Original Article
doi: 10.1111/joim.12288
Steroid plus antiviral treatment for Bell’s palsy
H. M. Kang, S. Y. Jung, J. Y. Byun, M. S. Park & S. G. Yeo
From the Department of Otorhinolaryngology, School of Medicine, Kyung Hee University, Seoul, Korea
Abstract. Kang HM, Jung SY, Byun JY, Park MS, Yeo
SG (Kyung Hee University, Seoul, Korea). Steroid
plus antiviral treatment for Bell’s palsy. J Intern
Med 2015; 277: 532–539.
Objectives. The effectiveness of antiviral agents for the
treatment of Bell’s palsy is uncertain. We evaluated
whether a steroid with an antiviral agent (S + A
group) provided better recovery outcomes than a
steroid alone (S group) in patients with Bell’s palsy.
Subjects and design. A total of 1342 patients diagnosed
with Bell’s palsy who visited the Kyung Hee
Medical Center in Seoul, Korea, from 2002 to
2012 were included in this study. Patients in the
S + A group were treated with prednisolone and
antiviral agents (n = 569) and those in the S group
with prednisolone alone (n = 773). Outcomes were
measured using the House–Brackmann (HB) scale
according to age, initial disease severity, electro-
neurography (ENoG) findings and underlying com-
orbidities.
Results. The rate of recovery (HB grades I and II) with
initially severe Bell’s palsy (HB grades V and VI)
was higher in the S + A than in the S group
Introduction
Bell’s palsy is an acute peripheral facial paralysis
of unknown cause, with an annual incidence of
11–40 per 100 000 [1, 2]. Its cause remains
unknown, although the findings of many studies
have suggested that it is primarily due to viral
infection, including infection with herpes simplex
(HSV), Epstein–Barr and varicella zoster viruses
[3–6]. In particular, the detection of HSV in the
human geniculate ganglion and of the HSV genome
in endoneurial fluid in Bell’s palsy patients
strongly suggests that infection with HSV can
cause Bell’s palsy [7–9]. In addition to persistent
inflammation from viral infection or an autoim-
mune response, oedema within the facial nerve
due to ischaemia can also cause facial palsy,
which can be worsened because the facial nerve
passes through a narrow bony canal [10]. Steroids,
which decrease the swelling of the facial nerve, are
532 ª 2014 The Association for the Publication of the Journal of Internal Medicine
(P = 0.001). However, the rates of recovery were
similar with initially moderate palsy (HB grades II–
IV) (P = 0.502). In patients classified according to
age and ENoG-determined severity of palsy, the
overall recovery rate was higher in the S + A than
in the S group, but the differences were not
statistically significant (P > 0.05 for both). The
recovery rate without diabetes mellitus (DM) and
hypertension (HTN) was higher in the S + A group
than in the S group (P = 0.031). But in the patients
with HTN and DM, the difference in recovery rates
between the S + A and S groups was not statisti-
cally significant (P = 0.805).
Conclusions. Treatment with a steroid plus antiviral
agent resulted in significantly higher recovery rates
than steroid therapy alone in patients with initially
severe Bell’s palsy and without either HTN or DM,
and a nonsignificant trend towards higher recovery
rates in all patients with Bell’s palsy in this study.
Antiviral agents may therefore help in the treat-
ment of Bell’s palsy.
Keywords: age, antivirals, Bell’s palsy, electroneurog-
raphy, severity, steroid.
considered first-line agents in the treatment of
Bell’s palsy [11, 12].
Despite the evidence for a role of viral infection, the
therapeutic efficacy of antiviral agents for Bell’s
palsy remains unclear. It has been reported that
the combination of an antiviral agent and steroids
is more effective than steroids alone [13]; however,
other studies demonstrated that both antiviral
agents alone and the combination of an antiviral
and a steroid were not effective with regard to
improving recovery from Bell’s palsy [14]. It was
also reported that the combination of an antiviral
agent and a steroid yielded better outcomes than
the use of a steroid alone in patients with severe or
complete Bell’s palsy [15]. The most recent guide-
lines from the American Academy of Neurology
suggest that acyclovir combined with prednisone is
‘possibly effective’ for the treatment of Bell’s palsy
[16]. Although the therapeutic efficacy of antiviral

