosteroids on the outcome in Bell's palsy. Until rigorous data are available, as I note in my review, my reasons for recommending a short course of corticosteroids early in Bell's palsy are based on long-standing observations, by many surgeons, of facial-nerve swelling at surgery,1 changes on magnetic resonance imaging that are consistent with inflammation and edema in the meatal fundus and geniculate ganglion in patients with Bell's palsy,2,3 and the close association between herpes simplex virus infection and Bell's palsy.4 Diseases of the skin, brain, and peripheral nerves caused by herpes simplex virus are known to be highly inflammatory.5 Can we clinicians ignore the strong possibility that a short course of corticosteroids, which will reduce the inflammatory response and edema, might in turn shorten the course of facial-nerve paralysis or potentially prevent permanent facial disfigurement?
Dr. Magaldi correctly points out that Lyme disease must be considered in patients with bilateral facial palsy and recommends serologic testing for patients with bilateral facial palsy in regions where Lyme disease is endemic. I agree that this recommendation is a reasonable one in such regions. However, I would not recommend serologic testing for every patient with Bell's (unilateral facial) palsy, particularly in areas where Lyme disease is unlikely.
I share Dr. Djalilian's enthusiasm for promptly referring patients with Bell's palsy for electroneurography and possible surgical decompression before 14 days, but only with regard to patients who have complete facial paralysis and have not had a response to medical therapy. Meanwhile, as with corticosteroids, randomized, double-blind studies comparing surgical with medical treatment are needed.
Donald H. Gilden, M.D.
University of Colorado School of Medicine
Denver, CO 80262
don.gilden@uchsc.edu
References
Cawthorne T. The pathology and surgical treatment of Bell's palsy. Proc R Soc Med 1951;4:565-572.
Sartoretti-Schefer S, Wichmann W, Valavanis A. Idiopathic, herpetic, and HIV-associated facial nerve palsies: abnormal MR enhancement patterns. AJNR Am J Neuroradiol 1994;15:479-485.
Suzuki F, Furuta Y, Ohtani F, Fukuda S, Inuyama Y. Herpes virus reactivation and gadolinium-enhanced magnetic resonance imaging in patients with facial palsy. Otol Neurotol 2001;22:549-553.
Murakami S, Mizobuchi M, Nakashiro Y, Doi T, Hato N, Yanagihara N. Bell palsy and herpes simplex virus: identification of viral DNA in endoneurial fluid and muscle. Ann Intern Med 1996;124:27-30.
Whitley RJ. Herpes simplex viruses. In: Knipe DM, Howley PM, eds. Fields' virology. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2001:2461-509.
Without these studies, the pooled results are no longer in favor of corticosteroids.2 We concur with the Cochrane Collaboration and believe corticosteroids have not been shown to be effective in Bell's palsy. Cause-and-effect conclusions cannot be drawn from observational studies.
Michael E. Stuart, M.D.
Delfini Group
Seattle, WA 98115
mstuart@delfini.org
Sheri A. Strite
University of California, San Diego
San Diego, CA 92103
References
Gilden D. Bell's palsy. N Engl J Med 2004;351:1232-1231.
Salinas R, Alvarez G, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2004;4:CD001942-CD001942.
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;56:830-836.
Austin JR, Peskind SP, Austin SG, Rice DH. Idiopathic facial nerve paralysis: a randomized double blind controlled study of placebo versus prednisone. Laryngoscope 1993;103:1326-1333.
Adour KK, Wingerd J, Bell DN, Manning JJ, Hurley JP. Prednisone treatment for idiopathic facial paralysis (Bell's palsy). N Engl J Med 1972;287:1268-1272.
To the Editor: In the northeastern United States, it is appropriate to consider facial palsy to be a sign of Lyme disease, until proven otherwise, in a child or adult. In one study in southeastern Connecticut, 11 percent of children presenting with early disseminated Lyme disease had a facial palsy.1 The risks associated with untreated Lyme disease make serologic testing imperative. There are no data proving that recovery is faster or that long-term neurologic outcomes are better with early recognition and treatment of Bell's palsy due to Lyme disease, but the improved response to antimicrobial therapy provided early, rather than late, in the course of Lyme disease supports vigilance at the initial evaluation for this condition. Hence, I strongly disagree with the author's recommendation that "no tests are indicated" and recommend routine testing for Lyme disease in regions where it is endemic, especially when the palsy is bilateral.
John A. Magaldi, M.D.
