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The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.


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A 56-year-old man is seen for follow-up evaluation of Bell palsy, which was diagnosed 1 week ago. He had no other symptoms or clinical findings at the time of diagnosis and began a course of prednisone. Symptoms of unilateral facial paresis have persisted, and the patient asks what additional therapeutic options are available.

On physical examination, vital signs are normal. Right-sided facial paresis accompanied by slight sagging of the right eyebrow and flattening of the nasolabial fold on the right is noted. Cranial nerve testing shows weakness in the distribution of the right facial nerve (cranial nerve VII), with a mildly decreased ability to raise the eyebrow on the right, to close the right eye firmly, or to symmetrically bare his teeth. All other general medical and neurologic examination findings, including those from an otologic examination, are normal.

Q.

Which of the following adjuvant therapies should be recommended to this patient?

Acupuncture is a reasonable additional therapy for this patient. Bell palsy is a mononeuropathy of the facial nerve (cranial nerve VII) and is generally idiopathic in origin. Prognosis of full recovery can be predicted on the basis of symptom severity. This patient has mild symptoms overall, with incomplete paralysis. Although symptoms typically appear over 1 to 2 days, recovery is generally much slower and can take several months to be complete. He was appropriately treated with prednisone, which, when started within 72 hours of symptom onset, can hasten recovery. Use of antiviral medications, in addition to glucocorticoids, has been proposed as an additional therapy, but to date, results have has inconsistent. A recent randomized trial studied acupuncture, in addition to prednisone, for treatment of Bell palsy. Acupuncture with strong stimulation was compared with acupuncture without this stimulation. At 6 months, patients in the strong stimulation group had better facial function, decreased disability on assessment, and a better quality of life than a control group who did not receive acupuncture. Therefore, acupuncture with strong stimulation would be a reasonable adjuvant therapy for this patient to pursue.

Bell palsy can occur in the setting of Lyme disease, but this association in itself does not warrant empiric treatment with doxycycline in patients with Bell palsy. Additional diagnostic testing would be appropriate in patients considered at high risk or with symptoms suggestive of Lyme disease. However, empiric therapy for Lyme disease without additional evidence of disease or further testing would not be appropriate.

Originally designed to treat epilepsy, gabapentin also may benefit patients experiencing pain from certain other neurologic diseases. Bell palsy, however, is not typically a painful condition, which makes using this drug in this patient unwarranted.

Surgical decompression of the facial nerve is an invasive procedure and is not currently a standard recommended therapy for Bell palsy.

Key Point

  • Acupuncture with strong stimulation is a reasonable adjuvant therapy for patients with Bell palsy.
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