Herpes Zoster Oticus

(Geniculate Herpes; Ramsay Hunt Syndrome; Viral Neuronitis)

ByMickie Hamiter, MD, New York Presbyterian Columbia
Reviewed/Revised May 2023

Herpes zoster oticus is a herpes zoster virus infection of the clusters of nerve cells (ganglia) that control the nerves responsible for hearing and balance (8th cranial nerve) and for facial movement (7th cranial nerve).

Herpes zoster (shingles) is infection that results from a reactivation of the varicella-zoster virus, which causes chickenpox. After an episode of chickenpox, the virus lies dormant in nerve roots and can be reactivated, travelling down the nerve fibers to the skin, where it causes painful sores. Most often the cause of reactivation is unknown, but sometimes it occurs when the immune system is weakened, for example, by cancer, AIDS, or certain medications.

Herpes zoster oticus occurs when the herpes zoster virus is reactivated in the 7th (facial) and 8th (auditory or vestibulocochlear) cranial nerves. The 7th cranial nerve controls some muscles of the face. The 8th cranial nerve controls hearing and balance.

(See also Overview of the Inner Ear.)

Symptoms of Herpes Zoster Oticus

The symptoms of herpes zoster oticus include the following:

  • Severe ear pain

  • Fluid-filled blisters (vesicles) on the outside of the ear (pinna) and in the ear canal

  • Temporary or permanent paralysis of one side of the face (similar to Bell palsy)

  • Vertigo (a false sensation of moving or spinning) that lasts days to weeks

  • Hearing loss, which may be permanent or which may resolve partially or completely

  • Rarely, headache, confusion, or a stiff neck

Sometimes other cranial nerves are affected.

Diagnosis of Herpes Zoster Oticus

  • Physical examination

  • Sometimes laboratory tests of fluid from the blisters

  • Sometimes magnetic resonance imaging (MRI)

Doctors typically base the diagnosis of herpes zoster oticus on results of a physical examination. Sometimes doctors take scrapings of the vesicles for examination under a microscope and for culturing. MRI may also be done to make sure the symptoms are not caused by another disorder.

Treatment of Herpes Zoster Oticus

  • Sometimes antiviral medications to treat the infection

  • Sometimes opioid medications for pain

  • Rarely surgery to relieve pressure on the facial nerve

Other treatments may be given to people who have prolonged residual pain (called postherpetic neuralgia). These treatments include medicated skin patches, antiseizure medications, and tricyclic antidepressants.

People who have complete paralysis of the face may need a surgical procedure to relieve pressure on the facial nerve.

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