Restorative Neurology and Neuroscience 34 (2016) 897–905 897

DOI 10.3233/RNN-150605
IOS Press

Steroid/Antiviral for the treatment of Bell’s

palsy: Double blind randomized clinical trial
Eman Mohamed Khedra,∗ , Reda Badrya , Anwer Mohamed Alia , Noha Abo El-Fetoha , Dina Hatem
El-Hammadyb , Abeer Mohamed Ghandourb and Ahmed Abdel-Haleema
a Department of Neuropsychiatry, Assiut University Hospital, Assiut, Egypt
b Department of Rheumatology and Rehabilitation, Assiut University Hospital, Assiut, Egypt

Abstract.
Background: A large number of patients with Bell’s palsy fail to recover facial function completely after steroid therapy.
Only a few small trials have been conducted to test whether outcomes can be improved by the addition of antiviral therapy.
Objective: To evaluate the efficacy of treatment with steroid alone versus steroid + antiviral in a group of patients with
moderately severe to severe acute Bell’s palsy.
Methods: Fifty eligible patients out of a total of 65 with acute onset Bell’s palsy were randomized to receive the two
treatments. Evaluation was performed before starting treatment, after 2 weeks of treatment and 3 months after onset, using
the House and Brackmann facial nerve grading system (HB) and the Sunnybrook grading system.
This study was registered with ClinicalTrials.gov, number NCT02328079.
Results: Both treatments had comparable demographics and clinical scores at baseline. There was greater improvement in
the mean HB and Sunnybrook scores of the steroid + antiviral group in comparison to steroid group at 3 months. At the end
of the 3rd month, 17 patients (68%) had good recovery and 8 patients (32%) had poor recovery in the steroid group compared
with 23 patients (92%) and 2 (8%) respectively in the steroid and antiviral group (p = 0.034).
Conclusion: The combination of steroid and antiviral treatment increases the possibility of recovery in moderately severe to
complete acute Bell’s palsy.

Keywords: Bell’s palsy, steroid/antiviral, electroneurography, prognosis

ClinicalTrials. gov Registration <register@clinicaltrials.gov>
Clinical trial gov. Identifier: NCT02328079

1. Introduction the acute phase, the anti-inflammatory action of cor-

Bell’s palsy is an acute, peripheral facial paresis
of unknown cause (Hauser et al., 1971). It is com-
mon, with an annual incidence of 20 per 100,000 and
the diagnosis is usually established without difficulty
(Katusic et al., 1986). Treatment in the acute phase of
Bell’s palsy is aimed at strategies to speed recovery. In
∗ Corresponding author: Prof. Dr. Eman Mohamed KHEDR,
Professor of Neurology, Department of Neurology, Faculty of
Medicine, Assiut University Hospital, Assiut, Egypt; Head of Neu-
ropsychiatric department, Faculty of Medicine, Aswan University
Hospital, Aswan, Egypt. Tel.: +20 01005850632; Fax: +20 088
2333327; E-mail: emankhedr99@yahoo.com.
ticosteroids is designed to reduce inflammation and
edema of the facial nerve in order to minimize nerve
damage and thereby improve the outcome. Yet up to
30% of patients with Bell’s palsy fail to recover facial
function completely (Peitersen, 1982) with the result
that thousands of patients with Bell palsy are left with
permanent, potentially disfiguring facial weakness
each year.
More than 20 years ago, an autopsy study isolated
latent HSV type-1 from the majority of human genic-
ulate ganglia samples (Furuta et al., 1992). A few
years later, HSV-1 genome was detected in 79% of
facial nerve endoneurial fluid in patients with Bell’s

