May 06, 2020
The First Attack of Vertigo – Is it a Stroke or is it Inner Ear Disease?
Herpes Zoster Oticus (HZO) & Ramsey Hunt Syndrome (RHS)
These conditions are two forms of the same disease process where Ramsey Hunt Syndrome is Herpes Zoster Oticus with a facial nerve weakness.
The cause of this condition is a reactivation of dormant chicken pox virus (varicella-zoster virus) in the nerve cell bodies of the vestibulocochlear nerve (syn. acoustic nerve, 8th cranial nerve) and, in the case of RHS, the nerve cell bodies of the facial nerve (syn. 7th cranial nerve) as well.
Most people have had chicken pox and it is normal for this virus to lie dormant in the nerve cell bodies.
If reactivated, in the nerve cell bodies supplying the skin of the body, the disease is called shingles.
This reactivation tends to occur more commonly in patients over 60 whose immune systems are gradually getting weaker and specifically in immunocompromised individuals.
The reactivation of the virus inflames the vestibulocochlear nerve
(syn. acoustic nerve, 8th cranial nerve) which affects balance and hearing function, and in the case of reactivation of the virus in the facial nerve cell bodies the facial movement function is affected.
Typically, patients experience acute spinning vertigo lasting for between 1 to 3 days, hearing loss, ear pain (& facial weakness in the RHS variant of HZO).
Examination reveals an ear rash, a sensorineural hearing loss, and, in RHS a facial weakness. Patients exhibit horizontal nystagmus beating to the healthy
Treatment consists of: –
1. Prednisolone, 60 mg for 5 days, with a proton pump inhibitor and no contra-indications to steroids. The steroid reduces nerve inflammation.
2. The antiviral Aciclovir: 800mg 5xday for 7 days.
3. The pain associated with this infection is usually adequately controlled with Ibuprofen (300mg – 400mg 3-4 x day). Neuralgia is treated with medications such as Pregabalin (Lyrica) 75mg twice a day to a maximum of 300mg twice a day after 7 days.
4. The facial weakness can expose the cornea of the eye in some patients: artificial tears such as hypromellose and an eye shield/dressing tape may be necessary.