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Lorenzini G, Cucchiara F, Pennati P. An unusual case of facial palsy in an immunocompetent adult woman. Intern Emerg Med 2023; 18:2333-2337. [PMID: 37148408 DOI: 10.1007/s11739-023-03295-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/24/2023] [Indexed: 05/08/2023]
Affiliation(s)
- Gianni Lorenzini
- Department of Emergency Medicine, Bassa Val Di Cecina Hospital, Via Montanara 52B, 57023, Cecina, LI, Italy
| | - Federico Cucchiara
- Department of Emergency Medicine, Bassa Val Di Cecina Hospital, Via Montanara 52B, 57023, Cecina, LI, Italy
| | - Paolo Pennati
- Department of Emergency Medicine, Bassa Val Di Cecina Hospital, Via Montanara 52B, 57023, Cecina, LI, Italy.
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Yoon SH, Shetty-Das R. Zoster Sine Herpete: Confirmatory Diagnosis Using Varicella-Zoster Virus DNA Polymerase Chain Reaction Analysis of Intact Skin Scrapings. Cureus 2023; 15:e41965. [PMID: 37588338 PMCID: PMC10427140 DOI: 10.7759/cureus.41965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2023] [Indexed: 08/18/2023] Open
Abstract
Zoster, commonly known as shingles, is a syndrome caused by the reactivation of the varicella-zoster virus (VZV) that results in characteristic vesicular eruptions in a unilateral dermatomal distribution. Timely diagnosis of zoster sine herpete (ZSH), a variant of shingles without the typical vesicular rash, can be challenging due to the absence of visual cues and limited application of traditional diagnostic methods. Recent case reports have demonstrated the utility of VZV DNA polymerase chain reaction (PCR) analysis of involved skin exudates for confirming ZSH. This report presents a case of acute ZSH involving the left trigeminal nerve, where the diagnosis was confirmed using VZV DNA PCR analysis of skin scrapings. The patient initially presented with radicular pain and was treated for presumed shingles, but persistent neuropathic pain persisted. The confirmatory VZV DNA PCR analysis of the involved skin scraping sample aided in establishing the diagnosis of ZSH. The case highlights the potential of using intact skin scrapings for VZV DNA PCR in confirming ZSH. Prompt initiation of antiviral therapy is crucial for minimizing the duration and severity of radicular pain in ZSH cases. Larger studies are needed to further evaluate the utility of VZV DNA PCR analysis for accurately diagnosing ZSH.
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Affiliation(s)
- Sean Ho Yoon
- Internal Medicine, NewYork-Presbyterian Queens, New York, USA
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Muacevic A, Adler JR. Ramsay Hunt Syndrome: An Introduction, Signs and Symptoms, and Treatment. Cureus 2023; 15:e33688. [PMID: 36793818 PMCID: PMC9925029 DOI: 10.7759/cureus.33688] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
Ramsay Hunt syndrome is the complication of the virus varicella-zoster and the infection caused by it, which shows apparent geniculate ganglion involvement. This article discusses the etiology, epidemiology, and pathology of Ramsay Hunt syndrome. Clinically it may be presented as a vesicular rash on the ear or even in the mouth, pain in the ear, and facial paralysis. Some other rare symptoms may also be present, which are also discussed in this article. Skin involvement is also seen in some cases as patterns due to anastomoses between cervical and cranial nerves. This article provides an overview of how the varicella-zoster virus causes facial paralysis and other neurological symptoms. Knowing about this condition and its clinical features is essential to make an early diagnosis and, thus, provide a good prognosis. A good prognosis is required to reduce the nerve damage, prevent further complications, and start an early therapy of acyclovir and corticosteroid. This review also presents a clinical picture of the disease and its complications. The incidence of Ramsay Hunt syndrome has gradually decreased over time because of the development of the varicella-zoster vaccine and better health facilities. The paper also talks about how the diagnosis of Ramsay Hunt syndrome is made and the various treatment options available. Facial paralysis in Ramsay Hunt syndrome presents differently than Bell's Palsy. If not treated for too long, it may cause permanent muscle weakness and may also cause a loss of hearing. It may be confused with simple herpes simplex virus outbreaks or contact dermatitis.
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Inagaki A, Takahashi M, Murakami S. Frequency-dependent hearing outcomes with or without preservation of intact ossicular articulations. Laryngoscope Investig Otolaryngol 2022; 8:185-191. [PMID: 36846434 PMCID: PMC9948566 DOI: 10.1002/lio2.1001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 11/27/2022] [Accepted: 12/15/2022] [Indexed: 12/28/2022] Open
Abstract
Objective To determine the frequency-specific benefits of ossicular chain preservation compared to performing disarticulations and reconstructions in transmastoid facial nerve decompression surgery in patients with an intact ossicular chain. Methods A retrospective chart review (January 2007 and June 2018) of patients undergoing transmastoid facial nerve decompression on the intact middle ear for severe facial palsy at a tertiary referral center. Surgery was performed with ossicular chain disarticulation on an as-needed basis using either ossicular chain preservation (without ossicular disarticulation), incudostapedial separation, or incus disarticulation technique. Hearing outcomes were assessed. Results The 108 patients were included in this study. Among these, 89 patients underwent ossicular chain preservation, 5 underwent incudostapedial separation and 14 underwent incus repositioning. The proportion of patients with a change in the 4-frequency air conduction pure-tone average of less than 10 dB was 91%, 60%, and 50%, respectively, for the three surgical techniques; these were significantly different (Fisher's exact test, p < .001). Frequency-specific analysis showed that air conduction was significantly better following the ossicular chain preservation technique compared with the incus repositioning technique at stimulation frequencies lower than 250 Hz and higher than 2000 Hz, and compared with the incudostapedial separation technique at 4000 Hz. Analysis of biometric measures determined on CT images suggested that the feasibility of the ossicular chain preservation technique correlates with incus body thickness on coronal CT images. Conclusions Ossicular chain preservation is an effective approach for hearing preservation in transmastoid facial nerve decompression or similar surgical procedures.
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Affiliation(s)
- Akira Inagaki
- Toyohashi Day‐Surgery ClinicToyohashiJapan,Department of Otolaryngology, Head and Neck SurgeryNagoya City University Graduate School of Medical SciencesNagoyaJapan
| | - Mariko Takahashi
- Department of Otolaryngology, Head and Neck SurgeryAichi Gakuin University School of DentistryNagoyaJapan
| | - Shingo Murakami
- Department of Otolaryngology, Head and Neck SurgeryNagoya City University East Medical CenterNagoyaJapan
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Corti M, Villafañe MF, Correa J. Ramsay-Hunt syndrome: Report of two cases with identification of the varicella zoster virus genome in cerebrospinal fluid. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2021; 41:625-630. [PMID: 34936248 PMCID: PMC8717913 DOI: 10.7705/biomedica.5985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 07/15/2021] [Indexed: 11/26/2022]
Abstract
Like other alpha-herpesviruses, the varicella-zoster virus (VZV) remains latent in the neural ganglia following the primary varicella infection. The reactivation of the VZV in the dorsal root ganglia results in herpes zoster. Herpes zoster eruption is characterized by localized cutaneous lesions and neuralgic pain mostly in older and immunocompromised persons, especially those living with the human immunodeficiency virus (HIV). The most commonly reported complications include VZV pneumonia, meningitis, encephalitis, and hepatitis. Several neurologic syndromes have been described associated with herpes zoster localized in cranial areas including peripheral nerve palsies and the Ramsay-Hunt syndrome, which has a varied clinical presentation and is the second most common cause of peripheral facial paralysis. Facial paralysis in this syndrome occurs in 60 to 90% of cases and it may precede or appear after the cutaneous lesions with a worse prognosis than idiopathic Bell paralysis. Here we present two cases of herpes zoster from the geniculate ganglia with peripheral facial paralysis that appeared simultaneously with vesicular herpetic otic lesions (multimetameric Ramsay-Hunt syndrome). In the two cases, amplifiable varicella-zoster viral DNA was found in the cerebrospinal fluid by RT-PCR Multiplex.
