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Herpes Zoster Oticus

(Geniculate Herpes; Ramsay Hunt Syndrome; Viral Neuronitis)

by Lawrence R. Lustig, MD

Herpes zoster oticus is infection of the 8th cranial nerve ganglia and the geniculate ganglion of the facial nerve by the herpes zoster virus.

Risk factors for herpes infection include immunodeficiency secondary to cancer, chemotherapy, radiation therapy, and HIV infection.

Symptoms and Signs

Symptoms include severe ear pain, transient or permanent facial paralysis (resembling Bell palsy), vertigo lasting days to weeks, and hearing loss (which may be permanent or which may resolve partially or completely). 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 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.


  • Perhaps corticosteroids, antivirals, and surgical decompression

Although there is no reliable evidence that corticosteroids, antiviral drugs, or surgical decompression makes a difference, they are the only possibly useful treatments. 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. Acyclovir 800 mg po q 4 h 5 times/day or valacyclovir 1 g po bid for 10 days may shorten the clinical course. 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). Before surgery, however, electroneurography is done and should show a > 90% decrement.

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