H. M. Kang et al.
agents in the treatment of Bell’s palsy is still
unclear, the clinical use of an antiviral–steroid
combination for the treatment of Bell’s palsy is
increasing.
This study was designed to determine the thera-
peutic efficacy of antiviral agents in Bell’s palsy
patients classified according to age, initial severity
of disease, electroneurography (ENoG) findings
and underlying comorbidities.
Subjects and methods
All patients with facial palsy who visited the
outpatient clinic of the Department of Otolaryngol-
ogy at Kyung Hee Medical Center, a tertiary teach-
ing hospital, from January 2002 to December
2012, were enrolled in this study. Bell’s palsy was
diagnosed as a sudden onset of unilateral facial
paralysis. Patients with facial paralysis resulting
from other causes, such as the presence of a
vesicular eruption of the auricle or tympanic
membrane or a defined lesion of the cerebellopon-
tine angle or central nervous system by brain or
temporal magnetic resonance imaging, as well as
patients with a history of middle ear disease (e.g.
chronic otitis media), were excluded. The study
protocol was approved by the institutional review
board, and all patients provided written informed
consent.
Patients with Bell’s palsy were treated with either
oral prednisolone alone or oral prednisolone plus
an oral antiviral agent, and the therapeutic out-
comes of the two treatment regimens were com-
pared. Adults (aged ≥16 years) were treated with
prednisolone for 2 weeks: 80 mg day 1 for the first
4 days, then 60 mg day 1 for 2 days, 40 mg day 1
for 2 days, 20 mg day 1 for 2 days and
10 mg day 1 for 4 days. Children (age ≤15 years)
and low-weight adults were started on
1 mg kg 1 day 1 oral prednisolone, and the dosage
was gradually decreased thereafter. The antiviral
agent acyclovir was administered at 1000–
2400 mg day 1 for 5 days, or the antiviral famci-
clovir was administered at 750 mg day 1 for
7 days.
The degree of facial palsy was measured using the
House–Brackmann (HB) grading system [17],
which assigns patients to one of the six categories
based on the degree of facial function. Grade 1
indicates normal function, grade 2 mild dysfunc-
tion (slight weakness noticeable on close inspec-
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Steroid plus antiviral treatment
tion, possible very slight synkinesis), grade ≤4
moderate palsy and grade ≥5 severe palsy. The
degree of facial palsy at the end-point of ‘recovery’
(i.e. no further improvement in facial palsy) was
also measured using the HB grading system based
on four different facial states (at rest, eye closure
with maximal effort, forehead wrinkling with max-
imal effort and raising mouth angle with maximal
effort). A good outcome or complete recovery was
defined as HB grade ≤2.
ENoG was performed 7–14 days after the onset of
symptoms using a Digitimer DS7A stimulator
(Biologic System, Sydney, Australia). The facial
nerve in the area around the stylomastoid foramen
was stimulated with a bipolar surface electrode,
and the compound muscle action potential was
measured. Results of ENoG were reported as the
maximal amplitude of the affected side of the face/
maximal amplitude of a healthy side of the face (%).
Statistical analysis
Groups were compared using Student’s t-test and
Mann–Whitney U-test and chi-squared test, as
appropriate. To assess the effects of combination
therapy and initial HB grade, multivariate logistic
regression analyses were performed adjusted for
the effects of sex, age and initial ENoG value,
because the analyses were stratified according to
the presence of hypertension (HTN) and/or diabe-
tes mellitus (DM), in line with some previous
studies in which the effects of these comorbidities
on recovery rate were reported. All statistical
analyses were performed using SPSS (18.0; SPSS
Inc., Chicago IL, USA), with statistical significance
defined as a P-value <0.05.
Results
A total of 1474 patients with Bell’s palsy visited the
outpatient clinic at our hospital over the 11-year
study period. In total, 132 of these patients were
excluded because they did not receive steroid
therapy (n = 72), the data from their medical
records were inadequate (n = 33), they were lost
to follow-up (n = 24) or because of other central
nervous system disorders (n = 3). Of the 1342
included patients (Fig. 1), 773 (57.6%) received a
steroid alone and 569 (42.4%) received a combina-
tion of a steroid and an antiviral agent. The steroid
alone group consisted of 351 (45.4%) male patients
and 422 (54.6%) female patients; the respective
patient numbers in the combination therapy group
ª 2014 The Association for the Publication of the Journal of Internal Medicine 533
Journal of Internal Medicine, 2015, 277; 532–539
 13652796, 2015, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/joim.12288 by Nat Prov Indonesia, Wiley Online Library on [11/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
H. M. Kang et al. Steroid plus antiviral treatment

