eMedicine Specialties > Emergency Medicine > Infectious Diseases

Herpes Zoster Oticus

Author: Christina Bloem, MD, Assistant Clinical Professor of Emergency Medicine, George Washington University
Coauthor(s): Christopher I Doty, MD, FACEP, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center; Jon Mark Hirshon, MD, MPH, Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine
Contributor Information and Disclosures

Updated: Nov 4, 2008

Introduction

Background

Herpes zoster oticus (HZ oticus) is a viral infection of the inner, middle, and external ear. HZ oticus manifests as severe otalgia and associated cutaneous vesicular eruption, usually of the external canal and pinna. When associated with facial paralysis, the infection is called Ramsay Hunt syndrome.

Pathophysiology

Reactivation of the varicella-zoster virus (VZV) along the distribution of the sensory nerves innervating the ear, which usually includes the geniculate ganglion, is responsible for HZ oticus. Associated symptoms such as hearing loss and vertigo are thought to occur as a result of transmission of the virus via direct proximity of cranial nerve (CN) VIII to CN VII at the cerebellopontine angle or via vasa vasorum that travel from CN VII to other nearby cranial nerves.

Frequency

United States

Ramsey Hunt syndrome accounts for up to 12% of all facial paralyses.

Mortality/Morbidity

Ramsay Hunt syndrome generally causes more severe symptoms and has a worse prognosis than Bell palsy.

  • Return-to-baseline neurologic function is predicted partially by severity of paralysis.
  • In several studies, only 10-22% of individuals with significant facial paralysis had complete recovery. In one study, however, 66% of patients with incomplete paralysis had complete recovery.
  • An additional complication of herpes zoster viral infection is postherpetic neuralgia.

Sex

Incidence in males and females is equal.

Age

Incidence of HZ oticus increases significantly in patients older than 60 years.

Clinical

History

  • Typically, patients present with severe otalgia. Complaints include the following:
    • Painful, burning blisters in and around the ear, on the face, in the mouth, and/or on the tongue.
    • Vertigo, nausea, vomiting
    • Hearing loss, hyperacusis, tinnitus
    • Eye pain, lacrimation
  • Onset of pain may precede the rash by several hours or days. Also, in patients with Ramsay Hunt syndrome, vesicles may appear before, during, or after facial palsy (zoster sine herpete).
  • When asked, patients may recall a distant history, perhaps in childhood, of chickenpox (varicella).
  • A minority of patients (<10%) give a history of previous herpes zoster viral infection.

Physical

  • Physical examination shows a vesicular exanthem, usually of the external auditory canal, concha, and pinna.
  • The rash also may appear on postauricular skin, lateral nasal wall, soft palate, and anterolateral tongue.
  • Vertigo and sensorineural hearing loss may be noted.
  • Paralysis of the facial nerve, mimicking Bell palsy, may be present.
  • Complete loss of the ability to wrinkle the ipsilateral brow distinguishes a peripheral lesion of cranial nerve VII from a central lesion of the same nerve, which spares the forehead.
  • Associated findings
    • Dysgeusia (alteration in taste)
    • Inability to fully close the ipsilateral eye, which may lead to the occasional presentation of drying and irritation of the cornea.

Causes

Herpes zoster oticus is caused by the reactivation of latent VZV, which has remained dormant within sensory ganglia (commonly the geniculate ganglion) of the facial nerve.

  • Individuals with decreased cell-mediated immunity resulting from carcinoma, radiation therapy, chemotherapy, or HIV infection are at greater risk for reactivation of latent VZV.
  • Physical and emotional stress often are cited as precipitating factors.

More on Herpes Zoster Oticus

Overview: Herpes Zoster Oticus
Differential Diagnoses & Workup: Herpes Zoster Oticus
Treatment & Medication: Herpes Zoster Oticus
Follow-up: Herpes Zoster Oticus
References
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References

  1. Furuta Y, Ohtani F, Mesuda Y. Early diagnosis of zoster sine herpete and antiviral therapy for the treatment of facial palsy. Neurology. Sep 12 2000;55(5):708-10. [Medline].

  2. Murakami S, Honda N, Mizobuchi M. Rapid diagnosis of varicella zoster virus infection in acute facial palsy. Neurology. Oct 1998;51(4):1202-5. [Medline].

  3. Whitley RJ, Weiss H, Gnann JW. Acyclovir with and without prednisone for the treatment of herpes zoster. A randomized, placebo-controlled trial. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. Ann Intern Med. Sep 1 1996;125(5):376-83. [Medline].

  4. Wood MJ, Johnson RW, McKendrick MW, Taylor J, Mandal BK, Crooks J. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med. Mar 31 1994;330(13):896-900. [Medline].

  5. Uscategui T, Doree C, Chamberlain IJ, Burton MJ. Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database Syst Rev. Jul 16 2008;CD006852. [Medline].

  6. Benson CA, Kaplan JE, Masur H. Treating opportunistic infections among HIV-exposed and infected children: recommendations from CDC, the National Institutes of Health, and the Infectious Diseases Society of America. MMWR Recomm Rep. Dec 17 2004;53(RR-15):1-112. [Medline].

  7. Pavan-Langston D. Herpes zoster antivirals and pain management. Ophthalmology. Feb 2008;115(2 Suppl):S13-20. [Medline].

  8. Harpaz R, Ortega-Sanchez IR, Seward JF. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Jun 6 2008;57:1-30; quiz CE2-4. [Medline].

  9. Adour KK. Otological complications of herpes zoster. Ann Neurol. 1994;35 Suppl:S62-4. [Medline].

  10. Bauer CA, Coker NJ. Update on facial nerve disorders. Otolaryngol Clin North Am. Jun 1996;29(3):445-54. [Medline].

  11. Murakami S, Hato N, Horiuchi J. Treatment of Ramsay Hunt syndrome with acyclovir-prednisone: significance of early diagnosis and treatment. Ann Neurol. Mar 1997;41(3):353-7. [Medline].

  12. Sweeney CJ, Gilden DH. Ramsay Hunt syndrome. J Neurol Neurosurg Psychiatry. Aug 2001;71(2):149-54. [Medline].

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Further Reading

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Keywords

herpes zoster oticus, HZ oticus, viral infection of the ear, Ramsay Hunt syndrome, facial paralysis, varicella-zoster virus, VZV, reactivation of varicella-zoster virus, reactivation of VZV, postherpetic neuralgia, otalgia, hearing loss, vertigo

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Contributor Information and Disclosures

Author

Christina Bloem, MD, Assistant Clinical Professor of Emergency Medicine, George Washington University
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FACEP, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Christopher I Doty, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Jon Mark Hirshon, MD, MPH, Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine
Jon Mark Hirshon, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robin R Hemphill, MD, MPH, Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University
Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Weiss, MD, DTM&H, Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine
Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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