Overview
Caused by varicella zoster virus invading the facial nerve and auditory nerve.
Manifestations include ear herpes, earache, tinnitus, vertigo, and taste disorders.
Can be treated with general therapy, medication, physical therapy, etc.
Herpes zoster is self-limiting and generally has a favorable prognosis.
Definition
Herpes zoster of the ear is one of the specific manifestations of herpes zoster, which is caused by varicella zoster virus invading the facial and auditory nerves, and mainly manifests as herpes of the ear canal or tympanic membrane. When the triad of facial paralysis, otalgia and herpes of the external auditory canal is present, it is called Ramsay-Hunt syndrome [1].
Incidence
Herpes zoster of the ear is sporadically prevalent, most often in adults, the vast majority of whom are over 50 years of age or have chronic diseases and immunodeficiencies [2].
Etiology
Causes
Herpes zoster of the ear is primarily caused by varicella-zoster virus invading the facial and auditory nerves.
Patients are the only source of infection, but the contagiousness is relatively small, mainly through air droplet transmission, direct contact with herpes fluid or its contaminated utensils may also be transmitted, low immunity such as patients with tumors, AIDS and other patients as susceptible people [2].
Predisposing factors
The following factors can predispose to the above etiology and cause an attack or exacerbation of the disease.
Previous chickenpox infection.
Suffering from immunodeficiency diseases such as AIDS.
Herpes zoster of the ear may also be triggered when certain factors such as fatigue, severe infections, malignant tumors, and the use of immunosuppressants (e.g. cyclophosphamide, cyclosporine) lead to a decrease in the resistance of the patient’s organism [1].
Pathogenesis
After primary infection with varicella-zoster virus (chickenpox), some of the virus can remain latent for a long time in the posterior root ganglia of the spinal cord or the sensory ganglia of the cerebral nerves.
When the body resistance is reduced (e.g. malignancy, use of immunosuppressive drugs, etc.), the latent virus is activated and travels down to the skin through the axons of the sensory nerve fibers, proliferating in the skin area it innervates and causing herpes zoster. Simultaneously, inflammation and necrosis of the involved nerves occur, producing neuralgia [3].
Symptoms
Main Symptoms.
Herpes zoster of the ear may have different clinical manifestations and the main symptoms are herpes of the ear, ear pain, auditory vestibular dysfunction, and peripheral facial paralysis.
Ear herpes
The main manifestation is the appearance of clustered small blisters in the area around the ear. The walls of the blisters are tense and shiny, the blister fluid is clarified, a red halo can be seen around the periphery of the blisters, and the skin between the clusters of blisters is normal [4].
Earache.
Herpes zoster is often associated with neuralgia, and herpes zoster of the ear may present with intra- and/or peri-auricular pain, but the pain tends to resolve within 1 month after complete resolution of the cutaneous mucosal lesions.
Auditory vestibular dysfunction
It mainly includes hearing impairment and vertigo [5].
Hearing impairment is mainly manifested as tinnitus and deafness, etc., and vertigo can be accompanied by nausea and vomiting [6].
Peripheral facial paralysis
The main manifestations are unilateral frontal lines disappearing or becoming shallow, inability to frown, inability to close the eyelids, large eye slits, tearing, unilateral shallow nasolabial folds, drooping of the corners of the mouth to the healthy side of the traction, puffing the cheeks, leakage of air when whistling, and impaired sense of taste, etc. [7].
Other symptoms
Some patients may present with general malaise, low-grade fever, headache and loss of appetite in the early stages of the disease [8].
Complications
Viral meningitis
Viral meningoencephalitis can develop if the cerebral nerve or cervical ganglion is invaded by the virus and spreads upward [9].
The main symptoms are headache, vomiting, and convulsions.
Postherpetic neuralgia
Postherpetic neuralgia is a more common complication of herpes zoster, and its pain originates from the damage of sensory nerves, which can be manifested as intermittent pain, chronic pain or spontaneous pain [10].
Patients with herpes zoster in the ear have a higher probability of developing postherpetic neuralgia, and the pain can last for weeks, months, or even years [11].
Consultation with a physician
Department of Medicine
Dermatology.
Prompt consultation with a dermatologist is recommended in the presence of clustered small blisters and ear pain in the area around the ear, along with tinnitus and deafness.