Yale University School of Medicine
New Haven, CT 06520
magaldimd@aol.com
References
Gerber MA, Shapiro ED, Burke GS, Parcells VJ, Bell GL. Lyme disease in children in southeastern Connecticut. N Engl J Med 1996;335:1270-1274.
To the Editor: Gilden suggests that there is controversy regarding surgical decompression of the facial nerve in Bell's palsy. Among neurologists, the evidence of the benefit of surgical decompression is compelling. Previously, there has been controversy regarding the segment of the facial nerve that needs decompression and the timing of surgery. The site of conduction block of the facial nerve in Bell's palsy is proximal to the geniculate ganglion in 94 percent of patients.1 Therefore, the results of earlier studies, in which other segments of the facial nerve were decompressed, cannot be compared with data on the current technique — decompression of the labyrinthine portion of the facial nerve by the middle cranial fossa approach. A randomized, multicenter clinical trial2 showed that eligible patients who underwent middle fossa decompression before the 14th day of paralysis were more than twice as likely to have normal or near-normal facial-nerve function as those receiving medical treatment alone. This finding underscores the importance of prompt referral of patients for electroneurography and possible decompression. After the 14-day time point, the option of decompression surgery does not exist for those who may otherwise have poor outcomes.
Hamid R. Djalilian, M.D.
Charles Drew University of Medicine and Science
Los Angeles, CA 90059
hadjalil@cdrewu.edu
References
Gantz BJ, Gmur A, Fisch U. Intraoperative evoked electromyography in Bell's palsy. Am J Otolaryngol 1982;3:273-278.
Gantz BJ, Rubinstein JT, Gidley P, Woodworth GG. Surgical management of Bell's palsy. Laryngoscope 1999;109:1177-1188.
Dr. Gilden replies: Dr. Stuart and Ms. Strite correctly point out the limitations of the available data from studies assessing the effects of corticosteroids on the outcome in Bell's palsy. Until rigorous data are available, as I note in my review, my reasons for recommending a short course of corticosteroids early in Bell's palsy are based on long-standing observations, by many surgeons, of facial-nerve swelling at surgery,1 changes on magnetic resonance imaging that are consistent with inflammation and edema in the meatal fundus and geniculate ganglion in patients with Bell's palsy,2,3 and the close association between herpes simplex virus infection and Bell's palsy.4 Diseases of the skin, brain, and peripheral nerves caused by herpes simplex virus are known to be highly inflammatory.5 Can we clinicians ignore the strong possibility that a short course of corticosteroids, which will reduce the inflammatory response and edema, might in turn shorten the course of facial-nerve paralysis or potentially prevent permanent facial disfigurement?
Dr. Magaldi correctly points out that Lyme disease must be considered in patients with bilateral facial palsy and recommends serologic testing for patients with bilateral facial palsy in regions where Lyme disease is endemic. I agree that this recommendation is a reasonable one in such regions. However, I would not recommend serologic testing for every patient with Bell's (unilateral facial) palsy, particularly in areas where Lyme disease is unlikely.
I share Dr. Djalilian's enthusiasm for promptly referring patients with Bell's palsy for electroneurography and possible surgical decompression before 14 days, but only with regard to patients who have complete facial paralysis and have not had a response to medical therapy. Meanwhile, as with corticosteroids, randomized, double-blind studies comparing surgical with medical treatment are needed.
Donald H. Gilden, M.D.
University of Colorado School of Medicine
Denver, CO 80262
don.gilden@uchsc.edu
References
Cawthorne T. The pathology and surgical treatment of Bell's palsy. Proc R Soc Med 1951;4:565-572.
Sartoretti-Schefer S, Wichmann W, Valavanis A. Idiopathic, herpetic, and HIV-associated facial nerve palsies: abnormal MR enhancement patterns. AJNR Am J Neuroradiol 1994;15:479-485.
Suzuki F, Furuta Y, Ohtani F, Fukuda S, Inuyama Y. Herpes virus reactivation and gadolinium-enhanced magnetic resonance imaging in patients with facial palsy. Otol Neurotol 2001;22:549-553.
Murakami S, Mizobuchi M, Nakashiro Y, Doi T, Hato N, Yanagihara N. Bell palsy and herpes simplex virus: identification of viral DNA in endoneurial fluid and muscle. Ann Intern Med 1996;124:27-30.
Whitley RJ. Herpes simplex viruses. In: Knipe DM, Howley PM, eds. Fields' virology. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2001:2461-509.