Symptoms of herpes zoster oticus include

Vesicles occur on the pinna and in the external auditory canal along the distribution of the sensory branch of the facial nerve. Symptoms of meningoencephalitis (eg, headache, confusion, stiff neck) are uncommon. Sometimes other cranial nerves are involved.

Diagnosis of herpes zoster oticus usually is clinical. If there is any question about viral etiology, vesicular scrapings may be collected for direct immunofluorescence or for viral cultures, and MRI is done to exclude other diagnoses.

Although there is no reliable evidence that corticosteroids, antiviral drugs, or surgical decompression makes a difference, they are the only possibly useful treatments. When used, corticosteroids are started with prednisone 60 mg po once/day for 4 days, followed by gradual tapering of the dose over the next 2 wk. Either acyclovir 800 mg po 5 times/day or valacyclovir 1 g po bid for 10 days may shorten the clinical course and is routinely prescribed for immunocompromised patients.

Vertigo is effectively suppressed with diazepam 2 to 5 mg po q 4 to 6 h. Pain may require oral opioids. Postherpetic neuralgia may be treated with amitriptyline.

Surgical decompression of the fallopian canal may be indicated if the facial palsy is complete (no visible facial movement), but must be performed within 2 wk of onset of the facial paralysis to be effective. Before surgery, however, electroneurography is done and should show a >90% decrement.