0922-6028/16/$35.00 © 2016 – IOS Press and the authors. All rights reserved
898 E.M. Khedr et al. / Steroid/Antiviral treatment for Bell’s palsy
palsy, but not in controls (Murakami et al., 1996). In
another study herpes simplex virus DNA was found in
the endoneurial fluid of 11 of 14 patients with Bell’s
palsy, but not in patients with Ramsay Hunt syndrome
or in controls with facial palsy due to fractures of the
temporal bone, bacterial infection, parotid tumours,
or neuroma (Minnerop et al., 2008). These findings
led to the idea that Bell’s palsy was due to reactiva-
tion of latent herpes viral infections in the geniculate
ganglia followed by spread to the facial nerve. In
the light of this finding, many physicians prescribed
both antiviral drugs and steroids to treat Bell’s palsy,
despite the unclear added benefit of antiviral therapy.
In 2001, the Quality Standards Subcommittee of
the American Academy of Neurology (AAN) pub-
lished an evidence-based practice guideline for the
treatment of Bell palsy (Grogan & Gronseth, 2001).
The 2001 guideline concluded that steroids were
probably effective and that antivirals (acyclovir) were
possibly effective in increasing the probability of
complete facial functional recovery in patients with
Bell’s palsy. The status of antiviral therapy is still
unclear. Although some systematic reviews (Allen
& Dunn, 2009; Quant et al., 2009; Turgeon et al.,
2015) found no clear evidence for the superiority of
combined steroids plus antiviral drugs compared to
steroids alone, other research groups (Hato et al.,
2007 & 2008; Minnerop et al., 2008; Shahidullah
et al., 2011; Numthavaj et al., 2011; Lee et al., 2013)
as well as Dong et al. (2015) in their systematic review
found that combined use had a significantly better
outcome than steroids alone, especially in severely
affected patients. The American Academy recom-
mended in 2012 that large randomized trials should
be conducted comparing outcomes in patients with
Bell’s palsy receiving steroids with or without antivi-
rals to determine whether the addition of antivirals to
steroid treatment results in a modest benefit (Gron-
seth & Paduga, 2012).
Previous electrophysiological investigations point
to a special prognostic value of the amplitude of
muscle evoked potential (MEP) in Bell’s palsy. The
MEP amplitude depends on the number of respond-
ing peripheral motor axons and it will be reduced
following degeneration of nerve fibers (May et al.,
1983, Fish, 1997, Danielides et al., 1994). Fish (1997)
suggested that a decrease in MEP amplitude of more
than 90%, compared to the healthy side, is a bad prog-
nostic sign. In contrast to the MEP amplitude, MEP
latency reflects in the function of the fastest axons,
so it can remain within a normal range for a long
time.
In this study we address the question: is treat-
ment with steroids + antiviral drugs (acyclovir)
superior to steroids alone for functional recovery of
facial nerve in patients with severe new-onset Bell’s
palsy? Recovery was quantified using the House &
Brackmann facial nerve grading system (HB) for pri-
mary outcome and Sunnybrook grading system score
changes for secondary outcome.
2. Materials and methods
2.1. This trial followed 2010 CONSORT
guidelines
The study was conducted at the Neuropsychi-
atry department, Assiut University Hospital from
first of April 2014 to the end December 2014. All
patients aged between 20–60 years who were diag-
nosed with acute onset facial palsy (unilateral) and
within the first three days of onset were included.
Diagnosis was based on impaired ipsilateral move-
ment of the affected side of the face, drooping of
the eyebrow and corner of the mouth, loss of the
ipsilateral nasolabial fold as well as Bell’s phe-
nomenon (upward movement of the eye on attempted
closure of the lid due to weakness of the orbicu-
laris oculi). Computerized brain scan (CT brain) was
performed for each patient to exclude other causes
of facial paralysis (brain infarction, hemorrhage,
multiple sclerosis, tumor, and infection). Otologi-
cal examination was performed to exclude cases
with otitis media. Metabolic profiling was performed
if needed, to exclude renal or liver impairment.
Exclusion criteria were: patients with brittle diabetes
mellitus, morbid obesity, renal or liver impairment,
osteopenia, pregnancy or breast-feeding; uncon-
trolled hypertension and a prior history of steroid
intolerance. A participants’ flow diagram is shown in
Fig. 1.
Sixty five patients with acute facial palsy were
recruited; 15 cases were excluded (8 had only mild
to moderate facial paralysis, three had severe uncon-
trolled diabetes mellitus, another two were pregnant
and last two cases had morbid obesity). The remain-
ing 50 cases were eligible for the study. The mean
age of the patients was 27.2 ± 4.5 years ranging from
20–36 years (35 males and 15 females). They had
moderately severe (grade IV) to complete Bell’s palsy
(grade VI) according to the criteria of the House &
Brackmann facial nerve grading system (HB) (House
& Brackmann, 1985). All participants gave informed
 E.M. Khedr et al. / Steroid/Antiviral treatment for Bell’s palsy
Fig. 1. Flow chart.
consent before participation after full explanation of
the study protocol which had been approved by the
Local Ethical Committee of Assiut University Hos-
pital.
3. Methods
Each patient was evaluated at baseline and at
follow up assessment points using HB and Sunny-
brook scales for facial palsy (Ross et al., 1996). The
HB score grades the degree of nerve damage by
measuring the upwards (superior) movement of the
mid-portion of the top of the eyebrow, and the out-
wards (lateral) movement of the angle of the mouth.
The score ranges from I (normal) to VI (total paral-
ysis). The Sunnybrook facial grading is a regionally
weighted system that includes evaluation of resting
symmetry, degree of voluntary movement and synki-
nesis to form a composite score from 0 to 100, where
0 is complete paralysis and 100 normal function.
3.1. Electrophysiological investigations
We had intended to use electrophysiology mea-
sures at baseline to evaluate a possible predictive
role in recovery. A Nihon Kohden Machine model
9400 (Japan) was used to collect the signal. EMG
parameters included a band pass of 20–1000 Hz and
a recording time window of 200 ms.
899
Electroneurography: Facial nerve conduction was
