Herpes Zoster Oticus – Ramsay Hunt Syndrome

What is Herpes Zoster Oticus?

Herpes zoster involving the facial nerve and the dermatomes around the ear, it is known as Herpes Zoster oticus or the Ramsay Hunt Syndrome.

What is Herpes Zoster or Shingles?

Herpes zoster is also known as shingles, it is a reactivation of the same virus that causes chickenpox in childhood. It is caused by Varicella zoster. Varicella virus can remain dormant in the nerves for decades after chickenpox, and when the immunity weakens years later, it reactivates to cause herpes zoster. It can be understood as the second manifestation of the same primary viral infection. 

Signs and Symptoms of Herpes Zoster Oticus

It’s natural history can be divided into three phases, each phase is associated with slightly different signs and symptoms:

  1. Pre-eruptive phase
    1. Pain in a single or more dermatome is the most common feature, it can last ~ 1-10 days, average duration is 48 hours
    2. Can be experienced as itching or paraesthesia (crawling or pins and needle like sensation)
    3. Malaise and fever may be experienced
    4. When ear is involved, ear itching can be a symptom
Herpes zoster oticus, facial palsy and vesicles
 
https://en.wikipedia.org/wiki/Ramsay_Hunt_syndrome_type_2#/media/File:Ramsey_Hunt_Syndrome.png
Herpes zoster oticus – Ramsay Hunt Syndrome (image source: wikepedia)
  1. Acute eruptive phase – resolves in 10-15 days
    1. Redness with or without swelling limited to the dermatomes involved
    2. Herpetiform vesicles involving periauricular region, upto angle of mouth
    3. Otalgia – ear pain
    4. Facial palsy
    5. Dysarthria
    6. Headache
    7. Burning pain near the collar area
    8. Vertigo, tinnitus and hearing loss
    9. A few patients may experience the symptoms without the rashes – ‘zoster sine herpete’
  2. Chronic phase – Post herpetic neuralgia
    1. Seen in 20% of patients. 
    2. Persistent or recurrent pain lasting a month or more after all the vesicles have crusted. It is limited to the dermatome involved.
    3. Can persist for weeks to months, in few cases even years.

Diagnosis of herpes zoster oticus

It is primarily a clinical diagnosis, based on history and examination findings. Any blood tests if indicated are to rule out causes of immunosuppression, and to manage complications.

Treatment

Oral antiviral Acyclovir along with oral corticosteroids are the mainstay of the treatment. Early start of treatment has a better prognosis of complete recovery of the facial nerve. In immunocompromised adults and the elderly patients  prognosis regarding facial nerve recovery is poor, full recovery seen in almost ~ 50%. Prognosis of herpes zoster oticus is much worse than Bell’s Palsy.

Superinfection of the vesicles can be treated with topical antibiotic ointment, rarely needing oral antibiotic therapy. 

In uncomplicated cases pain can be managed with NSAIDS. Tricyclic antidepressants and anticonvulsants can be prescribed for severe neuralgia.

For post herpetic neuralgia preferred treatment is tricyclic antidepressants, anticonvulsants or opioid or non-opioid analgesics. Topical application of local anaesthetic such as lidocaine 5% is very effective in controlling the pain.

Complications

Complications of herpes zoster include the following:

  • Immunosuppression
  • Myelitis
  • Involvement of more than 2 dermatomes
  • Severe bacterial superinfection
  • Meningoencephalitis
  • Hearing loss and vertigo

All complicated cases should be managed as an inpatient in the hospital. Multidisciplinary approach is needed for treating these cases. Prognosis is poor in complicated & immunocompromised patients.

Role of vaccines in prevention

Zostavax and Shingrix are two types of vaccines that are available to reduce the incidence of herpes zoster in susceptible individuals.

For treatment of recent onset facial nerve paralysis it’s important to visit ENT doctor at the earliest. Early treatment has better prognosis of recovery as compared with late interventions.

This article was written by Dr Akanksha Saxena, Consultant ENT, Head & Neck Surgeon, ENT360. She is a practising ENT Specialist in Gurgaon with over 10 years of experience. Read more of her blogs here.