Kaohsiung Journal of Medical Sciences (2014) 30, 264e265

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Ramsay Hunt syndrome with vocal fold paralysis Dear Editor, Herpes zoster oticus, also called Ramsay Hunt syndrome, is usually caused by the reactivation of a pre-existing herpes zoster virus infection in the geniculate ganglion. The disease typically affects areas innervated by the facial nerve, and its symptoms and signs include otalgia, vesicular eruptions involving the external ear, facial paralysis, deafness, vertigo, and sometimes ipsilateral loss of taste in the anterior two-thirds of the tongue. Here, we report a case of herpes zoster oticus with the unusual complication of unilateral vocal fold paralysis. A 64-year-old male arrived at our hospital presenting with symptoms of left-sided earache, facial pain, odynophagia, and dysphagia that had rapidly worsened over a period of 1 week. A husky voice and left hearing loss occurred 3 days after the onset of symptoms. The throat pain and dysphagia worsened rapidly 3 days prior to when he arrived at our hospital. Dysphonia and left hearing loss were also noted. Physical examination showed diffuse auricular swelling with vesicular eruptions and discharge from the left external auditory canal. Flexible laryngoscopy revealed left vocal fold paralysis and multiple vesicles and ulcerations on his left hypopharynx, epiglottis, and aryepiglottic fold (Fig. 1). The patient was admitted for further evaluation and treatment. The pure-tone audiogram revealed left mixed hearing loss, with an air-conduction threshold of 65 dBHL and a bone-conduction threshold at 35 dBHL. Intravenous (IV) acyclovir (800 mg, 5 times daily) and IV Solu-Medrol (60 mg, 3 times daily) were administered upon admission. He presented with House-Brackmann Grade III left-sided facial paresis 3 days following admission. The sore throat and husky voice improved during his hospital stay, and he was discharged 1 week later. His hearing recovered completely 1 month after discharge; however, the vocal fold paralysis and facial weakness persisted upon examination during several follow-up visits at our clinic. Ramsay Hunt syndrome is usually diagnosed easily based on typical symptoms. In some rare circumstances, the

involvement of cranial nerves IIIeXII, cervical nerves, and aseptic meningitis can occur [1]. Whereas serologic testing might be helpful, sensitivity is not very high. Ko et al [2] reported that viral titers do not appear to be a prognostic indicator. Age, multiple nerve palsies, and the initial grading of the palsy are the only significant covariates for facial nerve function recovery [2]. Vocal fold paralysis rarely occurs in Ramsay Hunt syndrome [3]. Multiple neuropathies usually result in significant morbidities. In one recent report, a case of Ramsay Hunt syndrome complicated vocal fold paralysis was managed with injection laryngoplasty, for hoarseness and airway protection, and a percutaneous endoscopic gastrostomy tube was placed to maintain nutrition [4]. It is generally thought that acyclovir

Figure 1. Laryngoscopic examination showed left side vocal fold paralysis with multiple ulcers and swelling of the mucosa over the left arytenoid (arrow).

1607-551X/$36 Copyright ª 2013, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.kjms.2013.03.007

Letter to the Editor and prednisolone treatment is effective in achieving recovery in cases of facial palsy [2]. However, hearing loss has been reported to be less responsive to such treatment [5]. The treatment response for vocal fold paralysis has not yet been established. The need for injection laryngoplasty, or other vocal fold medicalization procedures for paralyzed vocal folds, remains unclear. As shown in our case, early identification of this syndrome and immediate treatment with antiviral agents and steroid treatment is crucial in the successful management of the disease.

References [1] Asnis DS, Micic L, Giaccio D. Ramsay Hunt syndrome presenting as a cranial polyneuropathy. Cutis 1996;57:421e4. [2] Ko JY, Sheen TS, Hsu MM. Herpes zoster oticus treated with acyclovir and prednisolone: clinical manifestations and analysis of prognostic factors. Clin Otolaryngol Allied Sci 2000;25:139e42. [3] Sato K, Nakamura S, Koseki T, Yamauchi F, Baba M, Mikami M, et al. A case of Ramsey Hunt syndrome with multiple cranial nerve paralysis and acute respiratory failure. Nihon Kyobu Shikkan Gakkai Zasshi 1991;29:1037e41 [Article in Japanese].

265 [4] Coleman C, Fozo M, Rubin A. Ramsay Hunt syndrome with severe dysphagia. J Voice 2012;26:e27e8. [5] Kim YH, Chang MY, Jung HH, Park YS, Lee SH, Lee JH, et al. Prognosis of Ramsay Hunt syndrome presenting as cranial polyneuropathy. Laryngoscope 2010;120:2270e6.

Hsun-Hua Lee Department of Neurology, Shuang Ho Hospital, Taipei, Taiwan Chi-Wei Yeh Shih-Han Hung* Department of Otolaryngology, Head and Neck Surgery, Taipei Medical University Hospital, Taipei, Taiwan Department of Otolaryngology, School of Medicine, Taipei Medical University, Taipei, Taiwan *Corresponding author. Department of Otolaryngology, Head and Neck Surgery, Taipei Medical University Hospital, Number 252, Wu-Hsing Street, Taipei City 110, Taiwan. E-mail address: [email protected] (S.-H. Hung)

Ramsay Hunt syndrome with vocal fold paralysis.

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