assessed in both sides using concentric needle
electrode. The compound muscle action potential
(CMAP) was obtained from the frontalis and orbic-
ularis oris muscles measured at the suprathreshold
stimulation, and measurements of amplitude from
peak to peak of CMAP were reported.
3.2. Randomization
Group allocations: the patients were classified
randomly into one of two treatment groups using
serially-numbered opaque closed envelopes. Each
patient was placed in the appropriate group after
opening the corresponding envelope.
3.3. Treatment
Group I received prednisolone 60 mg /day for the
first 7 consecutive days then reducing to 10 mg /day
steroid for the next 5 days with a total treatment
time of 12 days. Zovirax (antiviral drug) 400 mg four
times/day was added for the first 7 consecutive days
only. Group II received the same regimen of pred-
nisolone without antiviral drug.
All participants were given a case-by-case rehabil-
itation program that included massage to the facial
muscles to improve circulation and prevent contrac-
ture every day for 4 weeks (Cederwall et al., 2006).
Patients were also asked to perform exercises in
front of a mirror without overstretching or contract-
ing wrong muscles. These included compressing lips
together in attempt to whistle, smiling without show-
ing teeth, then smiling showing teeth. They were also
instructed to close the eyes slowly and gently, raise
eyebrows and hold for 10–15 seconds (wrinkle fore-
head).
To ensure double blinding, the random alloca-
tion sequence was kept by a different investigator to
the one who enrolled the participants (neurologist).
Moreover, a third investigator was responsible for
following up the patients and for assessment (reha-
bilitation doctor).
Study monitoring was carried out by calling the
patients regularly every week to ensure that the
patient received treatment and performed the exer-
cises.
3.4. Follow up
We followed up the patients clinically 2 weeks
after starting treatment then at the end of the 2nd and
900 E.M. Khedr et al. / Steroid/Antiviral treatment for Bell’s palsy
Table 1
Clinical and demographic data of studied groups
Steroid medication group N = 25
Age (years)
Onset of treatment (days)
House & Brackmann facial nerve grading system
Sunnybrook Facial Grading System
Resting Symmetry
Symmetry of Voluntary Movement
Synkinesis score
Composite score
Neurophysiological findings
Amplitude of CMAP of Facial nerve (mV)
Affected frontalis/Non affected frontalis (ratio %)
Amplitude of CMAP of Facial nerve (mV)
Affected orbicularis oris/Non affected orbicularis oris (ratio%)
P < 0.05 comparison between affected and unaffected side in each group separately.
3rd month using HB facial function scoring system
and Sunnybrook grading system. Primary outcome:
change in HB assessment score 3 months after palsy
onset. Grades I and II of HB were defined as com-
plete or good recovery, and grade III or higher were
defined as poor or incomplete recovery. Secondary
outcome was measured using changes in scores of
the Sunnybrook grading system. In the protocol we
had intended to use electrophysiology measures as
another secondary outcome. However, since most of
the patients found this too painful to be performed
at the follow up, it was performed at baseline only
and we tested whether it was a possible predictor of
recovery.
3.4.1. Statistical analysis
Patient scores on the Sunnybrook scale were nor-
mally distributed (Shapiro-Wilk test) and analysed
with parametric tests; this was not the case for the
HB scores, which were therefore assessed with non-
parametric tests. At baseline assessment (ie, before
treatment), mean values of different scales between
both groups were compared using the Mann–Whitney
test (HB scale) or unpaired t-tests (Sunnybrook
scores) for independent samples. The level of sig-
nificance was set at P < 0.05. For the HB scale a
non-parametric Friedman test was used to detect the
effect of time (before, following 2 weeks treatment,
and at 2 and 3 months after onset) for each group sep-
arately and Mann-Whitney pairwise comparisons for
the overall change score for each individual (base-
line 3rd month). For the Sunnybrook scale a one
way repeated measure analysis of variance (ANOVA)
was used to detect the effect of time for each group
separately. Two factor ANOVA for repeated mea-
surements with “treatment” (ie, steroid or steroid
Steroid and Antiviral group N = 25
37.4 ± 13.4 36.2 ± 14
1.84 ± 0.7 1.76 ± 0.9
4.8 ± 0.6 5 ± 0.8
17.6 ± 2.6 18.4 ± 2.4
40.5 ± 5.3 39.5 ± 3.9
5.6 ± 3.9 4.3 ± 3.7
17.2 ± 4.4 17.1 ± 5.1
1.5 ± 0.9/2.2 ± 1.1* (61) 1.2 ± 1.1/2.6 ± 1.7* (47)
3.1 ± 1.6/3.6 + 2.3* (54) 2.9 ± 3.4/3.6 + 2.3* (53)
+ antiviral) and “time” (before, following 2 weeks
treatment, and at 2 and 3 months after onset) as
the main factors was used to compare the differen-
tial effects of the treatments on changes in rating
scores. When necessary, a Greenhouse–Geisser cor-
rection was applied to correct for non-sphericity.
T-tests were carried out for comparisons at each time
point of assessment, and P-values in the text are
Bonferroni-corrected for the number of comparisons.
Non parametric Spearman correlation was performed
between Score Sunnybrook score or grading of HB
and the CMAP amplitude ratio (affected /Unaffected
side) of frontalis and orbicularis oris.
4. Results
There were no substantial confounding differences
between treatment groups. There were no side effects
of treatment (Table 1).
CMAP amplitudes of frontalis and orbicularis oris
were reduced on the affected side in comparison with
the non-affected side in both groups (P < 0.05). How-
ever there was no significant difference in the effect
between the groups (P < 0.05).
HB scores of each group were analyzed separately.
A non-parametric Friedman test showed a significant
effect of time (p = 0.0001 for each group). Mann-
Whitney pairwise comparisons were used to compare
the overall change in HB scores (baseline- 3rd month)
between groups. This showed a significant difference
between groups (steroid alone vs steroid and antivi-
ral group) with more improvement in the steroid +
antiviral group (P = 0.007) (Table 2 and Fig. 2).
At the end of the 3rd month 17 patients (68%) had
good recovery and 8 patients (32%) had poor recovery
 E.M. Khedr et al. / Steroid/Antiviral treatment for Bell’s palsy 901