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Affiliation(s)
- Marcelo Corti
- Departamento de Medicina, Orientación Enfermedades Infecciosas, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina; División VIH-Sida, Hospital de Infecciosas "Francisco Javier Muñiz", Buenos Aires, Argentina.
| | - María F Villafañe
- Departamento de Medicina, Orientación Enfermedades Infecciosas, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina; División VIH-Sida, Hospital de Infecciosas "Francisco Javier Muñiz", Buenos Aires, Argentina.
| | - Jorge Correa
- Departamento de Medicina, Orientación Enfermedades Infecciosas, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina; División VIH-Sida, Hospital de Infecciosas "Francisco Javier Muñiz", Buenos Aires, Argentina.
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Ishiyama G. Selected Otologic Disorders Causing Dizziness. ACTA ACUST UNITED AC 2021; 27:468-490. [PMID: 34351115 DOI: 10.1212/con.0000000000000977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article details updated clinical presentations and current treatment paradigms of the common otologic disorders that may present to the neurologist for vertigo, including Ménière disease, superior semicircular canal dehiscence syndrome, perilymphatic fistula, barotrauma, cholesteatoma, Ramsay Hunt syndrome, enlarged vestibular aqueduct syndrome, and autoimmune inner ear disease including Cogan syndrome. RECENT FINDINGS The recent data on modern imaging techniques with three-dimensional delayed IV contrast in Ménière disease, findings on the clinical and testing parameters to diagnose semicircular canal dehiscence and barotrauma, and clinical findings in Ramsay Hunt syndrome, cholesteatoma, and enlarged vestibular aqueduct syndrome are discussed in the article. The most recent findings on the treatment and evaluation of autoimmune inner ear disease and Cogan syndrome are also covered. SUMMARY This article discusses the common clinical otologic entities in patients who may present to the neurologist for vertigo, and it can be used as a guide in the diagnosis of these conditions with the use of auditory, vestibular, and imaging results.
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Abstract
Ramsay Hunt syndrome is a complication of varicella-zoster virus infection, which manifests by geniculate ganglion involvement. Clinical presentation of Ramsay Hunt syndrome includes virus affecting external ear by vesicular rash on the ear, ear pain and peripheral facial nerve paralysis. The review presents an analysis of etiology, clinical picture and diagnosis of the disease. The clinical features of combined cranial nerve involvement, contemporary treatment and prophylaxis options are described. Early diagnosis and medical therapy is a crucial factor for positive prognosis to improve damaged nerves in Ramsay Hunt syndrome.
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Affiliation(s)
- A L Guseva
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M V Zamergrad
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - O S Levin
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
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Pupić-Bakrač J, Pupić-Bakrač A, Terkeš V, Baraka I. Cranial polyneuropathy caused by herpes zoster infection: a retrospective single-center analysis. Eur Arch Otorhinolaryngol 2020; 278:517-523. [PMID: 32776261 DOI: 10.1007/s00405-020-06279-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/06/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Cranial polyneuropathy (CP) is a rare complication of herpes zoster (HZ) infection. This entity often produces situations of a diagnostic dilemma, as can be seen in a wide spectrum of clinical presentations. The aim of this study was to report the clinical characteristics, treatment, and outcomes of 11 patients from a single-institution experience. METHODS A retrospective analysis of patients treated for HZ CP over a 12-year period was performed. RESULTS The present study included 11 patients with CP caused by HZ infection-7 (63.63%) females, and 4 (36.36%) males. The mean age at presentation was 63 years (range, 38-85 years). Cranial nerve VII was affected in nine (81.82%) cases, CN VIII in six (54.55%) cases, CN V in five (45.45%) cases, CN III and IX in two (18.18%) cases, and CN VI and X in one (9.09%) case. The treatment of choice was acyclovir in all patients, while corticosteroids were administered in six (54.55%) patients. Complete CN recovery was observed in seven (63.63%) patients, while four (36.36%) patients suffered from permanent CN damage-two (18.18%) CN VII, one (9.09%) CN VII and VIII, and one (9.09%) CN VI. CONCLUSION Herpes zoster CP presents an interesting diagnostic and therapeutic challenge. Successful management of these patients depends on a thorough knowledge of the anatomy and topodiagnostic of CNs. Early administration of antiviral agents is crucial in terms of responsiveness to treatment and expedite recovery.
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Affiliation(s)
- Jure Pupić-Bakrač
- Department of Otorhinolaryngology and Maxillofacial Surgery, General Hospital Zadar, Bože Peričića 5, 23 000, Zadar, Croatia.
| | - Ana Pupić-Bakrač
- Department of Ophthalmology, General Hospital Zadar, Bože Peričića 5, 23 000, Zadar, Croatia
| | - Vedrana Terkeš
- Department of Infectology, General Hospital Zadar, Bože Peričića 5, 23 000, Zadar, Croatia
| | - Ivan Baraka
- Department of Otorhinolaryngology and Maxillofacial Surgery, General Hospital Zadar, Bože Peričića 5, 23 000, Zadar, Croatia
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Concurrent Treatment With Intratympanic Dexamethasone for Moderate-Severe Through Severe Bell's Palsy. Otol Neurotol 2020; 40:e1018-e1023. [PMID: 31469789 DOI: 10.1097/mao.0000000000002377] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine whether early intervention with intratympanic steroid injection, known as concurrent intratympanic steroid therapy, is effective as a supplement to systemic steroid therapy for treating moderate-severe to severe Bell's palsy. DESIGN An open-label historical control trial. SETTING Tertiary referral center. PARTICIPANTS A total of 35 Bell's palsy patients presenting with House-Brackmann grade IV or higher were treated with intratympanic steroid therapy concurrent with standard systemic treatment and compared with 108 patients treated with standard systemic therapy alone started within 7 days of onset. INTERVENTIONS In the concurrent intratympanic steroid therapy group, patients received both 410 mg of prednisolone (standard dose) and 1.65 mg of intratympanic dexamethasone for 10 consecutive days. Patients in the control group received the standard dose, or more, of systemic prednisolone. Both groups were additionally treated with valacyclovir. MAIN OUTCOMES AND MEASURES The primary outcome measure was restoration of a House-Brackmann score of grade I. RESULTS The rate of recovery to House-Brackmann Grade I was higher for the concurrent intratympanic steroid therapy group than for the control group (94% vs 73%, p = 0.008). The adjusted odds ratio was 5.47 (95% confidence interval: 1.18-25.21, p = 0.029). CONCLUSIONS The recovery rate was higher for concurrent intratympanic steroid therapy treatment than for standard-of-care control treatment, regardless of whether steroid with lower or equivalent glucocorticoid action was administered. This result suggests that concurrent treatment with intratympanic steroid therapy is a potentially beneficial supplement to systemic steroid administration.
