Herpes zoster oticus

Synonyms

Rumsay Hunt Syndrome

definition

Zoster oticus is a secondary disease caused by the varicella zoster virus in the ears. It is a special form of shingles (herpes zoster).

introduction

An infection with the Varicella zoster virus leaves as the first disease the chickenpox come up.
Because the virus a life long remains in the body of the infected person, it can be caused by a Reactivation of the virus in about 20% of those infected to one Second illness, of the Shingles come.
The Shingles occurs predominantly in the area of Upper body in appearance. Occasionally, the pronounced pain and blisters characteristic of shingles can also occur in the area of the auricle and / or des external ear canal occur. In this case one speaks of the so-called Herpes zoster oticus.

Is zoster oticus contagious?

As in shingles, the trigger for zoster oticus is the varicella-zoster virus, which belongs to the herpes virus group. Since zoster oticus is only a reactivation of the virus that has settled in the nerve cells, this is Risk of infection not so high.
In zoster oticus, the viruses are only found in the vesicle content of the rash. Since the virus-containing vesicle fluid Nevertheless is contagious, you should avoid direct contact with it. Although vaccination against the virus is available, people who have been vaccinated can develop herpes zoster oticus.

Epidemiology

More than 90% of the population are using the Varicella zoster virus infected and get sick with chickenpox (varicella) when infected for the first time. After that, they have lifelong immunity to chickenpox. Up to 20% of the partially immune adults, mostly over 40 years of age, later develop shingles, which can be associated with herpes zoster oticus. In about 2/3 of those suffering from herpes zoster oticus, the virus spreads to the Facial nerve, a cranial nerve, which leads to paralysis of the facial muscles (Facial palsy). There are no gender differences.

Pathogen

The varicella zoster virus is also called Human Herpes Virus-3 and belongs to the group of herpes viruses that can cause illness. It has a double-stranded DNA with a lipid envelope and occurs worldwide. It preferentially affects nerve cells and can form nerve nodes in the spinal canal (Spinal ganglion) last for years. It is transmitted through droplet infection.

causes

The initial infection with the Varicella zoster virus leads to chickenpox. Zoster oticus develops when the virus is reinfected or when the virus that is actually inactivated is reactivated in the body. These viruses migrate along nerve fibers in the spinal ganglia, where they persist and can only be activated again after years or decades. During reactivation, a larger part of the spinal ganglia is destroyed, which leads to acute pain, also known as zoster pain. The reactivation can be triggered by fluctuations or a drop in the immunity against the virus as a result of age, suppression of the body's own defense system (Immunosuppression) for example in transplant patients or defenses in the immune system (Immune insufficiency) For example HIV -Infected (AIDS). Possible causes are also violent vibrations of certain parts of the body, X-ray exposure, UV rays, Contact with toxic (toxic) Substances or other infectious diseases such as rabies.

The virus can be transmitted from people with shingles to those who are unprotected, who then get chickenpox. Likewise, a child with chickenpox can transmit the virus to an adult who will develop shingles.

Symptoms

Usually the first symptoms are Herpes zoster oticus vague symptoms such as fatigue and tiredness.

The vesicles characteristic of herpes zoster are found in zoster oticus on the auricle, on the earlobe, in the depths of the outer one Ear canal and also on the eardrum. They can also be found on the side of the neck, on the tongue and on the soft palate occurrence. The vesicles are the size of a pin or a grain of rice, as clear as water, taut and pearly. They form on a previously developed, slightly raised and sharply circumscribed reddening of the skin (Erythema) within two to three days. After two to seven days, the content of the vesicles becomes purulent and yellowish and the reddening subsides. After a week, the blisters dry out and a brownish / yellowish crust forms. The zoster heals again after about two to three weeks. However, scarring is common, leaving dark or light spots on the skin where the vesicles were previously (Hyper- and hypopigmentation).

Danger: The reactivation of the varicella zoster virus can also take place without any symptoms of the skin, which is referred to as herpes zoster sine herpete.

