Editor—Most patients with Bell's palsy clearly do well with or without treatment. Outside certain patient subgroups, identifying who will fare well and who won't remains impossible. Therefore if treatment is to be given, all who are eligible for treatment must be treated for the benefit of the few. Although systematic reviews do not show statistically significant benefits, they are at least suggestive of benefit. The differences are small but for a disorder with much disability and cosmetic blight associated with it, the difference between treatment and non-treatment may be clinically very significant.
Our remit was to provide a summary of the current evidence, define from it, with a degree of pragmatism, what advice to give, and to inform discussions with patients. The uncertainties in the current evidence base, and possible solutions to it are clearly discussed in the paper. We allowed for these uncertainties, providing “support” (level B or C advice) rather than “recommendations” (level A advice), all that is possible given the current level of evidence. Our advice is compatible with the current evidence given the uncertainties within it. We are also certain that further studies are indicated because of those uncertainties, including placebo controlled studies such as the Scottish one.
We accept that there is no evidence that referral will lead to better outcomes but suggest that any patient is best cared for by a practitioner with an interest, who may treat, investigate, or refer onward for further management as appropriate. The fact that a sizable proportion of patients have an alternative diagnosis justifies this approach. As the facial nerve is a cornerstone in otological practice we feel well placed to manage facial palsy, and are pleased to see that this is the starting point for the Scottish study.
Competing interests: None declared.