大林慈濟醫院耳鼻喉科實習醫師報告

Acyclovir in Treatment of Acyclovir in Treatment of HerpeseHerpese Zoster Zoster OticusOticus

Reported by: Intern Reported by: Intern 吳晉嘉吳晉嘉Directed by : V.S Directed by : V.S 黃俊豪黃俊豪

Patient profilePatient profile

•• Name Name ：：鄒鄒 C C 坤坤•• ID No : P100501809ID No : P100501809•• Age : 52 years oldAge : 52 years old•• Gender: MGender: M•• Admission date: 2005/3/22Admission date: 2005/3/22•• Discharge date: 2005/3/27Discharge date: 2005/3/27

Brief historyBrief history

•• Chief complaint: Right Chief complaint: Right otalgiaotalgia for 1 week.for 1 week.•• Suffered from URI episode, Suffered from URI episode, RR’’tt ear tinnitus, ear tinnitus,

otalgiaotalgia since one week ago.since one week ago.•• Dizziness, mild hearing loss of Dizziness, mild hearing loss of RR’’tt ear, ear,

giddiness for 5 days.giddiness for 5 days.•• Clustered painful vesicles on Clustered painful vesicles on pinnapinna were were

found 1 day before admission. found 1 day before admission. •• No facial expression change or mouth No facial expression change or mouth

angle deviation were noted. angle deviation were noted.

Physical examinationPhysical examination

•• 1.Vital signs:1.Vital signs:•• TPR: 36.3/100/16 BP: 113/68 mmHgTPR: 36.3/100/16 BP: 113/68 mmHg•• 2.Conscious:clear2.Conscious:clear•• 3.General appearance:fair3.General appearance:fair•• 4.Heart: regular, no murmur4.Heart: regular, no murmur•• 5.Chest:breaths sounds: clear, no 5.Chest:breaths sounds: clear, no ralesrales•• 6.Abdomen:soft,no distention, 6.Abdomen:soft,no distention, normactivenormactive bowel bowel

soundssounds•• 7.Extremities:no pitting edema, freely movable 7.Extremities:no pitting edema, freely movable

ENT local findingsENT local findings

Lab dataLab data

CBC CBC BCsBCsWBCWBC 5.37 GOT/AST5.37 GOT/AST 1717HbHb 15.7 GPT/ALT 15.7 GPT/ALT 4242PLPL 204 BUN204 BUN 1212

WBC DC CREWBC DC CRE 0.90.9N.segN.seg.. 56.756.7LymLym.. 35.035.0Mono.Mono. 4.54.5Eosin.Eosin. 3.23.2BasoBaso.. 0.60.6

AssessmentAssessment

•• HerpeseHerpese zoster zoster oticusoticusclustered painful vesicles, clustered painful vesicles, otalgiaotalgia, ,

tinnitus, dizziness and giddinesstinnitus, dizziness and giddinessno evidence of facial palsy, could not no evidence of facial palsy, could not

establish the diagnosis of Ramsay Hunt establish the diagnosis of Ramsay Hunt syndrome.syndrome.

ManagementManagement

•• PrednisolonePrednisolone 100mg IVD Q8H100mg IVD Q8H•• Acyclovir 500mg IVD Q8HAcyclovir 500mg IVD Q8H•• Acyclovir cream TOPI TID Acyclovir cream TOPI TID

After 5 days of treatment, the vesicles After 5 days of treatment, the vesicles decreased and decreased and otalgiaotalgia improved, he was improved, he was discharged.discharged.

About About herpeseherpese zoster zoster oticusoticus

•• VZV Reactivation( VZV Reactivation( geniculategeniculate ganglion)ganglion)distribution of ear sensory nerves Herpes distribution of ear sensory nerves Herpes zoster zoster oticusoticus viral infection of the inner, viral infection of the inner, middle, and external ear. middle, and external ear.

•• HZ HZ oticusoticus otalgiaotalgia and and cutaneouscutaneousvesicular eruption, usually of the external vesicular eruption, usually of the external canal and canal and pinnapinna. .