The so-called zoster pain has already been described above. With zoster oticus, this can occur in the ear, on the side of the face or on the neck. In 2/3 of the patients suffering from herpes zoster oticus, peripheral facial paralysis occurs in the first or second week of the disease, which is caused by the involvement of the Facial nerve caused by the virus. This leads to a weak or complete paralysis of the facial muscles on one side of the face. The patients cannot frown on the affected side, the eyelid closure is not or only incompletely possible and the Corner of the mouth hang down. Facial nerve palsy is often accompanied by a unilateral taste disturbance and impaired saliva secretion.

Facial paralysis can also occur with zoster colli.

General symptoms

Early signs of a developing Herpes zoster oticus can be unspecific general symptoms such as:

exhaustion,
fatigue,
head- and Body aches

Even dull, pulling pains usually burden the patient even before the visible Skin manifestations.
These come in the course of approximately three days add and show up at the beginning as a simple rising Redness. Subsequently, the vesicles fill with a clear one liquid. Sooner or later the vesicles open, dry out and crust. Within two to three weeks If the skin symptoms have subsided, provided they have occurred at all.

Localization of the symptoms

The pain and blisters that are characteristic of shingles (herpes zoster) usually occur in the area of the upper body.
Occasionally, however, this symptom can also be found in the head area.

If the above-average pain and the vesicles occur in the area of the auricle and / or the external auditory canal, one speaks of a zoster oticus.

Specific signs

scar or Pigment disorders the skin can stay behind if there is one Secondary infection of the area, i.e. an additional infection, for example with a bacterium, has occurred.
Also a so-called Zoster gangrenosus can cause scarring, as in the course of zoster gangrenosus Skin loss (Necrosis) is taking place.

After more or less successful healing of the skin symptoms, the pain can be as Herpes zoster oticus Symptom persist. This is called post-therapeutic neuralgia. Also Earache, one Hearing loss or a pathological hypersensitivity to normal sounds volume (Hyperacusis) can accompany the symptoms described above as symptoms of zoster oticus. In addition, he can Sense of balance be affected. This can be done with, for example Vomit and Vertigo express.

diagnosis

For the diagnosis, it is important to look at the patient's clinical symptoms, as the vesicles and reddening in the area of the ear are characteristic of herpes zoster. Further diagnostics are usually only necessary in case of problems. A pathogen can be detected. Direct virus detection is carried out using the polymerase chain reaction (PCR) made from affected tissue or vesicle contents. PCR is a technique used to replicate viral DNA if it should be in the samples. Specific antibodies against the virus can also be detected in the body. However, that is not very meaningful that it is Herpes zoster oticus reactivation of a virus already present in the body, i.e. the antibodies could have been produced by the body's defense system when it was first infected with chickenpox.

The Cerebrospinal fluid (Cerebrospinal fluid) is inflammatory changed, i.e. there are many more immune system cells and proteins than are normally found in the fluid. We obtained the liquor through a lumbar puncture. A hollow needle is inserted into the spinal canal in the Spine introduced and removed liquor. Under the microscope (Blood smear) find multinucleated giant cells.

Differential diagnosis

The blisters on the skin that are typical of herpes zoster can also be an atypical sign of an infection with the herpes simplex virus. This form of herpes simplex, which mimics the zoster, is also known as "zosteriform herpes simplex". Conversely, an irregularly localized zoster as "herpetiform zoster" can also imitate a herpes simplex infection. The clinical picture of the Eczema herpeticatum Like zoster oticus, it contains vesicles arranged in groups, but these burst very quickly. Eczema herpeticatum is caused by an additional herpes simplex infection in the presence of a chronic skin disease. Blistering also occurs in Hailey-Hailey's disease. In this skin disorder, the blisters form due to a congenital keratinization disorder of the skin.

The acute herpes zoster pain can be compared to the pain of a blood clot in the lungs (pulmonary embolism), a heart attack, appendicitis (appendicitis) or if you have migraines.

