Cranial polyneuropathy caused by herpes zoster infection: a retrospective single-center analysis

Clinical Characteristics and Prognosis of Herpes Zoster Laryngitis With Vocal Fold Immobility

OBJECTIVE

To investigate the clinical characteristics and prognosis of herpes zoster laryngitis with vocal fold immobility.

STUDY DESIGN

Retrospective study.

METHODS

Clinical characteristics, laryngeal signs on strobolaryngoscopy, imaging examination findings, and outcomes of patients were analyzed retrospectively.

RESULTS

This study included 17 patients (11 males [64.7%] and six females [35.3%]), with a mean age of 63.3 ± 6.7 years. The primary symptoms were hoarseness (94.1%), dysphagia (76.5%), pharyngalgia on one side (76.5%), and aspiration (70.6%). No patient had skin herpes of the head and neck. The duration of symptoms was 5-30 days (median: 10 days). Twelve patients (70.6%) were in an immunocompromised state before the disease. Strobolaryngoscopy showed congestion and swelling of the mucosa on one side of the larynx, with whitish eruptions on the supraglottic mucosa and ipsilateral vocal fold immobility. Five patients (29.4%) exhibited signs of ipsilateral accessory nerve injury. The imaging examination showed supraglottic inflammatory changes in 12 patients (70.6%). Among the 14 patients whose treatment could be clearly described, only one patient received antiviral treatment, whereas others received neurotrophic and symptomatic treatment. Notably, all patients demonstrated good outcomes because their symptoms eventually returned to normal.

CONCLUSION

Herpes zoster laryngitis is caused by varicella-zoster virus infection of the vagus nerve. It is characterized by laryngeal herpetic changes on one side and unilateral vocal fold immobility. The inducement of the disease tends to be associated with the abnormal immune state of patients. It can be easily misdiagnosed because of the absence of skin herpetic changes. Regardless of antiviral therapy, patients generally exhibit a favorable outcome.

Zoster Polyneuritis Cranialis and Intracranial Vasculopathy

A case report of varicella zoster virus (VZV) producing cranial polyneuropathy with intracranial vasculopathy afflicting the internal carotid artery, in a 45-year lady is presented. The clinical features included appearance of zosteriform rash in the left external auditory canal and concha, affliction of ophthalmic and maxillary divisions of V, VI, VII, VIII, IX and X cranial nerves. Contrast MRI brain demonstrated attenuated flow void in the left internal carotid artery. The diagnosis was confirmed with raised level of IgG VZV antibody in serum and detection of VZV IgG antibody in CSF, although PCR for VZV DNA in CSF was negative. The significance lies in atypical presentation, the diagnostic dilemma it poses, poor prognosis of cranial nerve function and the need for multidisciplinary approach to patient management and rehabilitation.

Bell's Palsy and Its Semantic Change over Time

BACKGROUND

From 1821 to 1829, Sir Charles Bell presented cases of facial paralysis from infection, trauma, and unknown causes. As such, "Bell's palsy" initially referred to facial palsy of any etiology. Today, the term is reserved for idiopathic peripheral facial palsy. The objectives of this analysis were to establish when the eponym came to vogue and delineate the semantic shift from its original definition to its current one.

METHODS

Extensive review of available 19th and 20th century literature mentioning "Bell's palsy" and "Bell's paralysis."

RESULTS

Historical accounts have eponymously attached Bell's name to facial paralysis as early as the 1840s-Bell's palsy was first used to describe cases of facial palsy of any cause. In 1886, Gowers characterized Bell's palsy as a "neuritis usually within the Fallopian Canal," distinguishing it as a separate etiology. Over the next decades, the definition narrowed to peripheral facial paralysis from cold exposure or unknown causes. By the 1940s, its natural history was well described-an acute, unilateral, idiopathic, and usually self-limited peripheral facial palsy.

CONCLUSION

The semantic change of a word over time can tell us a remarkable story of its history and origins. Absence of a discrete lesion, lack of proven treatment, and good prognosis without intervention distinguished Bell's palsy from other causes of facial paralysis. Over time, the definition has narrowed from a facial palsy of any cause to an idiopathic peripheral facial palsy. Recent evidence supporting Bell's palsy as a viral mononeuritis may have driven its recent semantic change toward this specific etiology.

Ramsay Hunt Syndrome With Cranial Polyneuropathy and Delayed Facial Nerve Palsy: A Case Report

Herpes zoster oticus is a viral disease caused by the reactivation of the varicella-zoster virus at the geniculate ganglion. The hallmark of the condition is multiple unilateral erythematous vesicles, which are distributed over the auricle and preceded by severe otalgia. If these symptoms are associated with facial nerve palsy, the condition is called Ramsay Hunt syndrome (RHS) which is usually accompanied by vestibulocochlear abnormalities. A 42-year-old woman came to our clinic with sudden onset of right-sided severe otalgia and several erythematous vesicles on the auricle two days ago. She provided a history of dysphagia and hoarseness for 10 days. After two days, ipsilateral facial nerve paralysis was noted. The patient was immunocompetent with an unremarkable medical history. Physical examination revealed the following: the vesicles distributed over the right auricle, external auditory canal, and eardrum; right sensorineural deafness; deviated uvula to the left side; absent gag reflex on the right side; right vocal cord palsy; and lower motor facial nerve paralysis of House-Brackmann grade III. The pure tone audiogram confirmed the diagnosis of right-sided sensorineural deafness. Acyclovir therapy and prednisolone tablets at a loading dose were initiated. At the four-month follow-up, the presenting manifestations were improved. Here, we report a case of RHS with early glossopharyngeal and vagus nerve palsy, followed by pain, vesicular eruptions, sensorineural hearing loss, and delayed onset of facial nerve paralysis. The condition resolved completely on medical treatment with acyclovir and prednisolone.

A case report of refractory otalgia after Ramsay Hunt syndrome successfully treated by applying pulsed radiofrequency to the great auricular nerve: A CARE-compliant article

RATIONALE

Ramsay Hunt syndrome is a type of herpes zoster infection involving geniculate ganglion and facial nerve. Unilateral facial palsy, otalgia, and painful vesicular rash on the auricle and external auditory canal are the typical symptoms. Although postherpetic neuralgia (PHN) is a devastating complication of herpes zoster infection, PHN following Ramsay Hunt syndrome has rarely been reported.

PATIENT CONCERNS

A 55-year-old immunocompetent female patient visited our pain clinic, for left-sided refractory otalgia (PHN) that persisted for 3 months after she was diagnosed with Ramsay Hunt syndrome. Although facial palsy and tinnitus had recovered within 2 to 4 weeks after symptom onset, the patient had been experiencing a persistent and severe otalgia radiating to mandibular angle, temporal and upper cervical area of neuropathic nature.

DIAGNOSES

The patient's pain persisted despite conservative medication and administration of ultrasound-guided stellate ganglion block, facial nerve block, and great auricular nerve block several times.

INTERVENTIONS

The patient was treated with the application of ultrasound-guided pulsed radiofrequency (PRF) to the great auricular nerve.

OUTCOMES

The patient experienced significant pain reduction more than 50% on a numeric rating scale after 2 weeks of PRF treatment.

LESSONS

Chronic otalgia might be a type of PHN after Ramsay Hunt syndrome with cervical nerve involvement. PRF treatment to the great auricular nerve can be a therapeutic option for refractory otalgia following Ramsay Hunt syndrome.