Neurology
If you have symptoms such as unilateral frontal lines disappearing or becoming shallow, inability to frown, inability to close the eyelids, large eye slits, tearing, unilateral shallow nasolabial folds, drooping of the corners of the mouth to the healthy side, leakage of air when puffing out the cheeks or whistling, and taste disturbance, we suggest you consult the Department of Neurology in a timely manner.
Emergency Department
When symptoms such as severe headache, dizziness, nausea and vomiting occur, it is recommended to consult the Emergency Department in a timely manner.
Preparation for medical treatment
Preparing for medical treatment: registration, preparation of documents, and common problems.
Tips
It is recommended to wear loose clothing to the clinic to facilitate a full body physical examination.
Record the changes and characteristics of your condition to give your doctor more reference.
Preparation Checklist
Symptom list
Particular attention should be paid to the time of onset of symptoms, special manifestations, etc.
Are there clusters of small blisters in the area around the ear?
Is there pain in the ear?
Is there any discomfort such as tinnitus, deafness, vertigo, nausea, or vomiting?
Are there any symptoms such as unilateral loss or lightening of frontal lines, inability to frown, inability to close the eyelids, large eye slits, tearing, unilateral shallow nasolabial folds, drooping of the corners of the mouth to the healthy side, leakage of air when puffing out the cheeks or whistling, and impaired sense of taste?
Were there any symptoms of general malaise, low-grade fever, headache and loss of appetite at the onset of the disease?
Medical history checklist
Any previous chickenpox infection?
Any immunodeficiency diseases such as AIDS?
Have you recently been overworked?
Any recent history of serious infections such as respiratory infections, gastrointestinal infections, urinary tract infections, etc.?
Is there a history of malignant tumor disease?
Any recent use of immunosuppressive drugs (e.g. cyclophosphamide, cyclosporine, etc.)?
Checklist
Test results in the last six months, which can be brought to the doctor’s office
Laboratory tests: blood test, HIV antibody, pathogenetic test, etc.
Imaging tests: magnetic resonance examination
Other tests: facial nerve electrogram and electromyography
List of medications used
Medications used in the last 3 months, if available in boxes or packages, bring them to the doctor’s office
Antiviral drugs: acyclovir, famciclovir, etc.
Pain medications: Pregabalin, diclofenac sodium, amitriptyline, etc.
Glucocorticoids: prednisone, methylprednisolone, etc.
Nutritional nerve drugs: vitamin B1, vitamin B12 and so on.
Topical drugs: glycerite lotion, acyclovir cream, etc.
Diagnosis
Diagnosis
Herpes zoster of the ear can be diagnosed according to the patient’s medical history, clinical manifestations, laboratory tests and imaging.
Medical history
The following is not necessary for the diagnosis of the disease, but the following history, if available, may provide some reference for the diagnosis of the disease
Previous chickenpox infection.
Immunodeficiency diseases such as AIDS.
Recent overexertion and poor rest.
Recent history of serious infections such as respiratory infections, gastrointestinal infections, urinary tract infections, etc.
Have a history of malignant tumor disease.
Recent application of immunosuppressants (e.g. cyclophosphamide, cyclosporine, etc.).
Clinical manifestations
Characteristic manifestations such as ear pain and ear herpes are present, which may also be accompanied by auditory vestibular dysfunction and peripheral facial paralysis [12].
Laboratory tests
Routine blood tests
It is mainly to know whether the patient has occurred blood system abnormality.
When the white blood cells and neutrophils are elevated to different degrees, it suggests the presence of infections, which helps to understand the triggering factors of the disease.
HIV Antibody
This is a measure of whether or not the patient has AIDS.
When the HIV antibody is positive, it is usually considered that the patient has AIDS, which is valuable in determining the causative factors of the disease.
Pathogenetic examination
The main herpes scrapings, viral DNA test, etc [13].
If the experimental results are positive or varicella-zoster virus is detected, it is of guiding significance to the diagnosis of the disease.
Imaging examination
Magnetic resonance examination
Magnetic resonance examination can be used to find out if the patient has any other ear diseases.
