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Herpes Zoster Oticus in Emergency Medicine

http://emedicine.medscape.com/article/1952189-overview

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Herpes Zoster Oticus in Emergency Medicine Overview of Herpes Zoster Oticus


Author: Christina Bloem, MD; Chief Editor: Steven C Dronen, MD, FAAEM more... Updated: Mar 29, 2011

Overview of Herpes Zoster Oticus


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. (See the image below.)

Herpes zoster oticus. Image courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic.

Ramsay Hunt syndrome accounts for up to 12% of all facial paralyses and generally causes more severe symptoms and has a worse prognosis than Bell palsy.[1, 2, 3] 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. The incidence rates of HZ oticus in males and females are equal, and incidence increases significantly in patients older than 60 years.

Pathophysiology of HZ Oticus
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 herpes zoster (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.

Clinical Manifestations of HZ Oticus


Patient history
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Herpes Zoster Oticus in Emergency Medicine

http://emedicine.medscape.com/article/1952189-overview

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 (see the image below)

Herpes zoster oticus. Image courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic.

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 examination
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, and 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 include the following: 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.

Complications
Complications of HZ oticus may include the following[4, 5, 6] : Postherpetic neuralgia Residual paralysis Rarely, herpes zoster encephalitis [5]

Etiology of HZ Oticus
Herpes zoster (HZ) oticus is caused by the reactivation of latent varicella-zoster virus (VZV) that 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 stress and emotional stress often are cited as precipitating factors.

Differential Diagnosis
The differential diagnosis of herpes zoster (HZ) oticus includes the following: Bell Palsy Headache, Cluster Headache, Migraine Headache, Tension Herpes Zoster Otitis Externa Otitis Media

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Herpes Zoster Oticus in Emergency Medicine

http://emedicine.medscape.com/article/1952189-overview

Stroke, Hemorrhagic Stroke, Ischemic Isolated facial nerve trauma also needs to be considered.

Laboratory Studies
Herpes zoster oticus (HZ oticus) is primarily a clinical diagnosis in the ED. Prior to initiating treatment with acyclovir, consider a baseline set of the following laboratory studies: Blood urea nitrogen (BUN) Creatinine Blood cell counts Electrolytes

Imaging Studies
If diagnosis of Ramsay Hunt syndrome is not established by physical examination alone, consider a head CT scan to investigate other etiologies of facial paralysis.

Treatment of HZ Oticus
Until recently, therapy for herpes zoster (HZ) oticus has been generally supportive, including warm compresses, narcotic analgesics, and antibiotics for a secondary bacterial infection.

Antiviral agents
Antiviral agents clearly play a role in limiting the severity and duration of symptoms if given early in the course of the illness. Early administration (< 72 h) of acyclovir showed an increased rate of facial nerve function recovery and prevented further nerve degeneration. Furthermore, use of antivirals has been shown to decrease the incidence and severity of postherpetic neuralgia.[7, 8, 9, 4] Evidence is accumulating that varicella-zoster virus (VZV) may be responsible for many cases of Bell palsy that go unrecognized because of a lack of cutaneous findings (zoster sine herpete). Accordingly, the clinician should entertain more liberal use of antivirals such as acyclovir, valacyclovir, and famciclovir.[2, 3] Studies have shown no difference between oral and IV acyclovir in immunocompetent patients with facial nerve paralysis.[10]

Corticosteroids
Systemic corticosteroids are used to relieve acute pain, decrease vertigo, and limit the occurrence of postherpetic neuralgia. The prevailing wisdom states that treatment with acyclovir plus prednisone has more effective return to facial nerve function and prevention of nerve degeneration than treatment with prednisone alone; however, a recent review uncovered very little data to support or negate this theory.[7] Patients treated with acyclovir plus prednisone had better outcomes (time to healing of rash, time to cessation of acute neuritis, time to return to usual activity and sleep, and time to cessation of analgesics) than those treated with either prednisone or acyclovir alone.[11] No evidence indicates that use of corticosteroids prevents development of postherpetic neuralgia.[8, 9] Furthermore, evidence proving benefit attributed specifically to steroids is still limited, with one review showing no randomized controlled trials supporting use of steroids as an adjuvant to antiviral medications in the treatment of Ramsay Hunt syndrome.[12]