Table 2
Changes in Sunnybrook Facial Grading System among studied groups along the course of illness
Groups Baseline 2weeks 2 months 3 months One way ANOVA Two way ANOVA
Mean ± SD Mean ± SD Mean ± SD Mean ± SD Repeated Repeated
measure analysis measure analysis
(effect of time) Time × group
Changes of Resting Symmetry(Sunnybrook Facial Grading System)
Steroid group 17.6 ± 2.6 15.8 ± 1.9 14.8 ± 1.0 13.2 ± 2.5 Df = 2.7, f = 26.9, P = 0.0001 F = 16.6, Df = 2.5,
Steroid + Antiviral group 18.4 ± 2.4 15 ± 0.02 14 ± 2.0 8.6 ± 0.4.2∗∗ Df = 1.9, f = 79.3, P = 0.001 P = 0.001
Changes of Symmetry of Voluntary Movement(Sunnybrook Facial Grading System)
Steroid group 40.5 ± 5.5 44.8 ± 5.5 53.9 ± 7 62.2 ± 7.1 Df = 2.3, f = 92.5, P = 0.0001 F = 15.2, Df = 2.4,
Steroid + Antiviral group 39.5 ± 3.9 48.0.±6.0 60.9 ± 7.4∗∗ 75.7 ± 11.1∗∗∗ Df = 1.8, f = 172, P = 0.001 P = 0.001
Changes of Synkinesis score (Sunnybrook Facial Grading System)
Steroid group 2.4 ± 1.9 5.2 ± 1.8 3.4 ± 1.2 2.6 ± 2.3 Df = 2.2, f = 14.6, P = 0.0001 F = 0.560, Df = 2.6
Steroid + Antiviral group 1.8 ± 1.7 5.1 ± 2.0 2.9 ± 1.6 1.7 ± 2 Df = 2.8, f = 23.6, P = 0.001 P = 0.619
Changes of Composite score(Sunnybrook Facial Grading System)
Steroid group 17.6 ± 4.9 20.85 ± 5.0 32.3 ± 8.1 45.8 ± 7.7 Df = 1.9, f = 175.2, P = 0.0001 F = 20.5 df = 2.207
Steroid + Antiviral group 17.9 ± 4.8 24.8 ± 7.1∗ 41.8 ± 9.8∗∗ 65.2 ± 15.5∗∗ Df = 1.9, f = 173, P = 0.001 P = 0.001
NB: The difference between groups at each time of assessment ∗ p<0.01, ∗∗ p<0.001.