Peripheral facial paralysis due to facial nerve and internal auditory canal tumors, otitis media, or middle ear mastoid cholesteatoma can be excluded by magnetic resonance examination, which is of significance in the differential diagnosis.
Other tests
Electroencephalography and electromyography are used to determine the extent of facial paralysis.
Depending on the results of neurography and electromyography, the severity of the condition can be determined.
Differential Diagnosis
Herpes zoster of the ear generally needs to be differentiated from diseases such as otitis externa, Bell’s palsy, and Meniere’s disease.
Otitis externa
Similarities: Both can present with ear pain and tinnitus.
Differences: Otitis externa is commonly caused by Staphylococcus aureus, hemolytic streptococcus, etc., and anti-infection is the mainstay of treatment; whereas herpes zoster is mainly caused by varicella zoster virus, and anti-viral treatment is the mainstay of treatment.
Bell’s palsy
Similarities: Both may present with facial paralysis such as crooked corners of the mouth, difficulty in closing the eyes, abnormal sense of taste, loss of frontal lines on the affected side, shallow or absent nasolabial folds, and enlarged eyelid fissures.
Differences: Bell’s palsy usually has an acute onset, and most of the clinical manifestations are obvious within 3 days or so, without earache or herpes in the ear; whereas herpes zoster in the ear not only presents with facial paralysis, but also with severe earache and herpes in the outer ear.
Meniere’s disease
Similarities: Both may present with symptoms such as vertigo, hearing impairment and tinnitus.
Differences: Meniere’s disease is characterized by recurrent episodes of rotational vertigo, hearing impairment, tinnitus, and/or ear fullness, but without herpes externa [14]. Although herpes zoster of the ear is associated with mild vertigo, tinnitus and hearing impairment, herpes zoster of the auricle or its surrounding skin and peripheral facial palsy may help to differentiate the two.
Treatment
Treatment objectives: to relieve acute-phase pain, control the development of the rash, shorten the course of the disease, and prevent the occurrence of acute and chronic complications such as posterior neuralgia [3].
Treatment principles: mainly including antiviral, pain relief, anti-inflammatory, prevention and treatment of complications. General treatment, drug treatment, physical therapy, etc. are adopted.
General treatment
Pay attention to rest and avoid exertion.
Supplement nutrition and water, and avoid spicy and stimulating food.
Avoid scratching the affected area to avoid blister rupture and secondary infection.
Medication
Systemic treatment
Antiviral drugs
Commonly used drugs include acyclovir and famciclovir.
Antiviral therapy is usually started within 48-72 hours after the onset of rash, and generally early and sufficient antiviral therapy, especially for patients over 50 years old, is favorable to reduce neuralgia and shorten the course of the disease [1].
It is contraindicated in those who are allergic to the product. Common adverse reactions are nausea, vomiting, diarrhea, loss of appetite, thirst, etc.; joint pain, headache, vertigo and other manifestations may occur with prolonged oral administration.
Analgesic drugs
Commonly used drugs include pregabalin, diclofenac sodium, amitriptyline and so on.
It is suitable for patients with acute phase pain [1].
Common adverse reactions of diclofenac sodium are headache, dizziness, nausea, vomiting, dyspepsia, hepatic impairment, etc. It is contraindicated in those who are allergic to the product, perioperative period of coronary artery bypass grafting surgery, have gastrointestinal ulcers or hemorrhage, severe hepatic, renal and cardiac failure, and in the second trimester of pregnancy.
Amitriptyline may have adverse reactions such as excessive sweating, dry mouth, blurred vision, dysuria, drowsiness, postural hypotension, bone marrow suppression, toxic liver damage, etc. It is contraindicated for those with severe heart disease, recent history of myocardial infarction seizure, epilepsy, glaucoma, urinary retention, hyperthyroidism, hepatic impairment, and allergy to tricyclic drugs.
Glucocorticoid
Commonly used drugs include prednisone, methylprednisolone and so on.
Early and reasonable application of glucocorticosteroids can inhibit the inflammatory process and shorten the course of herpes-associated pain in the acute phase [1].
Long-term application may cause side effects such as infection, osteoporosis, drug diabetes, and aseptic necrosis of the femoral head may occur in a few cases, which needs to be monitored and treated in time.
Nutritional nerve drugs
Commonly used drugs include vitamin B1, vitamin B12 and so on.