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Park JM, Kim SE, Yang HC. Clinical characteristics of herpes zoster laryngitis. Eur Arch Otorhinolaryngol 2020; 277:2907-2912. [PMID: 32506144 DOI: 10.1007/s00405-020-06074-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Herpes zoster laryngitis (HZL) is a recently recognized rare disease, easily mistaken for common viral laryngopharyngitis. There are only a few case reports in the English literature. No study has evaluated the clinical characteristics of HZL. In this study, we analyzed the clinical characteristics of HZL and compared them to those of Ramsay Hunt syndrome (RHS). MATERIALS AND METHODS Seventy-three patients who were initially diagnosed with HZL or RHS were enrolled in this study. Their medical records, including laryngoscopic findings, were analyzed retrospectively. The demographic factors, cranial nerve involvement, and recovery rate of both groups were evaluated. RESULTS Sixty patients in the non-HZL group and 13 patients in the HZL group were analyzed. Five more patients in the non-HZL group were newly identified with HZL during the retrospective chart review. The mean age of the patients in the HZL group was higher than that of the non-HZL group (p = 0.016). The prevalence of hypertension was higher in the HZL group (p = 0.012). Patients with multiple cranial nerve involvement were more common in the HZL group (p < 0.001). In addition, the prognosis of facial weakness (p = 0.002) and multisensory dizziness (p = 0.006) was poor in HZL group. CONCLUSION This study showed that a considerable proportion of HZL cases were misdiagnosed or overlooked if not suspected. Considering the poor prognosis of HZL patients with facial paralysis and dizziness, HZL should be diagnosed earlier and treated properly.
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Affiliation(s)
- Jong-Min Park
- Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School and Chonnam National University Hospital, 42 Jebong-ro Dong-gu, Gwangju, 61469, Korea
| | - Seong Eun Kim
- Department of Infectious Diseases, Chonnam National University Hospital, 42 Jebong-ro Dong-gu, Gwangju, 61469, Korea.
| | - Hyung Chae Yang
- Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School and Chonnam National University Hospital, 42 Jebong-ro Dong-gu, Gwangju, 61469, Korea.
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Tsau PW, Liao MF, Hsu JL, Hsu HC, Peng CH, Lin YC, Kuo HC, Ro LS. Clinical Presentations and Outcome Studies of Cranial Nerve Involvement in Herpes Zoster Infection: A Retrospective Single-Center Analysis. J Clin Med 2020; 9:jcm9040946. [PMID: 32235469 PMCID: PMC7230397 DOI: 10.3390/jcm9040946] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 12/13/2022] Open
Abstract
Varicella-zoster virus (VZV) infection can cause chickenpox and herpes zoster. It sometimes involves cranial nerves, and rarely, it can involve multiple cranial nerves. We aimed to study clinical presentations of cranial nerve involvement in herpes zoster infection. We included patients who had the diagnosis of herpes zoster infection and cranial nerve involvement. The diagnosis was confirmed by typical vesicles and a rash. We excluded patients who had cranial neuralgias or neuropathies but without typical skin lesions (zoster sine herpete or post-herpetic neuralgia). We included 330 patients (mean age, 55.0 ± 17.0 years) who had herpes zoster with cranial nerve involvement, including 155 men and 175 women. Most frequently involved cranial nerves were the trigeminal nerve (57.9%), facial nerve (52.1%), and vestibulocochlear nerve (20.0%). Other involved cranial nerves included the glossopharyngeal nerve (0.9%), vagus nerve (0.9%), oculomotor nerve, trochlear nerve, and abducens nerve (each 0.3%, respectively). One hundred and seventy patients (51.5%) had only sensory symptoms/signs; in contrast, 160 patients (48.5%) had both sensory and motor symptoms/signs. Of those 160 patients, sensory preceded motor symptoms/signs in 64 patients (40.0%), sensory and motor symptoms/signs occurred simultaneously in 38 patients (23.8%), and motor preceded sensory symptoms/signs in 20 patients (12.5%). At one month after herpes zoster infection, vesicles and rash disappeared in 92.6% of patients; meanwhile facial palsy showed a significant improvement in 81.4% of patients (p < 0.05). Cranial motor neuropathies are not infrequent in herpes zoster infections. Multiple cranial nerve involvement frequently occurred in Ramsay Hunt syndrome. We found a significantly increased seasonal occurrence of cranial nerve zoster in spring rather than summer. Cranial motor nerves were affected while the hosts sometimes had a compromised immune system.
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Affiliation(s)
- Po-Wei Tsau
- Department of Neurology, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei 105, Taiwan; (P.-W.T.); (M.-F.L.); (J.-L.H.); (H.-C.K.)
| | - Ming-Feng Liao
- Department of Neurology, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei 105, Taiwan; (P.-W.T.); (M.-F.L.); (J.-L.H.); (H.-C.K.)
| | - Jung-Lung Hsu
- Department of Neurology, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei 105, Taiwan; (P.-W.T.); (M.-F.L.); (J.-L.H.); (H.-C.K.)
| | - Hui-Ching Hsu
- Department of Traditional Chinese Medicine, Division of Chinese Acupuncture and Traumatology, Chang Gung Memorial Hospital, Taipei 105, Taiwan;
| | - Chi-Hao Peng
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taipei 105, Taiwan;
| | - Yu-Ching Lin
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Taipei 105, Taiwan;
| | - Hung-Chou Kuo
- Department of Neurology, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei 105, Taiwan; (P.-W.T.); (M.-F.L.); (J.-L.H.); (H.-C.K.)
| | - Long-Sun Ro
- Department of Neurology, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei 105, Taiwan; (P.-W.T.); (M.-F.L.); (J.-L.H.); (H.-C.K.)
- Correspondence: ; Tel.: +886-3-3281200-8351
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Cunniffe HA, Cunniffe NG. Herpes zoster oticus with meningitis masquerading as malignant otitis externa. BMJ Case Rep 2019; 12:12/6/e229569. [PMID: 31177200 DOI: 10.1136/bcr-2019-229569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This is a case of an 85-year-old woman whom was admitted with otalgia and an abducens nerve palsy alongside a Pseudomonas otitis externa; she was presumed to have malignant otitis externa. However, despite optimum treatment and resolution of her otitis externa, she went on to develop an ipsilateral facial nerve palsy and sensorineural hearing loss. After further investigation, it was discovered that varicella-zoster meningitis was causing her polyneuropathy. She eventually responded to antivirals and steroids and, at follow-up, her sixth and seventh cranial nerve palsies had completely resolved, though a hearing deficit remained. This case highlights the importance of keeping a diagnosis under review, with the help of the multidisciplinary team, when the clinical course is not progressing as expected.
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Affiliation(s)
- Harriet A Cunniffe
- ENT, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,ENT, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, UK
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Acute Facial Nerve Palsy With Ipsilateral Soft Palate Ulcers. J Oral Maxillofac Surg 2017; 75:1906-1914. [DOI: 10.1016/j.joms.2017.02.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 02/19/2017] [Accepted: 02/21/2017] [Indexed: 11/20/2022]
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Singh G, Subhalakshmi V, Balasubramanian S, Patidar M, Ealla KKR. Ramsay Hunt Syndrome: A Diagnostic Challenge for General Dental Practitioners. Contemp Clin Dent 2017; 8:337-339. [PMID: 28839425 PMCID: PMC5551344 DOI: 10.4103/ccd.ccd_1099_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Ramsay hunt syndrome is not just a syndrome but it's rather an infectious disease caused by reactivation of latent varicella-zoster virus in geniculate ganglion. This was first explained by J. Ramsay Hunt as a triad of complications like otalgia, mucosal and cutaneous rashes with or without trigeminal facial palsy. The facial palsy can occur with characteristic vesicles along the path of nerve. We present a case of Ramsay Hunt syndrome in a 48-year-old male. The unilateral pattern of facial involvement and presence of vesicles assisted us for early diagnosis, distinguishing the syndrome with diseases mimicking other severe neurological illnesses and prompt treatment.
