Introduction
Ramsay-Hunt syndrome (RHS) is a disorder characterized by facial paralysis, herpetic eruptions on the auricle and otalgia due to the reactivation of latent varicella zoster virus in the geniculate ganglion. A few cases of multiple cranial nerves invasion including vestibulocochlear nerve, glossopharyngeal nerve and vagus nerve were reported. However, there was no report about a rare case of Ramsay-Hunt syndrome with clinical tracheal aspiration of food materials. We report a patient with delayed onset swallowing difficulty after 16 days of Ramsay-Hunt syndrome development.
Case report
A 67-year old male presented to our hospital with 7-day history of right sided otalgia. One day before his visit, he suffered from dizziness. He had no chronic diseases except diabetes for 5 years.
Physical examination revealed vesicular eruptions and pustules in right ear auricle. He had vertigo and decreased hearing. The patient was given intravenous acyclovir 1500mg and intravenous dexamethasone 5mg daily for 9 days. During 9-days of admission, there showed no definite improvement but the patient discharged against medical advice.
After 7 days from discharge, the patient presented emergency room with additional symptom of right sided facial expression muscle weakness and swallowing difficulty. He admitted again and evaluated. And that time, physical examination revealed nasolabial fold flattening, drop of oral angle, and decreased movement of forehead wrinkles. Right side gag reflex was absent and uvular was deviated to left. He had respiratory symptoms including hoarseness, sputum, mild dyspnea that highly suggest tracheal aspiration. Enteral tube feeding is used to help prevent further aspiration. Intravenous acyclovir 1500mg administered daily for 6 days. The patient started to improve gradually. After 2 months his symptom has been improved complete remission of otalgia and skin lesions. However he had residual neurological deficits including facial palsy, hearing impairment, dizziness, and dysphagia.
Studies and imaging
Gadolinium-enhanced magnetic resonance imaging (MRI) of the brain did not show any evidence of acute pathology in both cerebral hemisphere and brainstem.
At second admission, electrophysiologic study for facial nerve was performed. In that study, facial nerve conduction study showed low compound muscle action potential amplitude on orbicularis oculi and orbicularis oris muscles.
In video fluoroscopic swallowing study (VFSS), there showed large amount of tracheal aspiration when swallow thin liquid, semisolid and solid materials. And there were also residual barium on pyriform sinus and valleculae fossa. Radionuclid salivagram study revealed markedly delayed esophageal transit.
Conclusion
RHS with multiple cranial nerve involvement should be considered, even though no further symptom developed in early phase. |
