Uncertainty about usefulness of antiviral drugs in Ramsay Hunt syndrome

Uscategui T, Doree C, Chamberlain IJ, Burton MJ

Published Online:

January 21, 2009

It seems logical that antiviral drugs might help patients with a herpes virus infection of the ear producing facial weakness (a condition known as 'Ramsay Hunt syndrome'). These drugs often help similar viral infections elsewhere in the body. However, trials that might address this issue have not been done and there is therefore some uncertainty about their usefulness. Since patients can experience side-effects when taking these drugs, the risks of these have to be balanced with the unknown prospect of benefit when considering whether to use them in Ramsay Hunt syndrome.

Abstract (click to read)

Background:

Herpes zoster oticus (HZO) is a viral infection of the ear and when associated with acute facial paralysis is known as Ramsay Hunt syndrome. Antiviral agents are the standard first-line treatment for herpes zoster infections at other body sites and are thought to reduce or minimise nerve damage, thereby improving outcomes. It has been suggested that these agents improve the chance of facial weakness improving or resolving completely in patients with Ramsay Hunt syndrome.

Objectives:

To determine the effectiveness of antiviral agents in the treatment of adult patients with Ramsay Hunt syndrome (HZO with facial palsy).

Search strategy:

We searched the Cochrane ENT Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, current issue), Medline (1950 - 2007), PubMed 2007 - 2008, EMBASE (1974 onwards) and other relevant databases. The date of the most recent search was June 2008.

Selection criteria:

Two authors scrutinized all possible citations to identify randomised controlled trials in which antiviral agents alone or in combination with other therapies (using different routes of administration and dosage schemes) were given as treatment for Ramsay Hunt syndrome. We contacted an author for further information.

Data collection and analysis:

Two reviewers independently assessed eligibility and trial quality.

Main results:

Only one randomised, controlled trial was identified and included. It was of low quality and included only 15 participants. In this 1992 trial, intravenous acyclovir and corticosteroids were compared with corticosteroids alone. Our analysis found no statistically significant difference between the two groups.

Authors' conclusions:

We found no evidence that anti-viral agents have a beneficial effect on outcomes in Ramsay Hunt syndrome, despite their widespread use in this condition. The use of these drugs in patients with herpes zoster infections in other parts of the body might suggest that they have a role in herpes zoster oticus. As usual, the absence of positive evidence of benefit (or, in this case, the 'negative' result of one small, statistically under-powered study) does not necessarily indicate that antivirals are ineffective. However, these drugs are associated with a number of adverse effects and this must be taken into consideration when undertaking the requisite risk-benefit analysis before instigating treatment.

This record should be cited as:

Uscategui T, Doree C, Chamberlain IJ, Burton MJ. Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006851. DOI: 10.1002/14651858.CD006851.pub2

Assessed as up to date:

August 13, 2008

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Primary Review Group:

Ear, Nose and Throat Disorders Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective is antiviral therapy in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy)?

Bottom line:

The review found no evidence that antiviral therapy had a beneficial effect on outcomes in Ramsay Hunt syndrome. Only one randomised controlled trial was identified, comparing acyclovir and corticosteroids with corticosteroids alone.There was no statistically significant difference in outcomes between the two groups.

Caveat:

The single study was of low quality and included only 15 participants.As usual, the absence of positive evidence of benefit (or in this case, the "negative" result of one small, statistically under-powered study) does not necessarily indicate that antivirals are ineffective. On the basis of fundamental pathophysiological principles, it would seem reasonable to use them. However, these drugs are associated with a number of adverse effects (such as nausea, headache, renal impairment, diarrhoea, dizziness, fatigue, skin rash, anorexia, leg pain, sore throat and hair loss), and this must be taken into consideration when undertaking the requisite risk-benefit analysis before instigating treatment.

Context:

Herpes zoster oticus is a viral infection of the inner, middle and external ear, and when associated with acute facial paralysis is known as Ramsay Hunt syndrome. Antiviral agents are the standard first-line treatment for herpes zoster infections at other body sites, and are thought to reduce or minimise nerve damage, thereby improving outcomes.

Cochrane Systematic Review:

Uscategui T et al.Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Reviews 2008, Issue 4. Article No. CD006851. DOI: 10.1002/14651858. CD006851.pub2. This review contains one trial involving 15 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Ear, nose, & throat > Ear > Herpes zoster oticus

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Uncertainty about usefulness of antiviral drugs in Ramsay Hunt syndrome

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