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Affiliation(s)
- Gautham Singh
- Graded Specialist Medicine, Military Hospital, c/o 99 APO, Udaipur, Rajasthan, India
| | - V Subhalakshmi
- Consultant Oral Pathologist, Military Hospital, c/o 99 APO, Udaipur, Rajasthan, India
| | - S Balasubramanian
- Graded Specialist Surgery, Military Hospital, c/o 99 APO, Udaipur, Rajasthan, India
| | - Madhvika Patidar
- Department of Oral Pathology and Microbiology, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
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Steele L, Ghedia R, Ahmad H, Mace A. Ramsay Hunt syndrome with cranial polyneuropathy with features of supraglottitis. BMJ Case Rep 2017; 2017:bcr-2017-221135. [PMID: 28784901 DOI: 10.1136/bcr-2017-221135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 67-year-old woman presented with a 1-week history of left otalgia and a 1-day history of odynophagia, pain extending into the face and neck, and a productive cough. Flexible nasendoscopy showed features of supraglottitis, with swollen arytenoids and pooling of saliva in the piriform fossae. Laboratory investigations revealed a mildly raised C reactive protein. A CT scan of the neck supported the diagnosis of supraglottitis and pharyngitis, with thickening of the mucosa of the left piriform fossae and left oropharynx. Standard supraglottitis treatment was instigated, but on day 4 of the admission, a vesicular rash and features of cranial nerve involvement (V, VII, VIII, X) developed. A revised diagnosis of Ramsay Hunt syndrome with cranial polyneuropathy was made and later confirmed by varicella zoster virus PCR. After 4 weeks, facial nerve function normalised, but features of other cranial nerve palsies were persistent.
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Affiliation(s)
- Lloyd Steele
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Hena Ahmad
- Imperial College Healthcare NHS Trust, London, UK
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Chen I, Fohtung RB, Oughli HA, Bauer R, Mattar C, Powderly WG, Thoelke MS. Concurrent Ramsay Hunt syndrome and disseminated herpes zoster in a patient with relapsed chronic lymphocytic leukemia. IDCases 2016; 6:79-82. [PMID: 27757380 PMCID: PMC5067093 DOI: 10.1016/j.idcr.2016.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 10/06/2016] [Accepted: 10/06/2016] [Indexed: 12/11/2022] Open
Abstract
Ramsay Hunt Syndrome (RHS) is a rare complication of latent varicella-zoster virus (VZV) infection that can occur in immunocompetent host. It usually involves ipsilateral facial paralysis, ear pain and facial vesicles. Disseminated herpes zoster is another complication of VZV infection typically seen in immunocompromised hosts. We describe a patient with relapsed chronic lymphocytic leukemia (CLL) who presented simultaneously with RHS and disseminated herpes zoster. While other complications have been documented to coexist with RHS, to our knowledge, this is the first reported case in the literature of concurrent RHS with disseminated herpes zoster.
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Affiliation(s)
- Ishita Chen
- School of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Raymond B Fohtung
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Hanadi Ajam Oughli
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
| | - Robert Bauer
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
| | - Caline Mattar
- Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, MO, USA
| | - William G Powderly
- Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, MO, USA
| | - Mark S Thoelke
- Division of Hospital Medicine, Washington University School of Medicine, Saint Louis, MO, USA
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Cranial Nerve Disorders. Neurology 2016. [DOI: 10.1002/9781118486160.ch13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Alzhrani F, Lenarz T, Teschner M. Facial palsy following cochlear implantation. Eur Arch Otorhinolaryngol 2016; 273:4199-4207. [DOI: 10.1007/s00405-016-4124-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 05/30/2016] [Indexed: 11/24/2022]
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Singh P, Singh VP. Mime therapy for Ramsay Hunt syndrome: A case study. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2016. [DOI: 10.12968/ijtr.2016.23.3.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/Aim: There are limited physiotherapy interventions and lack of significant outcome for Ramsay Hunt syndrome. This case report is the first to our knowledge that uses mime therapy as physiotherapy treatment for Ramsay Hunt syndrome. Method: A 53-year-old male patient received mime therapy along with electrical stimulation at two and half months post-diagnosis. The patient received electrical stimulation at the first week intervention as 30 minutes per session for 5 days a week and was discontinued at the third week intervention because the patient could not continue with facial muscle stimulation at home. Mime therapy was given three times a week for 13 weeks, with a total of 24 visits spread over 3 months. Findings: Facial symmetry was measured using the Sunnybrook Facial Grading System and severity of paresis was measured using the House-Brackmann scale throughout the course of treatment. House-Brackmann grades improved from grade V to grade II. Facial symmetry and synkinesis also improved. The facial disability index also showed improvement in both the physical function and social/wellbeing subscale components (Initial scores: physical subscale = 35/100; social/wellbeing subscale = 55/100. The final scores: physical subscale = 75/100; social/wellbeing subscale = 85/100). Conclusions: Overall, mime therapy was effective and benefits are stable for the short term. Therefore, mime therapy can be a good treatment choice for patients with Ramsay Hunt syndrome. Further research should include randomised controlled trials with a large sample size to prove its long-term effects.
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Affiliation(s)
- Priyanka Singh
- Assistant professor, Physiotherapy Department of Physiotherapy, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Sikkim, India
| | - Vijay Pratap Singh
- Associate professor Department of Physiotherapy, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Sikkim, India
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Abstract
Spontaneous idiopathic facial nerve (Bell's) palsy leaves residual hemifacial weakness in 29% which is severe and disfiguring in over half of these cases. Acute medical management remains the best way to improve outcomes. Reconstructive surgery can improve long term disfigurement. However, acute and surgical options are time-dependent. As family practitioners see, on average, one case every 2 years, a summary of this condition based on common clinical questions may improve acute management and guide referral for those who need specialist input. We formulated a series of clinical questions likely to be of use to family practitioners on encountering this condition and sought evidence from the literature to answer them. The lifetime risk is 1 in 60, and is more common in pregnancy and diabetes mellitus. Patients often present with facial pain or paraesthesia, altered taste and intolerance to loud noise in addition to facial droop. It is probably caused by ischaemic compression of the facial nerve within the meatal segment of the facial canal probably as a result of viral inflammation. When given early, high dose corticosteroids can improve outcomes. Neither antiviral therapy nor other adjuvant therapies are supported by evidence. As the facial muscles remain viable re-innervation targets for up to 2 years, late referrals require more complex reconstructions. Early recognition, steroid therapy and early referral for facial reanimation (when the diagnosis is secure) are important features of good management when encountering these complex cases.
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Affiliation(s)
- Graeme E Glass
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK and
| | - Kallirroi Tzafetta
- St. Andrews Centre for Plastic Surgery Broomfield Hospital, Chelmsford, UK
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Abstract
The aim of this study is to evaluate the types and clinical characteristics of peripheral facial palsy in children. The hospital charts of children diagnosed with peripheral facial palsy were reviewed retrospectively. A total of 81 children (42 female and 39 male) with a mean age of 9.2 ± 4.3 years were included in the study. Causes of facial palsy were 65 (80.2%) idiopathic (Bell palsy) facial palsy, 9 (11.1%) otitis media/mastoiditis, and tumor, trauma, congenital facial palsy, chickenpox, Melkersson-Rosenthal syndrome, enlarged lymph nodes, and familial Mediterranean fever (each 1; 1.2%). Five (6.1%) patients had recurrent attacks. In patients with Bell palsy, female/male and right/left ratios were 36/29 and 35/30, respectively. Of them, 31 (47.7%) had a history of preceding infection. The overall rate of complete recovery was 98.4%. A wide variety of disorders can present with peripheral facial palsy in children. Therefore, careful investigation and differential diagnosis is essential.