Guidelines

The so-called guidelines are Principles or courses of actionthat doctors can use for orientation. Clinical picture, Diagnosis and recommended Therapies are included.
Since zoster oticus is a special form of shingles and can take on serious courses, the guidelines can help with this identify correctly and to treat.
In the case of herpes zoster, oticus is mentioned in the guidelines every patient Highly recommended a antiviral therapy to start. Therapy is necessary here because the zoster oticus affects the nerves that are responsible for hearing, i.e. cranial nerves VII and VIII. Patients with zoster oticus can therefore avoid therapy hard of hearing or deaf become. It is therefore important to correctly diagnose herpes zoster.
According to the guidelines, the diagnosis is mainly made by the clinical picture posed. So-called tone threshold audiometry can be used for specific diagnostics to check hearing ability.

therapy

After the blisters have dried out, disinfectant ointments are applied to kill pathogens (antiseptic).

Of the Herpes zoster oticus must be treated antivirally. Therapy should be started no later than 72 hours after the appearance of skin symptoms. Usually comes Acyclovir for use, especially if it is a severe, complicated form of zoster oticus. This can be administered orally, i.e. in tablet form, or intravenously, via infusion. Also Brivudine, Famciclovir or Valaciclovir can be used as oral therapy. The drugs mentioned belong to the group of Antivirals. These are therefore active ingredients that specifically counteract the growth and reproduction of the herpes viruses. They inhibit the structure of the virus' DNA. Antiviral therapy often leads to freedom from pain and improvement in skin symptoms within hours.

Painkillers (Analgesics), Antidepressants, or drugs against epilepsy (Anti-epileptic drugs) how Gabapentin be taken. Tricyclic neuralgia usually help with herpes zoster Antidepressants how Amitriptyline preferably.

Drug treatment of herpes zoster oticus

So-called antiviral drugs for use. These are drugs that prevent viruses from multiplying hold up.

Preparations for systemic Therapy for people with an intact immune system (immunocompetent patients) can be considered are:

Acyclovir,
Famciclovir,
Valaciclovir and Briduvin.

Famciclovir, valaciclovir, and brivudine orally, i.e. supplied by mouth, whereas with acyclovir either the possibility of oral intake or the possibility of intravenous administration, i.e. administration in a vein, consists.
An intravenous administration is due to the higher active levels that can build up in the organism of the oral administration preferable.

In terms of the effect on Skin manifestations the above drugs are equivalent. Pain in the course of the Herpes zoster oticus According to studies, however, famciclovir, valaciclovir and brivudine fight faster.

in the Child- and Adolescence may only Acyclovir come into use. With people whose Weakened immune system or is suppressed (immunocompromised patients) is also exclusively Acyclovir given into the vein. Oral intake of famciclovir can also be considered in immunocompromised patients older than 25 years.

Furthermore, due to the usually pronounced pain, the patient should use local anesthetic Ear drops taken care of to prevent the persistent presence of the pain in the future. Also antibiotic ear drops should be considered as part of local treatment, as there is a possibility of bacterial Superinfection, i.e. an additional infection with a bacterium.

Homeopathic treatment of zoster oticus

At a Herpes zoster oticus there are many different homeopathic remedies, which are recommended in certain phases. So at the beginning, before the blisters appear, the person affected should Sulfur take in. Since zoster oticus is usually only noticeable through a general feeling of illness or pain in the area of the future rash, this phase is rather difficult to grasp.
If the vesicles are there and rather filled with pus, we recommend taking Anagallis arvensis.
At a clear vesicular fluid should Rhus toxicodendron be taken.
With severe Rashes and severe pain becomes Rhus vernix taken. In the follow-up treatment, especially if the herpes zoster oticus causes pain afterwards, although the rash has healed, take Kalmia latifolia devices.

Does herpes zoster oticus have to be treated in hospital?

Because of the serious irreparable Damages to be feared should be the Herpes zoster oticus treatment in time kick off. It is best to start treatment within first three daysafter the first symptoms show up.
Herpes zoster oticus is a diagnosis that requires an inpatient stay hospital justifies. In other words, this means that the herpes zoster oticus described below treatment should be done in the hospital.