1474 patients with Bell’s palsy

132 were excluded

72 were not treated with steroid
33 had insufficient medical records
24 were lost to follow-up
3 were diagnosed with another central nervous system disorder

1342 patients with Bell’s palsy included

569 patients were treated with steroid plus antiviral (acyclovir, famciclovir)

age severity of Bell’s palsy electroneurography findings underlying comorbidities

Evaluation of recovery rate of Bell’s palsy according to treatment modalities Fig. 1 Study population and
Steroid vs. steroid plus antiviral
study design.

were 284 (49.9%) and 285 (50.1%). Of the patients (90%) elderly patients, respectively (P = 0.277).
in the steroid group, 48 (6.2%) were children (age Although better therapeutic results were observed
≤15 years), 634 (82.0%) were adults (age 16– in the combination group, the differences were not
64 years) and 91 (11.8%) were elderly individuals statistically significant.
(age ≥65 years); in the combination group, the
corresponding numbers of patients were 10 Of patients with mild-to-moderate facial palsy (HB
(1.8%), 469 (82.4%) and 90 (15.8%). The initial grade ≤4), 564 (92.2%) in the steroid group and 415
HB grade on admission was 3.59  0.98 in the (91.0%) in the combination group recovered com-
steroid group and 3.65  0.96 in the combination pletely (P = 0.502). By contrast, recovery from
group (P = 0.067), and the final HB grade 6 months severe facial palsy (HB grade ≥5) was observed in
after treatment in these two groups was 105 (65.2%) patients in the steroid group and 95
1.72  0.74 and 1.74  0.78, respectively (84.1%) in the combination group (P = 0.001).
(P = 0.183). Severe facial palsy (HB grade ≥5) was Complete recovery was observed in 614 (87.1%)
observed in 161 patients (20.8%) in the steroid patients in the steroid group and 438 (89.6%) in
group and 113 (19.9%) in the combination group. the combination group with an ENoG value ≥10%
ENoG analysis as a prognostic indicator showed (P = 0.193), and in 43 (84.3%) and 31 (88.6%),
that 51 patients (6.6%) in the steroid group and 35 respectively, with an ENoG value <10% (P = 0.576)
(6.2%) in the combination group had a poor prog- (Table 3).
nosis (ENoG value <10%). The steroid alone and
combination groups included 466 (60.3%) and 324 Amongst patients with HTN, 271 in the steroid
(56.9%) patients, respectively, with neither HTN group (88.9%) and 188 (89.1%) in the combination
nor DM; there were also 227 (29.4%) and 157 group recovered completely (P = 0.930). Complete
(27.6%) patients with HTN alone, two (0.3%) and 34 recovery was observed in 400 (85.5%) patients in
(6.0%) with DM alone and 78 (10.1%) and 54 (9.5%) the steroid group and 322 (89.9%) in the combi-
with both diseases, respectively (Table 1). nation group without HTN (P = 0.055), in 70
(87.5%) and 75 (85.2%), respectively, with DM
House–Brackmann grading after the 6-month fol- (P = 0.669) and in 601 (86.7%) and 435 (90.4%),
low-up showed that 671 patients (86.8%) in the respectively, without DM (P = 0.052). Thus, the
steroid group and 510 (89.6%) in the combination therapeutic results were not affected by the pres-
group achieved complete remission (P = 0.115) ence or absence of HTN and DM. Amongst patients
(Table 2). When therapeutic results were assessed with both HTN and DM, 69 (88.5%) in the steroid
with respect to age, we found that 44 children group and 47 (87.0%) in the combination group
(91.7%) in the steroid group and 10 (100%) in the recovered completely (P = 0.805); amongst patients
combination group recovered completely; complete without HTN or DM, 399 (85.6%) and 294 (90.7%),
recovery was also observed in 550 (86.8%) and 419 respectively, recovered completely (P = 0.031)
(89.3%) adults (P = 0.193) and 77 (84.6%) and 81 (Table 4).