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Affiliation(s)
- Unsal Yılmaz
- Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | | | - Tuba Sevim Yılmaz
- Department of Public Health, Dokuz Eylul University Hospital, Izmir, Turkey
| | | | | | - Orkide Güzel
- Dr. Behçet Uz Children's Hospital, Izmir, Turkey
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A case of zoster sine herpete presenting with thoracic radicular pain diagnosed by polymerase chain reaction in skin exudate. DERMATOL SIN 2014. [DOI: 10.1016/j.dsi.2013.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Mantero V, Rigamonti A, Valentini S, Fiumani A, Piamarta F, Bonfanti P, Salmaggi A. Isolated acute dysphagia due to varicella-zoster virus. J Clin Virol 2014; 59:268-9. [DOI: 10.1016/j.jcv.2014.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 01/11/2014] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
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Rasmussen ER, Lykke E, Toft JG, Mey K. Ramsay Hunt syndrome revisited–emphasis on Ramsay Hunt syndrome with multiple cranial nerve involvement. ACTA ACUST UNITED AC 2014. [DOI: 10.7243/2052-6202-2-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Affiliation(s)
- Don Gilden
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Microbiology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Maria A Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Randall J Cohrs
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
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Worme M, Chada R, Lavallee L. An unexpected case of Ramsay Hunt syndrome: case report and literature review. BMC Res Notes 2013; 6:337. [PMID: 23985267 PMCID: PMC3847606 DOI: 10.1186/1756-0500-6-337] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 08/21/2013] [Indexed: 11/26/2022] Open
Abstract
Background Ramsay Hunt Syndrome (RHS) is a rare, severe complication of varicella zoster virus (VZV) reactivation in the geniculate ganglion. Facial paralysis is one of the features and without treatment, it fully recovers in as little as 20% of cases; this is much improved if treatment is started within 72 hours. This case is noteworthy in that coexistence of facial palsy with cervical dermatome involvement by VZV is not typical of RHS. Yet, it has been reported before. Case presentation A 54 year old Caucasian woman presented with right ear discomfort, difficulty hearing and a vesicular rash along the pinnae, 8 days after the eruption of a similar rash in the right C2-C4 dermatomes. 2 days later, she awoke with a partial right-sided facial paralysis, which improved with treatment (valacyclovir and prednisone). Conclusions This case is most pertinent to Family Practice, Otolaryngology and Neurology. It highlights the possible co-existence of RHS with cervical VZV reactivation and encourages physicians to monitor for this complication even before geniculate ganglion reactivation occurs. RHS is a rare disease that can present with vague symptoms. A high index of suspicion and close follow up are essential. Early intervention with antivirals and corticosteroids has shown significantly improved outcomes in these patients.
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Affiliation(s)
- Mali Worme
- 3474 St, Famille, Apt 2, Montreal, Quebec H2X 2K8, Canada.
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Abstract
OPINION STATEMENT Varicella zoster virus (VZV) is an exclusively human neurotropic alphaherpesvirus. Primary infection causes varicella (chickenpox), after which virus becomes latent in ganglionic neurons along the entire neuraxis. With advancing age or immunosuppression, cell-mediated immunity to VZV declines and virus reactivates to cause zoster (shingles), which can occur anywhere on the body. Skin lesions resolve within 1-2 weeks, while complete cessation of pain usually takes 4-6 weeks. Zoster can be followed by chronic pain (postherpetic neuralgia), cranial nerve palsies, zoster paresis, meningoencephalitis, cerebellitis, myelopathy, multiple ocular disorders and vasculopathy that can mimic giant cell arteritis. All of the neurological and ocular disorders listed above may also develop without rash. Diagnosis of VZV-induced neurological disease may require examination of cerebrospinal fluid (CSF), serum and/ or ocular fluids. In the absence of rash in a patient with neurological disease potentially due to VZV, CSF should be examined for VZV DNA by PCR and for anti-VZV IgG and IgM. Detection of VZV IgG antibody in CSF is superior to detection of VZV DNA in CSF to diagnose vasculopathy, recurrent myelopathy, and brainstem encephalitis. Oral antiviral drugs speed healing of rash and shorten acute pain. Immunocompromised patients require intravenous acyclovir. First-line treatments for post-herpetic neuralgia include tricyclic antidepressants, gabapentin, pregabalin, and topical lidocaine patches. VZV vasculopathy, meningoencephalitis, and myelitis are all treated with intravenous acyclovir.
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Affiliation(s)
- Maria A. Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Don Gilden
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Microbiology, University of Colorado School of Medicine, Aurora, CO, USA
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Joseph ST, Vishwakarma R, Ramani MK, Aurora R. Cochlear implant and delayed facial palsy. Cochlear Implants Int 2013; 10:229-36. [DOI: 10.1179/cim.2009.10.4.229] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Mantero V, De Toni Franceschini L, Lillia N, Guccione A, Santilli I, Agostoni E. Varicella-zoster meningoencephaloradiculoneuropathy in an immunocompetent young woman. J Clin Virol 2013; 57:361-2. [PMID: 23778237 DOI: 10.1016/j.jcv.2013.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 04/01/2013] [Accepted: 04/08/2013] [Indexed: 11/19/2022]
Abstract
The clinical manifestations of varicella-zoster virus infections can be divided into primary infection with chickenpox and reactivated infection with dermatomal shingles, disseminated herpes zoster, zoster sine herpete and varicella-zoster virus encephalitis, meningitis and vasculopathy. We present a case of zoster sine herpete leading to meningitis with cranial and peripheral nerve palsies. A 17-year-old woman was admitted to hospital with intermittent fever, drowsiness, slowness and subsequent frontal headache and horizontal diplopia. Cerebrospinal fluid examination revealed lymphocytic pleocytosis and PCR amplified varicella-zoster virus DNA. Laboratory and clinical findings were suggestive of meningoencephaloradiculoneuropathy, stemming from varicella-zoster virus and affecting cranial and peripheral nerves. Only 5% of patients with zoster develop cranial and peripheral nerve palsies. Diagnosis is imperative in order to initiate prompt antiviral therapy so as to minimize morbidity and the risk of death.
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Affiliation(s)
- Vittorio Mantero
- Department of Neurosciences, Niguarda Ca' Granda Hospital, Milan, Italy.
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Abstract
Herpes zoster oticus also known as Ramsay Hunt syndrome is a rare complication of herpes zoster in which reactivation of latent varicella zoster virus infection in the geniculate ganglion causes otalgia, auricular vesicles, and peripheral facial paralysis. Ramsay Hunt syndrome is rare in children and affects both sexes equally. Incidence and clinical severity increases when host immunity is compromised. Because these symptoms do not always present at the onset, this syndrome can be misdiagnosed. Although secondary to Bell's palsy in terms of the cause of acute atraumatic peripheral facial paralysis, Ramsay Hunt syndrome, with incidence ranged from 0.3 to 18%, has a worse prognosis. Herpes zoster oticus accounts for about 12% cases of facial palsy, which is usually unilateral and complete and full recovery occurs in only about 20% of untreated patients. The most advisable method to treat Ramsay Hunt syndrome is the combination therapy with acyclovir and prednisone but still not promising, and several prerequisites are required for better results. We present a case of 32-year-old man suffering from Ramsay Hunt syndrome with grade V facial palsy treated effectively with rehabilitation program, after the termination of the combination therapy of acyclovir and prednisone.
