Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults

Abstract

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. To determine the effectiveness of antiviral agents in the treatment of adult patients with Ramsay Hunt syndrome (HZO with facial palsy). 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. 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. Two reviewers independently assessed eligibility and trial quality. 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. 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. Uncertainty about usefulness of antiviral drugs in Ramsay Hunt syndrome 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.