534 ª 2014 The Association for the Publication of the Journal of Internal Medicine
Journal of Internal Medicine, 2015, 277; 532–539
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H. M. Kang et al. Steroid plus antiviral treatment

Table 1 Baseline characteristics and outcome measurements in patients with Bell’s palsy

Steroid Steroid + Antiviral agent P-value

Patients, n (%) 773 (57.6) 569 (42.4) –
Sex –
Male : female, n 351 : 422 284 : 285
(%) (45.4 : 54.6) (49.9 : 50.1)
Age group, n (%) –
Children 48 (6.2) 10 (1.8)
Adults 634 (82.0) 469 (82.4)
Elderly 91 (11.8) 90 (15.8)
Initial HB grade (mean  SD) 3.65  0.96 3.50  1.00 0.067
Final HB grade (mean  SD) 1.74  0.78 1.69  0.68 0.183
Facial palsy, n (%)
Moderate 612 (79.2) 456 (80.1) –
Severe 161 (20.8) 113 (19.9) –
ENoG value, n (%) –
≥10% 705 (93.3) 489 (93.3)
<10% 51 (6.8) 35 (6.7)
Underlying comorbidity (HTN/DM), n (%) –
Neither 466 (60.3) 324 (56.9)
HTN 227 (29.4) 157 (27.6)
DM 2 (0.3) 34 (6.0)
HTN + DM 78 (10.1) 54 (9.5)

HB, House–Brackmann; ENoG, electroneurography; HTN, hypertension; DM, diabetes mellitus.

Table 2 Recovery rates in patients with Bell’s palsy with incomplete recovery (OR 0.16, 95% CI 0.103–
0.263). In patients with either HTN or DM, initial
Steroid + severe facial palsy was significantly associated
antiviral with a low OR of complete recovery (OR 0.32,
Steroid agent P-value 95% CI 0.167–0.611). In patients with both HTN
Complete 671 (86.8) 510 (89.6) 0.115 and DM, initial HB grade and combination therapy
remission, were not associated with complete recovery
(Table 5).
n (%)
Incomplete 102 (13.2) 59 (10.4)
remission,
Discussion
n (%) Idiopathic facial palsy (Bell’s palsy) has a high rate
of spontaneous recovery (approximately 50–85%)
although its cause is not clear [14, 18]. A variety of
therapeutic approaches have become available,
Table 5 shows the adjusted odds ratio (OR) for the but the efficacy of definitive therapies remains
effects of antiviral therapy on complete recovery, unknown. Microsurgical exploration of the facial
adjusted for the presence of HTN and/or DM. In nerve at various stages of facial palsy has revealed
patients without either comorbidity, steroid–antiv- marked oedema during the acute phase [19, 20].
iral combination therapy moderately increased the Steroids may inhibit nerve swelling in the fallopian
OR for complete recovery [OR 1.59, 95% confidence canal and decrease vascular compression, result-
interval (CI) 0.972–2.607]. In addition, initial ing in the recovery of blood circulation to the nerve.
severe facial palsy (HB grade ≥5) was associated Steroid treatment has been shown to be effective in

ª 2014 The Association for the Publication of the Journal of Internal Medicine 535
Journal of Internal Medicine, 2015, 277; 532–539
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H. M. Kang et al. Steroid plus antiviral treatment

Table 3 Therapeutic responses in patients with Bell’s palsy: effect of age, initial grade, ENoG value and treatment modality

Steroid Steroid + antiviral agent P-value

Age group
Children 48 10
Complete remission 44 (91.7%) 10 (100%) 0.344
Incomplete remission 4 0
Adults 634 469
Complete remission 550 (86.8%) 419 (89.3%) 0.193
Incomplete remission 84 50
Elderly 91 90
Complete remission 77 (84.6%) 81 (90%) 0.277
Incomplete remission 14 9
Initial HB grade
Moderate (HB grade ≤4) 612 456
Complete remission 564 (92.2%) 415 (91.0%) 0.502
Incomplete remission 48 41
Severe (HB grade ≥5) 161 113
Complete remission 105 (65.2%) 95 (84.1%) 0.001
Incomplete remission 56 18
ENoG value
≥10% (moderate) 705 489
Complete remission 614 (87.1%) 438 (89.6%) 0.193
Incomplete remission 91 51
<10% (severe) 51 35
Complete remission 43 (84.3%) 31 (88.6%) 0.576
Incomplete remission 8 4