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Affiliation(s)
- Shailesh Gondivkar
- Department of Oral Diagnosis, Medicine and Radiology, K. M. Shah Dental College and Hospital, Piparia, Vadodara, Gujarat, India
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Kansu L, Yilmaz I. Herpes zoster oticus (Ramsay Hunt syndrome) in children: case report and literature review. Int J Pediatr Otorhinolaryngol 2012; 76:772-6. [PMID: 22445801 DOI: 10.1016/j.ijporl.2012.03.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 03/01/2012] [Accepted: 03/03/2012] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Approximately 10% of patients with peripheral facial nerve palsy are children. Facial nerve palsy is usually idiopathic. An uncommon cause is herpes zoster oticus (Ramsay Hunt syndrome). This syndrome usually affects adults and is rare in children. METHODS We reviewed the literature and describe the cause, clinical manifestations, and treatment of Ramsay Hunt syndrome. We also report a case of the syndrome in a 12-year-old boy. CONCLUSION Ramsay Hunt syndrome is characterized by peripheral facial paralysis associated with herpetic eruption on the auricula and external ear, and by vestibulocochlear dysfunction. It occurs by reactivation of latent varicella-zoster virus (VZV) in the geniculate ganglion, affecting the seventh and eighth cranial nerves. The diagnosis is based on history and physical findings. Treatment of Ramsay Hunt syndrome uses a combination of high-dose corticosteroids and acyclovir. Although the prognosis is better in children than in adults, it is not good enough.
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Affiliation(s)
- Leyla Kansu
- Department of Otolaryngology Head and Neck Surgery, Baskent University, Ankara, Turkey.
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Abstract
Ramsay Hunt syndrome is defined as herpes zoster oticus associated with an acute peripheral facial nerve paresis and quite often with other cranial nerve lesions. The combination of motor, sensory and autonomic involvement leads to a variety of neurological damage patterns, i. e. facial muscle paresis, hearing and balance disorders, sensory problems and disturbances of taste as well as lacrimal and nasal secretion. Additional variability of the clinical picture of Ramsay Hunt syndrome is produced by varying patterns of skin involvement explained by individual anastomoses between cranial and cervical nerves. Knowledge of these findings and an early diagnosis of Ramsay Hunt syndrome are important as prognosis of cranial nerve damage depends on the time at which acyclovir-corticosteroid therapy is started.
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Affiliation(s)
- Gunnar Wagner
- Department of Dermatology, Allergology and Phlebology, Klinikum Bremerhaven Reinkenheide, Postbrookstrasse 103, Bremerhaven, Germany.
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Sengoku R, Yaguchi H, Matsushima S, Mochio S. Zoster sine herpete: detection by skin exudates and contrast magnetic resonance imaging. Eur Neurol 2012; 67:154. [PMID: 22261654 DOI: 10.1159/000334924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 11/04/2011] [Indexed: 11/19/2022]
Affiliation(s)
- Renpei Sengoku
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan.
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Tsai J, Cohrs RJ, Nagel MA, Mahalingam R, Schmid DS, Choe A, Gilden D. Reactivation of type 1 herpes simplex virus and varicella zoster virus in an immunosuppressed patient with acute peripheral facial weakness. J Neurol Sci 2011; 313:193-5. [PMID: 21924743 DOI: 10.1016/j.jns.2011.08.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 08/23/2011] [Accepted: 08/29/2011] [Indexed: 12/29/2022]
Abstract
We describe a 26-year-old man treated with azathioprine for myasthenia gravis who developed acute left-sided peripheral facial weakness. Brain magnetic resonance imaging (MRI) revealed enhancement in the left geniculate ganglion and in the intracanalicular and tympanic segments of the facial nerve. Analysis of cerebrospinal fluid (CSF) and serum revealed intrathecal synthesis of anti-varicella zoster virus (VZV) IgG antibody. Although previous analyses of saliva, blood mononuclear cells, serum antibodies, middle ear fluid, and auricular and geniculate zone skin scrapings have shown that a small but definite proportion of patients with idiopathic peripheral facial palsy ("Bell's palsy") have the Ramsay Hunt syndrome zoster sine herpete (RHS ZSH), this is the first confirmation of RHS ZSH by intrathecal synthesis of anti-VZV IgG antibody. In addition, herpes simplex virus (HSV)-1 DNA was found in saliva of the patient on 3 consecutive days. Simultaneous reactivation of two alphaherpesviruses (HSV-1 and VZV) in our immunosuppressed patient underscores the need to consider opportunistic infection as a cause of facial weakness.
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Affiliation(s)
- Jean Tsai
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
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Gunson RN, Aitken C, Gilden D. A woman with acute headache and sacral dermatomal numbness. J Clin Virol 2010; 50:191-3. [PMID: 21130028 DOI: 10.1016/j.jcv.2010.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 11/01/2010] [Indexed: 12/29/2022]
Affiliation(s)
- R N Gunson
- West of Scotland Specialist Virology Centre, Gartnavel General Hospital, 1053 Great Western Road, Glasgow G12 0YN, United Kingdom.
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Neurological disease produced by varicella zoster virus reactivation without rash. Curr Top Microbiol Immunol 2010; 342:243-53. [PMID: 20186614 DOI: 10.1007/82_2009_3] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Reactivation of varicella zoster virus (VZV) from latently infected human ganglia usually produces herpes zoster (shingles), characterized by dermatomal distribution pain and rash. Zoster is often followed by chronic pain (postherpetic neuralgia or PHN) as well as meningitis or meningoencephalitis, cerebellitis, isolated cranial nerve palsies that produce ophthalmoplegia or the Ramsay Hunt syndrome, multiple cranial nerve palsies (polyneuritis cranialis), vasculopathy, myelopathy, and various inflammatory disorders of the eye. Importantly, VZV reactivation can produce chronic radicular pain without rash (zoster sine herpete), as well as all the neurological disorders listed above without rash. The protean neurological and ocular disorders produced by VZV in the absence of rash are a challenge to the practicing clinician. The presentation of these conditions varies from acute to subacute to chronic. Virological confirmation requires the demonstration of amplifiable VZV DNA in cerebrospinal fluid (CSF) or in blood mononuclear cells, or the presence of anti-VZV IgG antibody in CSF or of anti-VZV IgM antibody in CSF or serum.
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Morinaka S. Herpes zoster laryngitis with intractable hiccups. Auris Nasus Larynx 2009; 36:606-8. [DOI: 10.1016/j.anl.2009.01.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 12/27/2008] [Accepted: 01/06/2009] [Indexed: 10/21/2022]
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Abstract
Ramsay Hunt syndrome is a rare complication of herpes zoster in which reactivation of latent varicella zoster virus infection occurs in the geniculate ganglion, causing otalgia, auricular vesicles and peripheral facial paralysis. Because these symptoms do not always present at the onset, this syndrome can be misdiagnosed. We report the case of a patient who was diagnosed with simple otitis externa after presenting to the emergency department (ED) with a 3-day history of right-sided otalgia. Her condition subsequently evolved to include right-sided auricular vesicles and right-sided facial weakness. She presented to the ED again after 2 days and was correctly diagnosed with Ramsay Hunt syndrome. We describe the clinical presentation, diagnostic findings and management of this uncommon but important entity.
