Reconciling the clinical practice guidelines on Bell palsy from the AAO-HNSF and the AAN Seth R. Schwartz, Stephanie L. Jones, Thomas S.D. Getchius, et al. Neurology 2014;82;1927-1929 Published Online before print May 2, 2014 DOI 10.1212/WNL.0000000000000463 This information is current as of May 2, 2014
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.neurology.org/content/82/21/1927.full.html
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2014 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
VIEWS & REVIEWS
Seth R. Schwartz, MD, MPH Stephanie L. Jones Thomas S.D. Getchius Gary S. Gronseth, MD, FAAN
Correspondence to Thomas Getchius: [email protected]
Reconciling the clinical practice guidelines on Bell palsy from the AAO-HNSF and the AAN ABSTRACT
Bell palsy, named after the Scottish anatomist Sir Charles Bell, is the most common acute mononeuropathy, or disorder affecting a single nerve, and is the most common diagnosis associated with facial nerve weakness/paralysis. In the past 2 years, both the American Academy of Neurology and the Academy of Otolaryngology–Head and Neck Surgery Foundation have published clinical practice guidelines aimed at improving the quality of care and outcomes for patients diagnosed with Bell palsy. This commentary aims to address the similarities and differences in the scope and final recommendations made by each guideline development group. Neurology® 2014;82:1927–1929 GLOSSARY AAN 5 American Academy of Neurology; AAO-HNSF 5 American Academy of Otolaryngology–Head and Neck Surgery Foundation; CPG 5 clinical practice guideline; KAS 5 key action statements; RCT 5 randomized controlled trials.
The clinical practice guideline (CPG) on Bell palsy, recently produced by the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF),1 follows closely on the heels of the guideline on Bell palsy published by the American Academy of Neurology (AAN).2 In an effort to provide harmonization between these 2 guidelines for the end users, authors and staff from both CPGs have worked together to develop this commentary for publication in both Neurology® and Otolaryngology—Head and Neck Surgery. Both CPGs were developed to improve patient care and reduce variations in practice. This commentary compares and contrasts the 2 CPGs. The most notable difference between the guidelines is their scope. The AAN guideline scope is limited to making evidence-based recommendations regarding the use of steroids and antiviral medications for newly diagnosed patients with Bell palsy. In fact, the AAN effort was undertaken as an update to the 2001 “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.”3 The AAO-HNSF scope is much broader. It was conceived as an opportunity to improve the quality of care for patients with Bell palsy by identifying quality improvement opportunities in the diagnosis and management of the condition. Accordingly, the AAOHNSF guideline makes several recommendations regarding the clinical diagnosis of the condition, the use of testing in the evaluation of these patients (or more specifically recommendations against the use of routine laboratory testing and imaging), recognition of the importance of eye care, and finally recommendations for follow-up of these patients if total return to normal function does not occur. SCOPE
The guideline produced by the AAO-HNSF was a full multidisciplinary panel including 17 members from diverse clinician groups that manage Bell palsy (neurology, otolaryngology–head and neck surgery, neurotology, facial plastic and reconstructive surgery, emergency medicine, primary care, otology, nursing, physician assistants, and consumers). Fewer than half of the group members were otolaryngologists. GUIDELINE DEVELOPMENT GROUP COMPOSITION
From the Virginia Mason Medical Center (S.R.S.), Seattle, WA; the American Academy of Otolaryngology–Head and Neck Surgery Foundation (S.L.J.), Alexandria, VA; the American Academy of Neurology (T.S.D.G.), Minneapolis, MN; and the University of Kansas Medical Center (G.S.G.), Kansas City. This commentary is published simultaneously in Otolaryngology–Head and Neck Surgery and Neurology®. Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. © 2014 American Academy of Neurology
1927
Table 1
Oral steroid and antiviral therapy recommendations
Topic
AAN recommendation
AAO-HNSF recommendation
Oral steroids
For patients with new-onset Bell palsy, oral steroids should be Clinicians should prescribe oral steroids within 72 hours of symptom offered to increase the probability of recovery of facial nerve function onset for patients with Bell palsy 16 years and older
Antiviral therapy
For patients with new-onset Bell palsy, antivirals (in addition to steroids) might be offered to increase the probability of recovery of facial function
Clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell palsy
Abbreviations: AAN 5 American Academy of Neurology; AAO-HNSF 5 American Academy of Otolaryngology–Head and Neck Surgery Foundation.