HB, House–Brackmann; ENoG, electroneurography.

many studies of patients with Bell’s palsy [11, 12,
18]. In addition, the neuronal inflammation asso-
ciated with Bell’s palsy is thought to be secondary
to viral infection, with HSV detected in the endo-
neural fluid of many patients [21]. Increasingly,
these patients are being treated with a combination
of a steroid and an antiviral agent. We have shown
previously that the combination of a steroid and
acyclovir is more effective than steroid alone,
especially in patients with severe Bell’s palsy [22,
23]. However, the therapeutic effects of antiviral
agents for Bell’s palsy remain unclear. We therefore
compared the efficacy of antiviral agents plus a
steroid with steroid therapy alone in Patients with
Bell’s palsy classified by several clinical variables.
We assessed the baseline characteristics and out-
come measures of facial palsy in 1342 patients
treated over a 11-year period at a single hospital.
Of these 1342 subjects, 773 (57.6%) were treated
with steroid alone and 569 (42.4%) with a combi-
nation of a steroid and an antiviral agent, with
86.8% and 89.6%, respectively, achieving complete
recovery; this finding was consistent with our
previous results [22].
The efficacy of steroid therapy alone and in com-
bination with an antiviral agent has not been
clearly established. Comparison between studies
is difficult because of the use of different standards
to define recovery in patients with Bell’s palsy [20],
different systems to grade disease severity and
treatment with several different antiviral agents. In
addition, the small population sizes of many stud-
ies, due to the low incidence of Bell’s palsy, and the
lack of homogeneity amongst multicentre studies
may confound study results. We used the HB
grading system, which is most frequently used to

536 ª 2014 The Association for the Publication of the Journal of Internal Medicine
Journal of Internal Medicine, 2015, 277; 532–539
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H. M. Kang et al. Steroid plus antiviral treatment

Table 4 Therapeutic responses in patients with Bell’s palsy: effect of underlying comorbidities

Steroid Steroid + antiviral agent P-value

HTN
With HTN 305 211
Complete remission 271 (88.9%) 188 (89.1%) 0.930
Incomplete remission 34 23
Without HTN 468 358
Complete remission 400 (85.5%) 322 (89.9%) 0.055
Incomplete remission 68 36
DM
With DM 80 88
Complete remission 70 (87.5%) 75 (85.2%) 0.669
Incomplete remission 10 13
Without DM 693 481
Complete remission 601 (86.7%) 435 (90.4%) 0.052
Incomplete remission 92 46
HTN + DM
With HTN + DM 78 54
Complete remission 69 (88.5%) 47 (87.0%) 0.805
Incomplete remission 9 7
Without HTN + DM 466 324
Complete remission 399 (85.6%) 294 (90.7%) 0.031
Incomplete remission 67 30

HTN, hypertension; DM, diabetes mellitus.

evaluate the degree of facial nerve damage in Bell’s
palsy. HB grade ≤II was defined as complete
recovery, although stricter criteria set grade I as
complete recovery. HB grades I and II have been
used to indicate ‘favourable effects’, ‘satisfactory
outcomes’, ‘good outcomes’ and ‘complete recovery’
in previous studies by us and others, as patients
with grade II are able to function normally in daily
life [24–27]. We also defined favourable or complete
recovery as HB grades I and II.
Acyclovir and famciclovir are the antiviral agents
commonly used to treat patients with Bell’s palsy.
The therapeutic outcomes of antiviral agents were
assessed in patients divided by age into three
groups: children (age ≤15 years), adults (age 16–
64 years) and elderly individuals (age ≥65 years).
Although the therapeutic effects of combination
treatment were better than those of steroid alone in
each of these age groups, as well as in the overall
patient cohort, none of these differences was sta-
tistically significant. This result suggests that
antiviral agents can provide consistent treatment
results in patients with Bell’s palsy.
ENoG is a neurophysiological method used to
evaluate the degree of injury of facial nerves and
is the most frequently used prognostic indicator for
patients with Bell’s palsy. The effects of treatment
were assessed separately in patients with good
(ENoG value ≥10%) and poor (ENoG value <10%)
prognosis [28, 29]. Again, better therapeutic
results were observed in the combination group,
although the differences were not statistically sig-
nificant. The initial severity of facial nerve dys-
function in Bell’s palsy has been reported to
adversely affect prognosis [30], as well as having
a direct effect on antiviral efficacy [15, 23]. We
found no difference in recovery rates in patients
with moderate facial palsy (HB grade ≤4) treated
with steroid alone or combination therapy. In
patients with severe facial palsy (HB grade ≥5), a
higher rate of recovery was observed in the combi-
nation group compared with the steroid group.