Treatment in HIV patients


For treatment of herpes zoster in patients with HIV, inpatient parenteral regimens should be reserved for those with severe immunosuppression, trigeminal nerve involvement, ocular lesions, or multidermatomal involvement. Treatment of VZV is the same for both HIV-seronegative and seropositive patients. For acyclovir-resistant VZV, IV foscarnet is an appropriate alternative therapy (famciclovir and valacyclovir are not effective against acyclovir-resistant VZV). For outpatient regimens, famciclovir or valacyclovir for 7-10 days is recommended (both have the advantage of easier dosing regimens). Routine use of steroids is discouraged secondary to its immunosuppressive effects.[13]

Treatment in other situations


Treatment of pregnant women with VZV is the same as that of nonpregnant women.

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Herpes Zoster Oticus in Emergency Medicine

http://emedicine.medscape.com/article/1952189-overview

When secondary impetigo is present, a suitable antistaphylococcal antibiotic should be prescribed. Cyclic antidepressants, anticonvulsants, opioids, and topical analgesics are sometimes used in the treatment of postherpetic neuralgia.[4] These agents are more appropriately started by a pain management specialist in an outpatient setting. Prevention of herpes zoster by vaccination is recommended for all persons older than 60 years, even if they have had chickenpox or zoster in the past. This age group suffers significant morbidity from zoster and may, therefore, benefit from the vaccine. Contraindications to vaccine administration include age younger than 60 years, current use of antivirals, pregnancy, and certain immunosuppressive conditions.[14] Ensure that the patient has adequate and timely outpatient follow-up for management of HZ oticus.

Emergency department care


Adequate analgesia is important for individuals with significant pain from herpes zoster. Nausea and vomiting may require ED treatment. Complications, such as corneal irritation or secondary bacterial infection of the vesicles, should be managed with routine therapies. Involvement of more than one dermatome is atypical and should prompt the search for possible immunoincompetence. Consider admission for any of the following situations: Severe symptoms Involvement of multiple (>2) dermatomes Immunocompromise

Consultations
Consider an ophthalmologic consultation if corneal involvement with vesicles is noted, and consider a neurologic consultation if the etiology of the facial paralysis is unclear. Consultation with an ear, nose, and throat (ENT) specialist may be appropriate.

Prognosis
Prolonged or permanent facial paralysis is possible. Most patients with partial paralysis fully recover; many with severe symptoms are left with partial deficits.

Patient Education
Instruct patients how to tape eyes shut if lid paralysis is present.

Contributor Information and Disclosures


Author Christina Bloem, MD Assistant Clinical Professor of Emergency Medicine, George Washington University Disclosure: Nothing to disclose. Coauthor(s) Maria M Diaz, MD Staff Physician, Department of Emergency Medicine, Memorial Hospital Maria M Diaz, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Phi Beta Kappa Disclosure: Nothing to disclose. 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.

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Herpes Zoster Oticus in Emergency Medicine

http://emedicine.medscape.com/article/1952189-overview

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. Specialty Editor Board 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. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine Disclosure: eMedicine Salary Employment 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. Chief Editor Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte 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.

References
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Herpes Zoster Oticus in Emergency Medicine

http://emedicine.medscape.com/article/1952189-overview

1996;125(5):376-83. [Medline]. 9. 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]. 10. Furuta Y, Ohtani F, Mesuda Y, Fukuda S, Inuyama 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]. 11. Murakami S, Honda N, Mizobuchi M, Nakashiro Y, Hato N, Gyo K. Rapid diagnosis of varicella zoster virus infection in acute facial palsy. Neurology. Oct 1998;51(4):1202-5. [Medline]. 12. 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]. 13. Benson CA, Kaplan JE, Masur H, Pau A, Holmes KK. Treating opportunistic infections among HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. MMWR Recomm Rep. Dec 17 2004;53:1-112. [Medline]. 14. 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]. Medscape Reference 2011 WebMD, LLC

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