in the steroid group compared with 23 patients (92%)

and 2 (8%) respectively in the steroid and antiviral
group (p = 0.034).
One way repeated measures analysis (time effect)
on the score of each item (resting symmetry, sym-
metry of voluntary movement score, and total
Sunnybrook scale) showed significant improvement
in both groups (p = 0.001 for each), indicating that
symptoms improved following both types of treat-
ment. However two way repeated-measures ANOVA
revealed a significant interaction of Time (before,
versus 2 weeks after treatment, and then at the end
of 2nd and 3rd month of onset)×Group (steroid
vs steroid + antiviral) for resting symmetry, and
symmetry of voluntary movement score, (F = 16.6,
Df = 2.5, P = 0.0001, and F = 15.2, Df = 2.4, P = 0.001 Fig. 2. Shows changes in House Brackmann facial nerve grad-
respectively) while there was no difference between ing in patients with Bell’s palsy in the studied groups at different
groups in Synkinesis score (F = 0.560, Df = 2.6, and points of assessment (before treatment, 2 weeks after treatment,and
then at the end of 2nd and 3rd month of onset). Non-parametric
P = 0.619). The total Sunnybrook score behaved sim- Friedman test showed a significant effect of time (before, versus 2
ilarly to the HB score, with a significant Time×Group weeks after treatment, and then at the end of 2nd and 3rd month
interaction (F = 20.5, Df = 2.2, and P = 0.001) indi- of onset) with p = 0.001 for each group. Mann-Whitney pairwise
cating that steroid + antiviral treatment was more comparisons were used to compare the overall change score for
each individual (baseline- 3rd month) between groups showed a
effective than steroid alone. significant difference between groups (steroid alone vs steroid and
T- test comparisons between groups at each point antiviral group) with more improvement in steroid + antiviral group
of assessment revealed that the scores of the steroid + (P = 0.007). T-test was used to compare the mean value at each time
antiviral group improved more than the steroid group of assessment between groups with * for p < 0.05; ** for p < 0.01
and *** for p < 0.001.
at the end of the 2nd and 3rd month after onset par-
ticularly for symmetry of voluntary movement score,
and the total Sunnybrook score (P = 0.001 for each) base line assessment) and rating scores (HB and Sun-
(Fig. 3A, B, C, and D). nybrook score) at the 4th assessment point either for
There was no significant correlation between each group separately or for all patients combined
amplitude ratio of affected/ non affected CMAP (at (Table 3).
902 E.M. Khedr et al. / Steroid/Antiviral treatment for Bell’s palsy

Fig. 3. A, B, C, and D: Shows changes in the mean score of each item of Sunnybrook scale; (A): resting symmetry, (B): symmetry of
voluntary movement score, (C): Changes of synkinesis score, (D): Composite score in patients with Bell’s palsy in the studied groups at
different points of assessment ((before treatment, 2 weeks after treatment, and then at the end of 2nd and 3rd month of onset). There was
significant effect of time for each group separately for each item of scale along the course of follow up (P = 0.0001 for each), however to
way ANOVA (time × groups interaction) show that the improvement are significantly higher in steroid + antiviral group than steroid group
in resting symmetry, symmetry of voluntary movement, and composite scores (P = 0.0001 for each). The significant between groups at each
time of assessment are demonstrated in the figure with * for p < 0.05; ** for p < 0.01 and *** for p < 0.001.

