Sore throat and left ear pain
This elderly patient’s unilateral pattern of symptoms was key to the diagnosis.
Although it’s a clinical Dx, lab testing can provide confirmation
Diagnosis of Ramsay Hunt syndrome is typically made clinically, but can be confirmed with direct fluorescent antibody (DFA) analysis,10 polymerase chain reaction (PCR) testing,11 or viral culture of vesicular exudates. DFA for VZV has an 87% sensitivity.10 PCR has a higher sensitivity (92%),11 is widely available, and is the diagnostic test of choice according to the Centers for Disease Control and Prevention.12
For our patient, we obtained swabs of the oral vesicles and ordered a DFA analysis; however, the sample didn’t show VZV. This may have been due to inadequate sampling. (Proper sampling requires that there be an adequate collection of cells from the base of the vesicles.)
Oral antivirals, steroids are mainstays of treatment
Treatment with an oral steroid such as prednisone in addition to an antiviral such as acyclovir or valacyclovir may reduce the likelihood of postherpetic neuralgia and improve facial motor function; however, these benefits have not been demonstrated in randomized controlled trials.13
Our patient was treated with oral valacyclovir 1 g 3 times a day for 7 days and oral prednisone 50 mg/d for 5 days. After one week of treatment, his symptoms resolved and the vesicles in his mouth crusted over. He did not experience postherpetic neuralgia or have a recurrence.
CORRESPONDENCE
David A. Moss, MD, 4700 North Las Vegas Boulevard, Nellis AFB, NV 89191; david.moss.3@us.af.mil