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Uscategui T, Dorée C, Chamberlain IJ, Burton MJ. Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database Syst Rev 2008; 2008:CD006851. [PMID: 18843734 PMCID: PMC6956409 DOI: 10.1002/14651858.cd006851.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Herpes zoster oticus (HZO) is a viral infection of the ear and when associated with acute facial paralysis is known as Ramsay Hunt syndrome. Antiviral agents are the standard first-line treatment for herpes zoster infections at other body sites and are thought to reduce or minimise nerve damage, thereby improving outcomes. It has been suggested that these agents improve the chance of facial weakness improving or resolving completely in patients with Ramsay Hunt syndrome. OBJECTIVES To determine the effectiveness of antiviral agents in the treatment of adult patients with Ramsay Hunt syndrome (HZO with facial palsy). SEARCH STRATEGY We searched the Cochrane ENT Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, current issue), Medline (1950 - 2007), PubMed 2007 - 2008, EMBASE (1974 onwards) and other relevant databases. The date of the most recent search was June 2008. SELECTION CRITERIA Two authors scrutinized all possible citations to identify randomised controlled trials in which antiviral agents alone or in combination with other therapies (using different routes of administration and dosage schemes) were given as treatment for Ramsay Hunt syndrome. We contacted an author for further information. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed eligibility and trial quality. MAIN RESULTS Only one randomised, controlled trial was identified and included. It was of low quality and included only 15 participants. In this 1992 trial, intravenous acyclovir and corticosteroids were compared with corticosteroids alone. Our analysis found no statistically significant difference between the two groups. AUTHORS' CONCLUSIONS We found no evidence that anti-viral agents have a beneficial effect on outcomes in Ramsay Hunt syndrome, despite their widespread use in this condition. The use of these drugs in patients with herpes zoster infections in other parts of the body might suggest that they have a role in herpes zoster oticus. As usual, the absence of positive evidence of benefit (or, in this case, the 'negative' result of one small, statistically under-powered study) does not necessarily indicate that antivirals are ineffective. However, these drugs are associated with a number of adverse effects and this must be taken into consideration when undertaking the requisite risk-benefit analysis before instigating treatment.
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Affiliation(s)
- Teresa Uscategui
- A&E Department, Basildon and Thurrock University Hospital, Nethermayne, Basildon, Essex, UK, SS16 5NL.
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Hato N, Sawai N, Teraoka M, Wakisaka H, Takahashi H, Hinohira Y, Gyo K. Valacyclovir for the treatment of Bell's palsy. Expert Opin Pharmacother 2008; 9:2531-6. [DOI: 10.1517/14656566.9.14.2531] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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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 2008:CD006852. [PMID: 18646170 DOI: 10.1002/14651858.cd006852.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Inflammation and oedema of the facial nerve due to viral infection by the herpes zoster virus are implicated in the aetiology and clinical manifestation of Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Corticosteroids, with their powerful anti-inflammatory effect, have a potential role to play in the reduction or minimisation of nerve damage when administered together with antiviral therapy, and therefore may improve the outcome for patients with Ramsay Hunt syndrome. OBJECTIVES To determine the effectiveness of corticosteroids as an adjuvant to antiviral therapy in adult patients with Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). SEARCH STRATEGY We searched the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library Issue 4, 2007), MEDLINE (1950 to December 2007) and EMBASE (1974 to December 2007), CINAHL (1982 to December 2007), LILACS, KoreaMed, IndMed, PakMediNet, ZETOC, Cambridge Scientific Abstracts (Conference Proceedings Database), ISI Proceedings (Web of Science), the National Research Register (NRR), the UK Clinical Research Network Portfolio Database (UKCRN), the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Research Findings Register (ReFeR) and the metaRegister of Controlled Trials (mRCT). SELECTION CRITERIA All randomised controlled trials in which corticosteroids (by any route of administration at any dosage) were given as an adjuvant to antiviral agents in the treatment of Ramsay Hunt syndrome. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed eligibility and trial quality of the available studies, whether they were published or unpublished. No trials were found and therefore no data were analysed. MAIN RESULTS This is an empty review as no trials were found that fulfilled the inclusion criteria. AUTHORS' CONCLUSIONS Since no randomised controlled trials investigating the use of corticosteroids as an adjuvant to antiviral treatment in Ramsay Hunt syndrome were identified, such studies are needed to assess the effects of such therapy.
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Affiliation(s)
- Teresa Uscategui
- Department of Paediatrics, Basildon University Hospital, Nethermayne, Basildon, Essex, UK, SS16 5NL.
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Unilateral associated laryngeal paralysis due to varicella-zoster virus: virus antibody testing and videofluoroscopic findings. The Journal of Laryngology & Otology 2007; 122:170-6. [DOI: 10.1017/s0022215107000898] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractThe relationship between varicella-zoster virus and idiopathic associated laryngeal paralysis was examined in five patients, using complement fixation or enzyme immunoassay testing. In all cases, significant changes in serum levels of varicella-zoster virus antibody were observed. Videofluoroscopy was useful in assessing the severity of the dysphagia and in making an accurate diagnosis; both laryngeal elevation and weakness of pharyngeal wall contraction were also observed. In two cases in which antiviral therapy was delayed, the outcome was poor, with increased levels of varicella-zoster virus immunoglobulin M found on enzyme immunoassay. The outcome of the condition may thus depend both on the speed of antiviral therapy commencement following onset of symptoms, and on the levels of varicella-zoster virus immunoglobulin M antibody (measured by enzyme immunoassay). Our study suggests that varicella-zoster virus should be considered in the differential diagnosis of patients with idiopathic associated laryngeal paralysis, and rapid antiviral therapy should be initiated when necessary.
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Abstract
Facial nerve palsy affects individuals of all ages, races, and sexes. Psychological and functional implications of the paralysis present a devastating management problem to those afflicted, as well as the carriers. Since Sir Charles Bell's original description of facial palsy in 1821, our understanding and treatment options have expanded. It is essential that a multidisciplinary approach, encompassing ophthalmologists; Ear, Nose, and Throat surgeons; plastic surgeons; and psychologists work closely to optimize patient management in a staged approach. Although the etiology remains unknown, strong histological, cerebral spinal fluid, and radiological evidence suggests a possible association with herpes simplex virus in idiopathic facial nerve palsy (Bell's palsy). The use of steroids has been suggested as a means of limiting facial nerve damage in the acute phase. Unfortunately, no single randomized control trial has achieved an unquestionable benefit with the use of oral steroid therapy and thus remains controversial. In the acute phase, ophthalmologists play a pivotal role in preventing irreversible blindness from corneal exposure. This may be successfully achieved by using intensive lubrication, medical therapy (botulinum toxin), or surgery (upper lid weighting or tarsorraphy). Once the cornea is adequately protected and recovery deemed unlikely, longer term planning for eyelid and facial reanimation may take place in an individualized manner. Onset is sudden and management potentially lengthy. Physician empathy, knowledge, and experience are essential in averting long-term lifestyle and psychological discomfort for patients.