•• Facial paralysisFacial paralysis called Ramsay Hunt called Ramsay Hunt syndrome.syndrome.

DisscussionDisscussion

•• Is Acyclovir effective in treatment of Is Acyclovir effective in treatment of herpeseherpese zoster zoster oticusoticus ??-- Most obvious and suffering signs were Most obvious and suffering signs were facial palsy ( Ramsay Hunt syndrome)facial palsy ( Ramsay Hunt syndrome)-- Facial palsy Facial palsy 的的prognosis prognosis 較較BellBell’’s palsys palsy差差--期望使用期望使用acycloviracyclovir的病人可以有較佳的的病人可以有較佳的prognosisprognosis

Journal ReviewJournal Review•• PubmedPubmed: Keyword : Keyword

---- ““Ramsay Hunt syndromeRamsay Hunt syndrome”” AND acyclovir AND acyclovir ---- 30 papers 30 papers Chose 3 papers.Chose 3 papers.

•• Evidence 1:Acyclovir improves recovery rate of facial nerve Evidence 1:Acyclovir improves recovery rate of facial nerve palsy in Ramsay Hunt syndrome. palsy in Ramsay Hunt syndrome. Minoru Minoru KinishiKinishi …… AurisAuris NasusNasusLarynx 28 (2001) 223Larynx 28 (2001) 223––226226

•• Evidence 2: Evidence 2: Herpes zoster oticus treated with acyclovir and prednisolene: clinicalmanifestations and analysis of prognostic factors. J.Y. KO, T.S. SHEEN , M.M. HSU Clinl. Otolaryngol. (2000,25, 139-142)

•• Evidence 3:Acyclovir in the treatment of Ramsay Hunt Evidence 3:Acyclovir in the treatment of Ramsay Hunt syndrome.syndrome.Uri N, Greenberg Uri N, Greenberg OtolaryngolOtolaryngol Head Neck Head Neck SurgSurg. 2003 . 2003 Oct;129(4):379Oct;129(4):379--8181..

EvidenceEvidence 11

•• Acyclovir improves recovery rate of facial Acyclovir improves recovery rate of facial nerve palsy in Ramsay Hunt syndromenerve palsy in Ramsay Hunt syndromeAurisAuris NasusNasus Larynx 28 (2001) 223Larynx 28 (2001) 223––226226Minoru Minoru KinishiKinishi *, *, MutsuoMutsuo AmatsuAmatsu, Mitsuhiro , Mitsuhiro MohriMohri, Miki Saito,, Miki Saito,ToshifumiToshifumi Hasegawa, Shingo HasegawaHasegawa, Shingo Hasegawa

---- Individual case control study Individual case control study Evidence level: 3bEvidence level: 3b

MethodMethod

•• 138 patients with Ramsay Hunt syndrome 138 patients with Ramsay Hunt syndrome who were treated between 1992 and 1999 who were treated between 1992 and 1999 at Kobe University Hospital. ( Vesicles + at Kobe University Hospital. ( Vesicles + facial palsy)facial palsy)

•• 91 were treated with Acyclovir + 91 were treated with Acyclovir + Steroid Steroid 47 were treated with steroid alone 47 were treated with steroid alone ( delay of eruption of vesicles)( delay of eruption of vesicles)

MethodMethod

•• Nerve excitability testing (NET) 14th dayNerve excitability testing (NET) 14th day3 groups: 3 groups: 刺激兩邊神經刺激兩邊神經Good: Good: 兩邊剌激閾值相差小於或等於兩邊剌激閾值相差小於或等於3.5mA3.5mAPoor:Poor:兩邊剌激閾值相差大於兩邊剌激閾值相差大於3.5mA3.5mAAbsent:Absent:患部對最大刺激仍無反應患部對最大刺激仍無反應

•• Facial voluntary movement was evaluated Facial voluntary movement was evaluated with the Housewith the House--BrackmannBrackmann grading grading systemsystem

(75%)

(53%)

P

(90%)(64%)