They can promote the recovery of damaged nerves and reduce the occurrence of postoperative neuralgia.
A history of allergy to this product is prohibited. Oral vitamin B1 overdose may occur headache, fatigue, irritability, diarrhea and other adverse reactions; oral vitamin B12 may occur hypokalemia, hyperuricemia and other adverse reactions.
Localized treatment
The principle of treatment is based on antiviral, drying and anti-inflammatory.
When the blisters are unbroken, topical glycerite lotion and acyclovir cream can be used; after herpes breakout, 3% boric acid solution or 1:5000 furacilin solution can be used as appropriate to apply wet compresses, and 0.5% neomycin ointment or 2% mupirocin ointment can be used externally [1].
Physical therapy
It mainly includes local irradiation such as ultraviolet rays and infrared rays, which can promote the blisters to dry up and crust, and relieve the pain [1].
The irradiated area should be cleaned before treatment, and the non-irradiated area should be covered with a blackout cloth. Special protective eyewear should be worn during treatment, and the eyes should be closed and covered with double gauze to avoid direct light to the eyes during treatment; try not to change the body position during irradiation.
Prognosis
Cure
Herpes zoster of the ear is self-limiting and can be cured, and the prognosis is generally good, while some people with more severe conditions may be left with permanent facial paralysis and sensorineural deafness [2].
Prognostic factors
The prognosis of herpes zoster of the ear is influenced by a number of factors, and the following factors may lead to a poor prognosis.
Advanced age, poor immunity or immunodeficiency diseases.
Poor lifestyle, such as chronic smoking, alcohol consumption, and late nights.
Poor health, recurrent respiratory infections, urinary tract infections, etc.
Insufficiently timely diagnosis or treatment of the disease, resulting in prolonged illness and serious complications.
Daily
Daily Management
Dietary management
Avoid intake of spicy and stimulating, pan-fried and deep-fried foods.
Replenish water and give food with high calories, high protein (e.g. milk, eggs, lean meat), high vitamins (e.g. fresh vegetables, fruits), and easy to digest.
Life management
Ensure sufficient rest and sleep, keep the indoor environment comfortable, air circulation, open the windows regularly every day for ventilation.
Patients need to wear loose cotton clothes and pants to reduce friction; healthy side lying position, do not scratch the blisters, to avoid blister rupture and trauma secondary infection; blisters rupture, oozing, timely replacement of the patient’s clothing and bed linen [4].
Patients should rest in bed during the acute fever period, and light physical activities and appropriate exercise can be performed during the recovery period.
Psychological support
It is recommended that the patient’s family members help the patient to establish confidence, encourage the patient to eliminate negative emotions in an appropriate way, so that the patient’s mood is stable and comfortable, and actively cooperate and participate in the treatment.
Disease monitoring
Monitor the changes of skin lesions, including the presence of new blisters or rupture, wound oozing.
Pay attention to the observation of his or her mental state, hearing, vision, feeding, to prevent the occurrence of viral meningitis.
Closely observe the skin reaction after topical application of drugs; drug treatment may lead to abnormal elevation of blood glucose, liver and kidney function, etc., monitor the relevant indexes, and if abnormalities are found, the doctor should be informed in time for symptomatic treatment [4].
Follow-up review
According to the results of the review and timely adjustment of drug dosage, regular follow-up can be timely understanding of the changes in the condition, early symptomatic treatment, can delay the progress of the disease as well as to prevent the occurrence of complications.
Regular follow-up is required according to the doctor’s instructions, and the follow-up period is usually 1~2 weeks.
Blood tests, blood biochemistry, pathogenetic tests and other related tests may be required during the follow-up.
Prevention
Herpes zoster of the ear can help prevent the disease and reduce the risk of developing the disease through the following healthy lifestyles or behaviors, etc.
Regular routine, avoid staying up late, take rest and avoid over-exertion.
Exercise moderately to strengthen the body’s resistance.
Pay attention to personal hygiene and change clothes in time to prevent infection.
Avoid gathering of people and wear a good mask when going to public places.
People of advanced age, malignant tumors, AIDS, long-term application of immunosuppressive drugs and other immunity or resistance is poor, can be injected with herpes zoster vaccine.