In contrast, the AAN guideline was written by 2 authors with oversight and support from the 20-plus members of the AAN Guideline Development Subcommittee, all of whom are neurologists. Therefore the AAN CPG is not multidisciplinary.
supporting text. In addition, in the “Clinical context section” of the AAN guideline, an example of a situation where the harms might outweigh the benefits is discussed. However, the AAO-HNSF discussion of harms and benefits is more explicit.
CPG–SYSTEMATIC REVIEW INTERSECTION The development of both guidelines involved a systematic review of the literature and both made recommendations based on the results of these reviews. The AAN performed its own systematic review of the literature, which included duplicate and independent study selection and data abstraction, constructed relevant evidence tables, and was explicit in assessing the risk of bias and explaining the evidence synthesis methods used. The AAO-HNSF, however, developed its CPG using the existing 30 systematic reviews/metaanalyses that were already published.
ASSESSMENT OF THE EVIDENCE There were a few recent high-quality randomized trials assessing the impact of steroids and antiviral therapy in patients newly diagnosed with Bell palsy. Both guidelines recognized the quality of these studies and accordingly recommended the use of steroids in newly diagnosed patients. Both also recognized the clear lack of efficacy for oral antiviral therapy without steroids and recommended against independent use of this class of drugs. Both guidelines also acknowledged a lack of strong evidence for the efficacy of combined steroid and antiviral therapy (both Class I randomized controlled trials [RCT] found no benefit of combined therapy). Despite this lack of strong evidence, both concluded that existing studies did not rule out the possibility of some small benefit of combined therapy. The AAN observed that several RCT of antivirals and steroids vs steroids alone suggested a benefit of the combination. In the AAN guideline, these “positive” studies were determined to have a high risk of bias (Class IV)4 because of the absence of blinded, independent outcomes assessment. Thus, in the AAN guideline, the reason for discounting these positive studies was transparently stated. By contrast, the flaws of the positive antivirals studies were not discussed in detail in the AAO-HNSF guideline. Thus, the reasons the AAO-HNSF guideline discounted these studies was not clearly stated.
FORMAT OF RECOMMENDATIONS The recommendations or key action statements (KAS) for both CPGs attempt to spell out exactly what action is to be taken, by whom, and under what circumstance. Table 1 compares the oral steroid and antiviral therapy recommendations more closely. In the oral steroids recommendations, the AAO-HNSF was more specific, stating “within 72 hours,” while AAN choose to be vague, stating “with new onset.” The AAN used the passive voice, while the AAO-HNSF used the active voice. The rationale for why the clinician should take action is included in the AAN statement, while the AAO-HNSF includes this information in the evidence profile and supporting text.
The KAS in the AAO-HNSF guideline and the recommendations in the AAN guideline are arrived at through review and weighing of the evidence and an assessment of the harms and benefits of carrying out the recommended action. A harm benefit assessment is an important component of guidelines. The strength of a given recommendation is arrived at through a combination of both these elements. In the AAO-HNSF guideline, the benefit– harm assessment is stated in the evidence profile for each KAS. The AAN discussed the potential harms of the therapies, along with the benefits, throughout the BENEFITS VS HARMS
1928
Neurology 82
May 27, 2014
DISCUSSION The fact that both groups arrived at the same recommendations regarding the use of steroids and antiviral medications using different processes demonstrates the robustness of these recommendations. Table 2 provides a quick comparison of the 2 guidelines. Ultimately, these 2 documents are complementary. The methods for CPG development and interpretation of the evidence are evolving. A best method has not been identified but both organizations are striving to meet the standards set by the Institute of
Table 2
Comparison of AAO-HNSF and AAN Bell palsy guidelines AAO-HNSF
patients we serve. We must also teach each other. There is much to learn.