Complications of a herpes zoster oticus

Will the symptoms of the Herpes zoster oticus If the disease is not taken seriously and the disease is not adequately treated, it threatens Hearing lossthat go to the full deafness can lead.
Also a peripheral one Fascial palsy is a worried complication of otic zoster. In the context of peripheral fascial palsy (nerve paralysis), the muscles that are responsible for the facial expressions is responsible, weak or even complete on one half of the face paralyzed. Even the frown is on the side on the side VII. Cranial nerve (Facial nerve) is impaired in its function is no longer possible. In addition, the following is an expression of peripheral facial paralysis:

an incomplete Eyelid closure,
an incomplete Mouth closure and or
a hanging Corner of the mouth.

Also the inner ear or the Vestibulochochlear nerve can be affected. This can lead to ringing in the ears, hearing loss up to deafness, vertigo, nausea and nausea. Other affected cranial nerves can include: Trigeminal nerve, abducens nerve, hypoglossal nerve and vagus nerve. Symptoms of irritation of the vagus nerve are hiccups (Singultus) and swallowing disorders. Symptoms of involvement of the trigeminal nerve are sensitivity disorders (sensibility disorders) and there is a risk of injury to the conjunctiva (Konjungtivis), Cornea (Cornea) and also of the optic nerve (Optic nerve), which can lead to impaired vision. The special form in which the first branch of the trigeminal nerve is affected is called zoster ophtalmicus because of the involvement of the eye.

In addition, postherpetic neuralgia can occur. This is a chronic pain syndrome that occurs in 10-15% of patients. In the area where the zoster has spread, the patient has persistent or recurring pain for four weeks. The duration is indefinite, the pain is excruciating, and there is even a risk of suicide. The likelihood that the neuralgia will persist for a long time increases with age. This can be months to years.

Inflammation of the meninges (meningitis) causing the varicella zoster virus (Herpes zoster encephalitis), or the generalization (Generalized zoster) are also serious complications. Generalized zoster denotes an entire affliction of the nervous system. This type of zoster is life-threatening, but usually only occurs in people who have weakened immune systems (e.g., AIDS patients). Infection with the varicella zoster virus can also cause the embryo to die during pregnancy.

Facial paralysis - paralysis of the facial nerve

Facial paralysis is a facial paralysis and can have various causes, but it is often based on a previous herpes zoster.
Since the facial nerve, or the facial nerve, can be affected by the reinfection by the virus in zoster oticus, damage to the nerve and thus facial paralysis can occur.
Facial paralysis is noticeable with a drooping corner of the mouth, no eyelid closure and no frown on the affected side. But it can also be weak, so that you can only see a change on closer inspection.
Facial paralysis usually only occurs temporarily or its dimensions can be reduced. In 80% of the cases, however, healing occurs. The risk that facial paralysis will not heal increases with age. It is therefore important to identify and treat herpes zoster oticus quickly, so that such late effects as facial paralysis can be prevented.
If facial paralysis occurs, it can be treated with glucocorticoids and antivirals. In addition, physiotherapy should be carried out afterwards so that the affected muscles are trained again.

Read more on this topic at: Facial palsy

prophylaxis

Since the zoster oticus can only break out when an infection with the Varicella zoster virus has taken place, vaccination against chickenpox is very useful. The vaccination is one of the standard vaccinations for children and adolescents. Women of childbearing potential should always be vaccinated, as a possible infection during pregnancy will harm the child. However, vaccination should be avoided during pregnancy.

The vaccine is a live vaccine (Zostavax) that contains weakened viruses. The body's defense system forms antibodies against the pathogens, kills them and thus becomes immune to the disease.

Acyclovir should be used as prophylaxis in patients who have a weakened immune system, especially bone marrow transplant recipients, during the period of severe immunocompromise.

forecast

The prognosis of zoster oticus is usually favorable, but that of its complications is poor. 2/3 of the infections heal without consequences and a relapse of the disease is rare. Herpes zoster neuralgia occurs in 10 to 15% of cases, and in every second case in over 60-year-olds, and lasts for months or even years. Facial paralysis and hearing disorders often only partially regress.

In immunocompromised people, the course of the disease is severe and the prognosis is poor. Fatal forms and complications occur.

Early or timely antiviral therapy significantly improves the prognosis.