ª 2014 The Association for the Publication of the Journal of Internal Medicine 537
Journal of Internal Medicine, 2015, 277; 532–539
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H. M. Kang et al. Steroid plus antiviral treatment

Table 5 Adjusted OR of complete recovery amongst patients with Bell’s palsy

Neither DM nor HTN Either DM or HTN Both DM and HTN

OR 95% CI OR 95% CI OR 95% CI
Initial HB grade (moderate : severe) 0.16 0.103–0.263 0.32 0.167–0.611 1.58 0.328–7.653
Sex (male : female) 0.98 0.614–1.550 0.93 0.491–1750 1.35 0.452–4.057
Treatment (steroid : steroid + antiviral) 1.59 0.972–2.607 1.05 0.554–1.972 0.79 0.266–2.378
Electroneurography (≥10% : <10%) 0.65 0.280–1.496 1.69 0.375–7.605 0.58 0.111–3.079
Age 0.98 0.960–0.992 1.01 0.797–1.047 1.00 0.941–1.058

DM; diabetes mellitus, HTN; hypertension; HB, House–Brackmann; OR, odds ratio; CI, confidence interval.

These results are consistent with those of earlier of the vasa nervosum [34]. Disorders of the
studies [15, 23] and provide a rationale for the use microcirculation appear to undermine the effects
of antiviral agents in the treatment of severe Bell’s of antiviral agents in patients with HTN and/or
palsy. DM.

Hypertension and DM are underlying comorbidi- In summary, we found that therapeutic outcomes
ties that can affect the prognosis of patients with were better with steroid–antiviral combination
Bell’s palsy. Some evidence has suggested that therapy than with steroid treatment alone in
HTN improves the prognosis of these patients [31], patients without HTN or DM, and in patients with
whereas no effect of HTN has also been demon- initially severe Bell’s palsy. Combination therapy
strated [25]. Similarly, DM has been reported to was also effective in groups classified by other
be unrelated to the prognosis of Bell’s palsy [30], variables, including age, ENoG value and underly-
whereas other studies have found that DM wors- ing comorbidities. Our findings provide further
ens prognosis [32, 33]. Although earlier studies evidence for the ‘possible effectiveness’ of antiviral
addressed the relationship between HTN and DM agents and support the clinical application of this
and the prognosis of Bell’s palsy, in the present treatment, in patients with Bell’s palsy.
study, we investigated the effects of different
therapeutic approaches in the presence or The recovery rate in patients receiving combination
absence of these underlying conditions. Recovery treatment was generally higher than in patients
rates were similar in HTN patients treated with treated with steroid alone, providing evidence for
steroid alone or combination therapy, although the efficacy of antiviral therapy in the treatment of
slightly improved recovery rates were observed in Bell’s palsy.
patients without HTN treated with combination
therapy compared with steroid alone (P = 0.055).
Therapeutic responses to steroid alone and com- Acknowledgement
bination treatment were similar in patients with This work was supported by the National Research
DM, but combination treatment resulted in higher Foundation of Korea (NRF) grant funded by the
recovery rates in patients without DM (P = 0.052) Korean government (No. 2011-0030072).
and significantly higher recovery rates in patients
with neither HTN nor DM (P = 0.031). Multivariate
logistic regression analyses showed that combi- Conflict of interest statement
nation therapy in patients without DM or HTN
No conflicts of interest to declare.
increased the OR value with marginal significance
(OR 1.59, 95% CI 0.972–2.607, P = 0.063), sug-
gesting that combination therapy in these patients
may aid recovery. That is, antiviral agents were References
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Correspondence: Seung Geun Yeo, MD, PhD, Department of
Otorhinolaryngology, Head & Neck Surgery, School of Medicine,
Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul
130-702, Korea.
(fax: 82-2-958-8470; e-mail: yeo2park@gmail.com).
ª 2014 The Association for the Publication of the Journal of Internal Medicine 539
Journal of Internal Medicine, 2015, 277; 532–539