AAN
AUTHOR CONTRIBUTIONS Content Recommends steroids
Yes
Yes
Recommends against antivirals alone
Yes
Yes
Option for combined therapy
Yes
Yes
Recommends history and physical examination to Yes rule out other causes
NR
Recommends against routine laboratory testing and routine imaging
Yes
NR
Recommends eye care if impaired eye closure
Yes
NR
Recommends follow-up if incomplete resolution
Yes
NR
Methods Group composition
Multidisciplinary
Single specialty
Systematic review
Yes
Yes
Harm benefit assessment
Yes
Yes
Abbreviations: AAN 5 American Academy of Neurology; AAO-HNSF 5 American Academy of Otolaryngology–Head and Neck Surgery Foundation; NR 5 no recommendation for or against (beyond the scope of the clinical practice guideline); Yes 5 addressed in the clinical practice guideline.
Medicine.5 Both the AAO-HNSF and AAN recognize the need to improve their guideline development processes for additional clarity and transparency. For future guidelines, the AAN has adopted a structured format of recommendation wording similar to that of the AAO-HNSF.6 In addition, the AAN now uses a modified Delphi process for transparently considering factors other than the quality of the evidence for formulating recommendations. This new process was used in the recently published sports concussion7 and atrial fibrillation AAN guidelines.8 The AAO-HNSF recognizes that to continue developing high-quality guidelines it will need to be more transparent in the description of its methods for synthesizing the evidence from existing systematic reviews. The AAO-HNSF does not have the resources to develop their own systematic reviews and will continue to use high-quality reviews performed by other organizations to inform their guidelines. These organizations include other specialty societies, such as the AAN, the Agency for Healthcare Research, Quality Evidence-based Practice Centers, and the Cochrane Collaboration. As guideline developers, we must work together to create the best CPGs for our respective constituents and those allied health professionals who treat the
Seth Schwartz: drafting/revising the manuscript, accepts responsibility for conduct of research and final approval. Stephanie L. Jones: drafting/revising the manuscript, accepts responsibility for conduct of research and final approval. Thomas Getchius: drafting/revising the manuscript, analysis or interpretation of data, accepts responsibility for conduct of research and final approval. Gary Gronseth: drafting/revising the manuscript, accepts responsibility for conduct of research and final approval.
STUDY FUNDING No targeted funding reported.
DISCLOSURE S. Schwartz and S. Jones report no disclosures relevant to the manuscript. T. Getchius is an employee of the American Academy of Neurology and has nothing to disclose. G. Gronseth receives compensation from the American Academy of Neurology for evidence-based medicine related activities. He is a member of the Neurology Now editorial advisory board and is a compensated associate editor of Neurology. Go to Neurology.org for full disclosures.
Received January 3, 2014. Accepted in final form February 20, 2014. REFERENCES 1. Baugh R, Basura G, Ishii L, et al. Clinical practice guideline: Bell’s palsy. Otolaryngol Head Neck Surg 2013;149(suppl 3): S1–S27. 2. Gronseth GS, Paduga R. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2012;79:2209–2213. 3. 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. 4. American Academy of Neurology. Clinical Practice Guideline Process Manual, 2011 ed. St. Paul, MN: American Academy of Neurology; 2011. 5. Institute of Medicine. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press; 2011. 6. Rosenfeld RM, Shiffman RN, Robertson P. Clinical Practice Guideline Development Manual, third edition: a quality-driven approach for translating evidence into action. Otolaryngol Head Neck Surg 2013;148:S1–S55. 7. Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidencebased guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;80:2250–2257. 8. Culebras A, Messe SR, Chaturvedi S, Kase CS, Gronseth G. Summary of evidence-based guideline update: prevention of stroke in nonvalvular atrial fibrillation: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2014;82:1–9.
