Herpes Zoster Oticus

Herpes zoster oticus (Ramsay Hunt syndrome) is reactivation of varicella zoster virus in the geniculate ganglion of the facial nerve, causing ear pain, vesicles in the ear and ipsilateral facial paralysis. It accounts for about 10 to 15 percent of acute facial palsies.

• More common over 60 years, with immunosuppression, HIV and malignancy.
• Prognosis for full facial recovery is worse than in Bell palsy.

Severe otalgia, then vesicles on the pinna, external auditory canal, tympanic membrane, soft palate or tongue, with ipsilateral lower motor neurone facial palsy.

• Vestibulocochlear involvement: vertigo, tinnitus, sensorineural hearing loss, nystagmus; occasionally other cranial nerves (V, IX, X) are affected.
• Pain may precede the rash and facial palsy by days.
• Differential diagnosis: Bell palsy, otitis externa (including malignant), otitis media, cholesteatoma, herpes simplex, stroke, parotid tumour, skull base tumour, Lyme disease, HIV related facial palsy, sarcoidosis.
• Complications: permanent facial weakness, synkinesis, hearing loss, chronic vertigo, post herpetic neuralgia, corneal exposure injury, meningoencephalitis, zoster in other dermatomes.

Clinical diagnosis; confirmatory PCR.

• PCR of vesicle swab or saliva for varicella zoster virus; serology (IgM, rising IgG).
• Audiometry, vestibular testing, MRI with gadolinium of the internal auditory canal for atypical or non improving cases.
• HIV test, glucose, full blood count; lumbar puncture if meningism.

Antiviral plus corticosteroid, started early (within 72 hours).

• Supportive: eye protection (lubricating drops hourly while awake, ointment and eye patch or taping at night), analgesia, antiemetics and vestibular suppressants for vertigo, facial exercises, reassurance.
• Pharmacological: valaciclovir 1 g three times daily for 7 days, or aciclovir 800 mg five times daily for 7 to 10 days, or famciclovir 500 mg three times daily for 7 days; prednisolone 1 mg/kg daily (usual 60 mg) for 5 to 7 days then taper over 7 to 14 days. Severe or immunocompromised: aciclovir 10 mg/kg IV every 8 hours for 7 to 10 days. Paracetamol 1 g four times daily; for neuropathic pain add gabapentin 300 mg at night titrated to 900 to 1800 mg daily; prochlorperazine 5 mg three times daily or cinnarizine 15 mg three times daily for vertigo (3 days).
• Procedures: tarsorrhaphy or lid weight for persistent exposure; facial reanimation surgery for permanent palsy.
• Special groups: pregnancy, aciclovir and prednisolone are acceptable at these doses; diabetes, monitor glucose on steroids; renal impairment, adjust antiviral dose; HIV, give IV aciclovir and review antiretroviral therapy; children, weight based aciclovir.
• Red flags: eye pain or redness, bilateral palsy, severe headache or confusion, rapidly worsening hearing, immunosuppression, no recovery by 3 weeks.
• Follow-up: review at 1 week and every 2 to 4 weeks; audiology at baseline and 3 months; ophthalmology for eye symptoms; surgery referral if no recovery at 6 to 12 months.