Bell's palsy - What Is the Standard of What Care for...

Info iconThis preview shows page 1. Sign up to view the full content.

View Full Document Right Arrow Icon
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: What Is the Standard of What Care for Treating Bell’s Palsy? Palsy? Joe Lex, MD, FAAEM Temple University School of Medicine Philadelphia, PA joseph.lex@tuhs.temple.edu Emergency Medicine Emergency Medicine Common Wisdom “A patient with Bell’s patient palsy should receive a steroid and acyclovir or valacyclovir.” valacyclovir.” Emergency Medicine Bell’s Palsy Definition: acute peripheral facial acute palsy of unknown origin palsy Some facts • Risk increase 3-fold in pregnancy • Recurrence rate 8 – 10% • Diabetes in 5 – 10% Emergency Medicine Cause • • • Most cases: herpes simplex virus Most (HSV) (HSV) Second most common cause: Second herpes zoster virus (HZV) herpes Other causes: cytomegalovirus Other (CMV), Lyme disease, Epstein-Barr virus (EBV) virus Emergency Medicine Presentation • • About ¾ of patients notice upon About awakening awakening Forehead sparing suggests central Forehead lesion, but not 100% sensitive Emergency Medicine Case Definition Diffuse unilateral facial muscle Diffuse paralysis paralysis • With or without loss of taste on With anterior 2/3 of tongue anterior • With or without altered secretion: With saliva, tears saliva, Emergency Medicine Natural Course • • Onset acute over day or two Course progressive with maximum Course weakness in less than 3 weeks weakness If onset prolonged, slow, progressive, If and relapsing – think tumor and Emergency Medicine Peitersen E. Acta Otolaryngol Suppl. 2002;(549):4-30. Natural Course Recovery (partial or complete) within 6 Recovery months months • 85% had function return within 3 85% weeks, other 15% after 3-5 months weeks, • Sequelae were slight in 12% of Sequelae patients, mild in 13% and severe in 4% 4% Emergency Medicine Peitersen E. Acta Otolaryngol Suppl. 2002;(549):4-30. Natural Course Improper axon healing can cause Improper facial synkinesis facial • Blink causes mouth twitch • Smile causes wink • Salivary stimulus causes lacrimation Salivary (so-called “crocodile tears”) (so-called Emergency Medicine Peitersen E. Acta Otolaryngol Suppl. 2002;(549):4-30. Do Antivirals Help?? Cochrane database: 3 studies over 12 Cochrane years involving 246 patients: 1. Acyclovir with prednisolone vs. 1. Acyclovir prednisolone alone prednisolone 2. Acyclovir alone vs. steroid alone 3. Valacyclovir with steroid vs. steroid Valacyclovir alone or vs. placebo alone alone Emergency Medicine Allen D, et al. Cochrane Database 2004;(3):CD001869. Do Antivirals Help?? “More data are needed from a large More multicenter randomized controlled and blinded study with at least 12 months’ follow up before a definitive recommendation can be made regarding the effect of acyclovir or valaciclovir on Bell's palsy.” palsy.” Emergency Medicine Allen D, et al. Cochrane Database 2004;(3):CD001869. Do Corticosteroids Help? In 53 years, only 4 usable trials with a In total of 179 patients total 1. cortisone acetate with placebo 2. prednisone plus vitamins versus prednisone vitamins alone vitamins 3. high-dose prednisone administered high-dose intravenously against saline solution intravenously 4. not-placebo controlled, tested not-placebo efficacy of methylprednisolone efficacy Emergency Medicine Salinas et al. Cochrane Database 2004;(4):CD001942. Do Corticosteroids Help? • • Steroid therapy: 46/59 (78%) of Steroid patients had incomplete recovery of facial function at 6 months of Control group: 43/58 (74%) of Control patients had incomplete recovery of facial function at 6 months of Emergency Medicine Salinas et al. Cochrane Database 2004;(4):CD001942. Do Corticosteroids Help? “…available evidence from available randomized controlled trials does not show significant benefit from treating Bell’s palsy with corticosteroids.” corticosteroids.” Emergency Medicine Salinas et al. Cochrane Database 2004;(4):CD001942. The Evidence Says… Based on literature going Based back almost 55 years… back …we don’t know. Emergency Medicine The Experts Say… “Despite the absence of definitive Despite data, …it is standard practice now, data, including my own practice, for all patients with Bell’s palsy seen within the first week of onset to be treated with corticosteroids (typically prednisone 60 to 80 mg per day) plus valacyclovir (1 g three times daily) for one week.” one Ronthal M. UpToDate® June 2006 (Emergency Medicine ) www.utdol.com David M. Rind, MD David Senior Deputy Editor, UpToDate UpToDate UpToDate believes that we need to tell UpToDate people how an expert actually practices, even when the evidence doesn’t make the answer clear…(similar) to a clinical consult: no consultant finishes a consult note by writing “In the absence of clinical trials, I can make no recommendation about how you should manage this patient.” you Emergency Medicine Personal communication, 24 October 2006 David M. Rind, MD David Senior Deputy Editor, UpToDate UpToDate At the same time, it is clear that such a At recommendation is an opinion open to debate and disagreement. In the absence of solid evidence, we have no reason to think that our expert is any smarter than anyone else’s expert…UpToDate is trying to help clinicians make reasonable decisions about what to do in the face of uncertainty. uncertainty. Emergency Medicine Personal communication, 24 October 2006 Take Home Message Despite lack of solid evidence, the Despite Standard of Care is to treat Standard • Valacyclovir: $9.33 per tablet tid x 7 Valacyclovir: days = US$195.93 US$195.93 • Prednisone: $0.50 per tablet Emergency Medicine Sir Charles Bell Sir ...
View Full Document

This note was uploaded on 01/11/2012 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

Ask a homework question - tutors are online