Neurology 82
May 27, 2014
1929
Reconciling the clinical practice guidelines on Bell palsy from the AAO-HNSF and the AAN Seth R. Schwartz, Stephanie L. Jones, Thomas S.D. Getchius, et al. Neurology 2014;82;1927-1929 Published Online before print May 2, 2014 DOI 10.1212/WNL.0000000000000463 This information is current as of May 2, 2014 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/82/21/1927.full.html
References
This article cites 6 articles, 6 of which you can access for free at: http://www.neurology.org/content/82/21/1927.full.html##ref-list1
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.neurology.org/content/82/21/1927.full.html
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2014 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
VIEWS & REVIEWS
Seth R. Schwartz, MD, MPH Stephanie L. Jones Thomas S.D. Getchius Gary S. Gronseth, MD, FAAN
Correspondence to Thomas Getchius: [email protected]
Reconciling the clinical practice guidelines on Bell palsy from the AAO-HNSF and the AAN ABSTRACT
Bell palsy, named after the Scottish anatomist Sir Charles Bell, is the most common acute mononeuropathy, or disorder affecting a single nerve, and is the most common diagnosis associated with facial nerve weakness/paralysis. In the past 2 years, both the American Academy of Neurology and the Academy of Otolaryngology–Head and Neck Surgery Foundation have published clinical practice guidelines aimed at improving the quality of care and outcomes for patients diagnosed with Bell palsy. This commentary aims to address the similarities and differences in the scope and final recommendations made by each guideline development group. Neurology® 2014;82:1927–1929 GLOSSARY AAN 5 American Academy of Neurology; AAO-HNSF 5 American Academy of Otolaryngology–Head and Neck Surgery Foundation; CPG 5 clinical practice guideline; KAS 5 key action statements; RCT 5 randomized controlled trials.
The clinical practice guideline (CPG) on Bell palsy, recently produced by the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF),1 follows closely on the heels of the guideline on Bell palsy published by the American Academy of Neurology (AAN).2 In an effort to provide harmonization between these 2 guidelines for the end users, authors and staff from both CPGs have worked together to develop this commentary for publication in both Neurology® and Otolaryngology—Head and Neck Surgery. Both CPGs were developed to improve patient care and reduce variations in practice. This commentary compares and contrasts the 2 CPGs. The most notable difference between the guidelines is their scope. The AAN guideline scope is limited to making evidence-based recommendations regarding the use of steroids and antiviral medications for newly diagnosed patients with Bell palsy. In fact, the AAN effort was undertaken as an update to the 2001 “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.”3 The AAO-HNSF scope is much broader. It was conceived as an opportunity to improve the quality of care for patients with Bell palsy by identifying quality improvement opportunities in the diagnosis and management of the condition. Accordingly, the AAOHNSF guideline makes several recommendations regarding the clinical diagnosis of the condition, the use of testing in the evaluation of these patients (or more specifically recommendations against the use of routine laboratory testing and imaging), recognition of the importance of eye care, and finally recommendations for follow-up of these patients if total return to normal function does not occur. SCOPE
The guideline produced by the AAO-HNSF was a full multidisciplinary panel including 17 members from diverse clinician groups that manage Bell palsy (neurology, otolaryngology–head and neck surgery, neurotology, facial plastic and reconstructive surgery, emergency medicine, primary care, otology, nursing, physician assistants, and consumers). Fewer than half of the group members were otolaryngologists. GUIDELINE DEVELOPMENT GROUP COMPOSITION
From the Virginia Mason Medical Center (S.R.S.), Seattle, WA; the American Academy of Otolaryngology–Head and Neck Surgery Foundation (S.L.J.), Alexandria, VA; the American Academy of Neurology (T.S.D.G.), Minneapolis, MN; and the University of Kansas Medical Center (G.S.G.), Kansas City. This commentary is published simultaneously in Otolaryngology–Head and Neck Surgery and Neurology®. Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. © 2014 American Academy of Neurology
1927
Table 1
Oral steroid and antiviral therapy recommendations
Topic
AAN recommendation
AAO-HNSF recommendation
Oral steroids
For patients with new-onset Bell palsy, oral steroids should be Clinicians should prescribe oral steroids within 72 hours of symptom offered to increase the probability of recovery of facial nerve function onset for patients with Bell palsy 16 years and older
Antiviral therapy
For patients with new-onset Bell palsy, antivirals (in addition to steroids) might be offered to increase the probability of recovery of facial function
Clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell palsy
Abbreviations: AAN 5 American Academy of Neurology; AAO-HNSF 5 American Academy of Otolaryngology–Head and Neck Surgery Foundation.