5. Discussion ery of the facial nerve in 85% of the placebo group,

Although there is a consensus that early use of
prednisolone is an effective treatment for Bell’s palsy,
the use of antiviral agents has led to some contro-
versy. The first large-scale investigation of antiviral
agents was performed by Sullivan et al. (2007) in a
randomized, placebo-controlled, double blind study
of 496 patients with Bell’s palsy who were treated
within 72 h of the onset of facial palsy for 10 days
with either prednisolone, acyclovir, both, or placebo.
Assessment at 9 months indicated complete recov-
96% of the prednisolone-only group (reduction in
absolute risk was 11%), 78% of the acyclovir-only
group, and 93% of those who received acyclovir
and prednisolone. A similar result was observed
in a randomized, placebo-controlled, double blind
study by Engstrom and colleagues (Engstrom et al.,
2008) who assessed the effectiveness of valacyclovir
alone or combined with prednisolone in patients with
Bell’s palsy. They concluded that early treatment
with prednisolone alone shortened the time to facial
recovery and that valacyclovir did not affect recov-
 E.M. Khedr et al. / Steroid/Antiviral treatment for Bell’s palsy
Table 3
Correlation between amplitude ratio of affected/ non affected CMAP and rating scores (House & Brackmann and Sunnybrook score) at 4th
assessment point
Variable
Steroid group
HB of facial grading system R = –0.372
P = 0.067
Composite score of Sunnybrook score R = –0.126
P = 0.549
HB of facial grading system R = –0.132
P = 0.528
Composite score of Sunnybrook score R = 0.301
P = 0.057
HB; House & Brackmann.
ery. Many systematic reviews (Allen et al., 2009;
Quant et al., 2009; Turgeon et al., 2015) also found
no clear evidence for the superiority of combining
steroids with antiviral drugs compared to steroids
alone. However many of these studies examined
patients with paralysis ranging from mild to severe
so that any improvements in particular subsets of
patients might not have been apparent (Linder et al.,
2010).
The present study was a randomized, double-blind,
controlled trial in patients with moderate to severe
forms of acute Bell’s palsy. The results differ from
the studies above in that we found a positive addi-
tional effect of combined treatment. Our hypothesis
is that the difference is due to the higher initial levels
of severity in our group. In fact, our findings are
consistent with those previously reported by Hato et
al. (2007) who also found that patients with severe
Bell’s palsy had a more favorable result with steroid-
Valacyclovircombination therapy than steroid
alone.
Data on the predictive value of electrophysiolog-
ical tests are conflicting, mainly due to selection
biases: etiology and degree of palsy; tests involved;
and initial timing for evaluation, prognostic follow-
up time, and small sample size. In the present study
there was no evidence that CMAP amplitude ratio of
affected /unaffected sides at base line predicted the
clinical rating score at the end of the study. How-
ever, this null conclusion may be related to the small
sample size and the early time point at which elec-
trophysiology was assessed (within the first 3 days of
onset).
It should be noted that although this was not
placebo-controlled trial, since it was an add-on design
to test the effect of administering an antiviral drug,
903
CMAP amplitude ratio of frontalis
Antiviral group Total cases
R = 0.092 R = –0.56
P = 0.663 P = 0.697
R = –0.185 R = –0.149
P = 0.376 P = 0.301
CMAP amplitude ratio of orbicularis oris
r = 0.200 R = –0.013
p = 0.338 P = 0.928
R = –0.063 R = 0.154
P = 0.763 P = 0.285
participants did not know who was getting the antivi-
ral and who was not. In this selected group the data
suggests quite strongly that treatment with antiviral +
steroid improves final outcome and shortens the time
to achieve it. Two months after treatment, 17 (68%)
of 25 patients treated with steroid alone had good
recovery and 8 patients (32%) had poor recovery.
In contrast, of the 25 patients treated with com-
bined steroid + antiviral therapy, 23 patients (92%)
had good recovery whereas only 2 (8%) had poor
recovery.
6. Conclusion
Although treatment with prednisolone is likely to
be cost-effective, the combined treatment increases
the possibility of recovery in moderately severe to
complete Bell’s palsy. Therefore, the use of antivirals
should be considered in this category of patients.
6.1. Limitation of the study
The small sample size and short term follow up are
important limitations. Further validation is required
in a large prospective clinical trial for patients with
different degrees of Bell’s palsy in order to find the
optimal dose and timing of steroids and antiviral.
More laboratory investigations to check for evidence
of zoster reactivation are also needed. Other ther-
apeutic options have still to be explored such as
enhancing motor cortical excitability of facial mus-
cles through non-pharmacological means such as
repetitive transcranial magnetic stimulation of the
brain or peripheral magnetic stimulation of facial
nerves (Khedr et al., 2014; 2011; 2012).
904 E.M. Khedr et al. / Steroid/Antiviral treatment for Bell’s palsy
Acknowledgments
The authors would like to thank Professor Dr. John
C Rothwell Professor of Human Neurophysiology,
UCL Institute of Neurology, for his valuable com-
ments and revision of this manuscript.
Conflict of interest
No conflict of interest.
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