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Affiliation(s)
- Imran Rahman
- Manchester Royal Eye Hospital, Manchester, United Kingdom
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Yamakawa K, Hamada M, Takeda T. Different real-time PCR assays could lead to a different result of detection of varicella-zoster virus in facial palsy. J Virol Methods 2007; 139:227-9. [PMID: 17134766 DOI: 10.1016/j.jviromet.2006.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2006] [Revised: 09/27/2006] [Accepted: 10/19/2006] [Indexed: 11/22/2022]
Abstract
Real-time PCR is a useful tool for rapid detection of viral genomic DNA. However, there are many types of real-time PCR, and this variation may induce different results. The sensitivity of two different real-time PCR assays was evaluated for the detection of the varicella-zoster virus (VZV) genome: LightCycler PCR and TaqMan PCR. Auricular skin cells and saliva were sampled from 201 patients with facial nerve paralysis. A hundred and seventy-one of these patients were diagnosed clinically with Bell's palsy, and the remaining 30 with Ramsay Hunt syndrome. In 30 specimens obtained from Ramsay Hunt syndrome patients, VZV DNA was detected in 26 skin and 3 saliva specimens using the LightCycler PCR, while 28 skin and 9 saliva specimens were positive using the TaqMan PCR. None of the patients with Bell's palsy were positive for VZV by the LightCycler PCR, whereas five of these patients were positive by the TaqMan PCR. The TaqMan PCR assay has a better sensitivity compared to the LightCycler PCR for the detection of VZV genome from patients with facial palsy. Further study is required to develop a more sensitive real-time PCR.
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Affiliation(s)
- K Yamakawa
- Department of Otolaryngology, Kochi Medical School, Kohasu, Oko-chou, Kochi 783-8505, Japan.
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Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, Betts RF, Gershon AA, Haanpaa ML, McKendrick MW, Nurmikko TJ, Oaklander AL, Oxman MN, Pavan-Langston D, Petersen KL, Rowbotham MC, Schmader KE, Stacey BR, Tyring SK, van Wijck AJM, Wallace MS, Wassilew SW, Whitley RJ. Recommendations for the management of herpes zoster. Clin Infect Dis 2007; 44 Suppl 1:S1-26. [PMID: 17143845 DOI: 10.1086/510206] [Citation(s) in RCA: 446] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The objective of this article is to provide evidence-based recommendations for the management of patients with herpes zoster (HZ) that take into account clinical efficacy, adverse effects, impact on quality of life, and costs of treatment. Systematic literature reviews, published randomized clinical trials, existing guidelines, and the authors' clinical and research experience relevant to the management of patients with HZ were reviewed at a consensus meeting. The results of controlled trials and the clinical experience of the authors support the use of acyclovir, brivudin (where available), famciclovir, and valacyclovir as first-line antiviral therapy for the treatment of patients with HZ. Specific recommendations for the use of these medications are provided. In addition, suggestions are made for treatments that, when used in combination with antiviral therapy, may further reduce pain and other complications of HZ.
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Affiliation(s)
- Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA.
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Ogita S, Terada K, Niizuma T, Kosaka Y, Kataoka N. Characteristics of facial nerve palsy during childhood in Japan: frequency of varicella-zoster virus association. Pediatr Int 2006; 48:245-9. [PMID: 16732788 DOI: 10.1111/j.1442-200x.2006.02197.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of this study was to clarify the clinical characteristics of facial nerve palsy and the frequency of varicella-zoster virus association in Japanese children, retrospectively. METHODS The subjects were 30 facial nerve palsy patients less than 15 years old, treated in the Department of Pediatrics, Kawasaki Medical School Hospital, Okayama, Japan, during the last 10 years. RESULTS The male/female and right/left ratios were 16/14 and 16/13, respectively. The patients included 21 cases (70%) of Bell's palsy, four cases (13%) due to otitis media, three cases (10%) of Ramsay Hunt syndrome and two cases (7%) due to birth trauma. There were six cases of zoster sine herpete among the Bell's palsy cases. CONCLUSION Varicella-zoster virus-associated facial palsy was found in nine (36%) of the 25 patients examined. Zoster sine herpete was more frequently encountered in children than adults. Ramsay Hunt syndrome was found in school-age children and zoster sine herpete was often found in preschool children. The period of recovery was fast for facial nerve palsy due to acute otitis media, which occurred within 23 months of age, after myringotomy and administration of antibiotics.
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Affiliation(s)
- Satoko Ogita
- Department of Pediatrics, Kawasaki Medical School, Kurashiki City, Okayama Prefecture, Japan
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Gök U, Alpay HC, Akpolat N, Yoldaş T, Kilic A, Yilmaz B, Kabakuş N. Comparisons of steroid, acyclovir, lipoprostoglandin E1 and steroid + acyclovir treatments in facial paralysis: a rat study. Int J Pediatr Otorhinolaryngol 2005; 69:1199-204. [PMID: 15869809 DOI: 10.1016/j.ijporl.2005.03.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2004] [Accepted: 03/12/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To induce experimental peripheral facial paralysis by inoculation of HSV1 and to compare the effects of steroid, acyclovir, lipoprostoglandin E2 and steroid + acyclovir treatments in terms of clinical recovery, electrophysiologically and histopathologically. MATERIALS AND METHODS A total of 132 adult female rats were used in this study. HSV type 1 strain was inoculated at the back of the left ear by using 27 gauge needle. Of all animals, 70 (53%) rats which developed facial paralysis were divided into five groups (n = 14 for each group) as control, steroid + acyclovir, lipoprostaglandin E1, steroid only and acyclovir only. At the end of the 21 days period, the rats were clinically examined and electrophysiological tests were performed, then decapitated and the nerve specimens were obtained. RESULTS A modified electroneurography (ENoG) test was performed and the latencies and the amplitudes were compared. The findings of the intact side were better, but with no significant difference. Histopathologicaly edema was significantly smaller in all groups compared to the controls (p < 0.05). Similarly, no difference was seen in terms of vacuolar degeneration and Schwann cell hyperchromatisation among the groups and no significant difference in recovery period and rate of facial paralysis when all groups were compared. CONCLUSION Facial paralysis induced by HSV1 recovered spontaneously within a week. In the treatment of facial paralysis, steroid alone, acyclovir alone, steroid + acyclovir, or lipoprostaglandin E1 all reduced edema in the infected facial nerve but there was no statistical difference in of the rate or degree of recovery.
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Affiliation(s)
- Uzeyir Gök
- Firat University, Medical Faculty, Otorhinolaryngology Department, Elaziğ, Turkey
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Affiliation(s)
- M A Pogrel
- Department of Oral and Maxillofacial Surgery, University of California, San Francisco, San Francisco, CA 94143, USA.
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Honda N, Yanagihara N, Hato N, Kisak H, Murakami S, Gyo K. Swelling of the intratemporal facial nerve in Ramsay Hunt syndrome. Acta Otolaryngol 2002; 122:348-52. [PMID: 12030588 DOI: 10.1080/000164802753648295] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Although Ramsay Hunt syndrome is one of the most important diseases causing peripheral facial palsy, the detailed pathology of the disease in the intratemporal facial nerve remains unclear. The purpose of this study was to increase knowledge of the pathogenesis of the syndrome by means of surgical findings. Between April 1976 and March 1997 we performed subtotal decompression of the facial nerve in 74 patients with severe Ramsay Hunt syndrome. The grade of nerve swelling was assessed using a microscope and recorded in a standardized form. The relationships between nerve swelling, the timing of surgery and the swelling of each segment were analyzed. Pronounced neural swelling, involving the geniculate ganglion and the horizontal segment, was consistent finding in the acute phase. Although the incidence of pronounced swelling of the horizontal segment gradually declined with time after onset, in most cases nerve swelling persisted even beyond the 16th week after onset. These data suggest that diffuse viral neuritis occurs throughout the intratemporal facial nerve. We assume that the viral inflammatory swelling involving the geniculate ganglion and horizontal segment is mostly responsible for the acute facial palsy in the acute phase.
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Affiliation(s)
- Nobumitsu Honda
- Department of Otolaryngology, Ehime University School of Medicine, Japan.
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