In contrast, the AAN guideline was written by 2 authors with oversight and support from the 20-plus members of the AAN Guideline Development Subcommittee, all of whom are neurologists. Therefore the AAN CPG is not multidisciplinary.
supporting text. In addition, in the “Clinical context section” of the AAN guideline, an example of a situation where the harms might outweigh the benefits is discussed. However, the AAO-HNSF discussion of harms and benefits is more explicit.
CPG–SYSTEMATIC REVIEW INTERSECTION The development of both guidelines involved a systematic review of the literature and both made recommendations based on the results of these reviews. The AAN performed its own systematic review of the literature, which included duplicate and independent study selection and data abstraction, constructed relevant evidence tables, and was explicit in assessing the risk of bias and explaining the evidence synthesis methods used. The AAO-HNSF, however, developed its CPG using the existing 30 systematic reviews/metaanalyses that were already published.
ASSESSMENT OF THE EVIDENCE There were a few recent high-quality randomized trials assessing the impact of steroids and antiviral therapy in patients newly diagnosed with Bell palsy. Both guidelines recognized the quality of these studies and accordingly recommended the use of steroids in newly diagnosed patients. Both also recognized the clear lack of efficacy for oral antiviral therapy without steroids and recommended against independent use of this class of drugs. Both guidelines also acknowledged a lack of strong evidence for the efficacy of combined steroid and antiviral therapy (both Class I randomized controlled trials [RCT] found no benefit of combined therapy). Despite this lack of strong evidence, both concluded that existing studies did not rule out the possibility of some small benefit of combined therapy. The AAN observed that several RCT of antivirals and steroids vs steroids alone suggested a benefit of the combination. In the AAN guideline, these “positive” studies were determined to have a high risk of bias (Class IV)4 because of the absence of blinded, independent outcomes assessment. Thus, in the AAN guideline, the reason for discounting these positive studies was transparently stated. By contrast, the flaws of the positive antivirals studies were not discussed in detail in the AAO-HNSF guideline. Thus, the reasons the AAO-HNSF guideline discounted these studies was not clearly stated.
FORMAT OF RECOMMENDATIONS The recommendations or key action statements (KAS) for both CPGs attempt to spell out exactly what action is to be taken, by whom, and under what circumstance. Table 1 compares the oral steroid and antiviral therapy recommendations more closely. In the oral steroids recommendations, the AAO-HNSF was more specific, stating “within 72 hours,” while AAN choose to be vague, stating “with new onset.” The AAN used the passive voice, while the AAO-HNSF used the active voice. The rationale for why the clinician should take action is included in the AAN statement, while the AAO-HNSF includes this information in the evidence profile and supporting text.
The KAS in the AAO-HNSF guideline and the recommendations in the AAN guideline are arrived at through review and weighing of the evidence and an assessment of the harms and benefits of carrying out the recommended action. A harm benefit assessment is an important component of guidelines. The strength of a given recommendation is arrived at through a combination of both these elements. In the AAO-HNSF guideline, the benefit– harm assessment is stated in the evidence profile for each KAS. The AAN discussed the potential harms of the therapies, along with the benefits, throughout the BENEFITS VS HARMS
1928
Neurology 82
May 27, 2014
DISCUSSION The fact that both groups arrived at the same recommendations regarding the use of steroids and antiviral medications using different processes demonstrates the robustness of these recommendations. Table 2 provides a quick comparison of the 2 guidelines. Ultimately, these 2 documents are complementary. The methods for CPG development and interpretation of the evidence are evolving. A best method has not been identified but both organizations are striving to meet the standards set by the Institute of
Table 2
Comparison of AAO-HNSF and AAN Bell palsy guidelines AAO-HNSF
patients we serve. We must also teach each other. There is much to learn.