P

ConclusionConclusion

•• Acyclovir + Steroid therapy is an Acyclovir + Steroid therapy is an advisable treatment modality to improve advisable treatment modality to improve the recovery rate of facial nerve function the recovery rate of facial nerve function in Ramsay Hunt syndromein Ramsay Hunt syndrome

Evidence 2Evidence 2

• Herpes zoster oticus treated with acyclovir and prednisolone: clinical manifestations and analysis of prognostic factorsClinl. Otolaryngol. (2000,25, 139-142)J.Y. KO, T.S. SHEEN , M.M. HSU

--Retrospective cohort study--Evidence level: 2b

Method and materialMethod and material

• Retrospectively 1991.1 ~ 1996.6• 45 Patients suffering from herpes zoster

oticus treated with acyclovir and prednisolone (20 men and 25 women)

• 24 R’t, 21 L’t• Evaluated the prognostic factors for

recovery of facial palsy

Electroneuroneography (ENoG)

Evidence 3Evidence 3

•• Acyclovir in the treatment of Ramsay Acyclovir in the treatment of Ramsay Hunt syndrome. Hunt syndrome. OtolaryngolOtolaryngol Head Neck Head Neck SurgSurg2003;129:3792003;129:379--8181NECHAMA URI, MD, ELHANAN GREENBERG, MD, RUTH KITZESNECHAMA URI, MD, ELHANAN GREENBERG, MD, RUTH KITZES--COHEN, MD, COHEN, MD, and and ILANA DOWECK, MD, ILANA DOWECK, MD, Haifa, IsraelHaifa, Israel

---- CaseCase--seriesseries---- Evidence level: 4Evidence level: 4

MATERIALS AND METHODSMATERIALS AND METHODS

•• 1987 to 1997, 31 patients (12 males and 1987 to 1997, 31 patients (12 males and 19 females) with 19 females) with RHS:CarmelRHS:Carmel Medical Medical Center (HBGS: IVCenter (HBGS: IV--VI)VI)

•• First week of illness: First week of illness: IV acyclovir 5 mg/kg every 8 hours for 7 IV acyclovir 5 mg/kg every 8 hours for 7 days and hydrocortisone 100 mg 3 times days and hydrocortisone 100 mg 3 times per day. treatment began : 1 to 7 days, per day. treatment began : 1 to 7 days, median of 3 days.median of 3 days.

•• F/U HBGS( Ad, 1W,3M, 1Y): good: I or II.F/U HBGS( Ad, 1W,3M, 1Y): good: I or II.

ResultResult

•• Age or gender:no significant difference in Age or gender:no significant difference in recovery rate recovery rate

•• Auditory symptoms : patients with no Auditory symptoms : patients with no auditory symptoms improved better than auditory symptoms improved better than did those with symptoms (did those with symptoms (P=P=0.05)0.05)

•• Vestibular symptoms : no vestibular Vestibular symptoms : no vestibular symptoms improved better (symptoms improved better (P P =0.029)=0.029)

Facial function degree: after acyclovirFacial function degree: after acyclovir P

TableTable--22

結論結論

•• 用用acycloviracyclovir來治療在產生來治療在產生Ramsay Hunt Ramsay Hunt syndromesyndrome的的HerpeseHerpese zoster zoster oticusoticus病人有証病人有証據支持有效據支持有效, , 可以改善可以改善facial nerve palsyfacial nerve palsy的的預後。預後。

•• HerpeseHerpese zoster zoster oticusoticus的病人用的病人用acyclovir + acyclovir + steroidsteroid的治療成效也會因一開始神經退化的治療成效也會因一開始神經退化的程度，性別，年紀等有所不同。的程度，性別，年紀等有所不同。

Acyclovir in Treatment of Herpese Zoster OticusPatient profileBrief historyPhysical examinationENT local findingsLab dataAssessmentManagementAbout herpese zoster oticusDisscussionJournal ReviewEvidence 1MethodMethodConclusionEvidence 2Method and materialEvidence 3MATERIALS AND METHODSResultTable 1Table-2結論