AAN
AUTHOR CONTRIBUTIONS Content Recommends steroids
Yes
Yes
Recommends against antivirals alone
Yes
Yes
Option for combined therapy
Yes
Yes
Recommends history and physical examination to Yes rule out other causes
NR
Recommends against routine laboratory testing and routine imaging
Yes
NR
Recommends eye care if impaired eye closure
Yes
NR
Recommends follow-up if incomplete resolution
Yes
NR
Methods Group composition
Multidisciplinary
Single specialty
Systematic review
Yes
Yes
Harm benefit assessment
Yes
Yes
Abbreviations: AAN 5 American Academy of Neurology; AAO-HNSF 5 American Academy of Otolaryngology–Head and Neck Surgery Foundation; NR 5 no recommendation for or against (beyond the scope of the clinical practice guideline); Yes 5 addressed in the clinical practice guideline.
Medicine.5 Both the AAO-HNSF and AAN recognize the need to improve their guideline development processes for additional clarity and transparency. For future guidelines, the AAN has adopted a structured format of recommendation wording similar to that of the AAO-HNSF.6 In addition, the AAN now uses a modified Delphi process for transparently considering factors other than the quality of the evidence for formulating recommendations. This new process was used in the recently published sports concussion7 and atrial fibrillation AAN guidelines.8 The AAO-HNSF recognizes that to continue developing high-quality guidelines it will need to be more transparent in the description of its methods for synthesizing the evidence from existing systematic reviews. The AAO-HNSF does not have the resources to develop their own systematic reviews and will continue to use high-quality reviews performed by other organizations to inform their guidelines. These organizations include other specialty societies, such as the AAN, the Agency for Healthcare Research, Quality Evidence-based Practice Centers, and the Cochrane Collaboration. As guideline developers, we must work together to create the best CPGs for our respective constituents and those allied health professionals who treat the
Seth Schwartz: drafting/revising the manuscript, accepts responsibility for conduct of research and final approval. Stephanie L. Jones: drafting/revising the manuscript, accepts responsibility for conduct of research and final approval. Thomas Getchius: drafting/revising the manuscript, analysis or interpretation of data, accepts responsibility for conduct of research and final approval. Gary Gronseth: drafting/revising the manuscript, accepts responsibility for conduct of research and final approval.
STUDY FUNDING No targeted funding reported.
DISCLOSURE S. Schwartz and S. Jones report no disclosures relevant to the manuscript. T. Getchius is an employee of the American Academy of Neurology and has nothing to disclose. G. Gronseth receives compensation from the American Academy of Neurology for evidence-based medicine related activities. He is a member of the Neurology Now editorial advisory board and is a compensated associate editor of Neurology. Go to Neurology.org for full disclosures.
Received January 3, 2014. Accepted in final form February 20, 2014. REFERENCES 1. Baugh R, Basura G, Ishii L, et al. Clinical practice guideline: Bell’s palsy. Otolaryngol Head Neck Surg 2013;149(suppl 3): S1–S27. 2. Gronseth GS, Paduga R. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2012;79:2209–2213. 3. 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. 4. American Academy of Neurology. Clinical Practice Guideline Process Manual, 2011 ed. St. Paul, MN: American Academy of Neurology; 2011. 5. Institute of Medicine. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press; 2011. 6. Rosenfeld RM, Shiffman RN, Robertson P. Clinical Practice Guideline Development Manual, third edition: a quality-driven approach for translating evidence into action. Otolaryngol Head Neck Surg 2013;148:S1–S55. 7. Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidencebased guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;80:2250–2257. 8. Culebras A, Messe SR, Chaturvedi S, Kase CS, Gronseth G. Summary of evidence-based guideline update: prevention of stroke in nonvalvular atrial fibrillation: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2014;82:1–9.
Neurology 82
May 27, 2014
1929
Reconciling the clinical practice guidelines on Bell palsy from the AAO-HNSF and the AAN Seth R. Schwartz, Stephanie L. Jones, Thomas S.D. Getchius, et al. Neurology 2014;82;1927-1929 Published Online before print May 2, 2014 DOI 10.1212/WNL.0000000000000463 This information is current as of May 2, 2014 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/82/21/1927.full.html
References
This article cites 6 articles, 6 of which you can access for free at: http://www.neurology.org/content/82/21/1927.full.html##ref-list1
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
