CASE REPORT |
https://doi.org/10.5005/jp-journals-10023-1256 |
Laryngeal Herpes: Atypical Presentations
1,4,5Department of ENT, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India
2Department of ENT, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
3Department of ENT, Index Medical College, Hospital and Research Center, Indore, Madhya Pradesh, India
Corresponding Author: Nitin Mittal, Department of ENT, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India, Phone: +91 9770311077, e-mail: dr.nitin.mittal20@gmail.com
Received: 01 June 2024; Accepted: 22 June 2024; Published on: 17 July 2024
ABSTRACT
Laryngeal herpes is a rare entity. Varicella zoster virus (VZV) can involve the pharyngolaryngeal region and cranial nerves. The first contact with this virus, transmitted by airborne particles shed from the skin of an infected person, produces symptoms. After resolution of symptoms, VZV travels to the dorsal root ganglia of the spinal cord, where it remains dormant for years. Reactivation of the virus occurs secondary to impaired cellular immunity. A case of a 60-year-old man presented with a change in voice and difficulty in swallowing. Another case of a 75-year-old woman presented with a change in voice, sore throat, and right facial palsy. In both cases, flexible laryngoscopy showed vesicles on the right side of the larynx. Cases were confirmed by laryngeal swab PCR testing. Both cases were treated with oral steroids and oral antiviral valacyclovir 500 mg three times a day for 10 days. This clinical condition should be kept in mind when a patient presents with unilateral sore throat and voice change.
Keywords: Flexible laryngoscope, Pharyngolaryngeal herpes, Polymerase chain reaction, Varicella zoster
How to cite this article: Bansal R, Mittal N, Sankhla U, et al. Laryngeal Herpes: Atypical Presentations. Int J Phonosurg Laryngol 2024;14(1):10–12.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
INTRODUCTION
Ramsay Hunt syndrome (RHS) is a common presentation of the head and neck herpes zoster.1-3 An infection with the varicella zoster virus (VZV) results in two types of clinical symptoms. Varicella (chickenpox) is the initial result of coming into contact with this virus, which is spread by airborne viral particles shed from an infected person’s skin.4 Following the resolution of the symptoms, VZV travels via sensory fibers to the dorsal root ganglia of the spinal cord, where it remains dormant for years. Herpes zoster (shingles) is caused by the reactivation of latent VZV, typically as a result of compromised cellular immunity. The most prone cranial nerves are the trigeminal nerve (V) and the facial nerve (VII); however, there have been reports of involvement with the glossopharyngeal nerve (IX) and the vagus nerve (X).5 In these locations, dormant VZV can cause cranial nerve symptoms and pharyngolaryngeal involvement without skin lesions.6 We have two cases of laryngeal herpes: one with single cranial nerve involvement and the second with multiple nerve involvement.
CASE DESCRIPTION
Case I
A 60-year-old male presented with a complaint of a change in voice and difficulty in swallowing for 5 days. He denied any other constitutional symptoms and had no history of systemic disease. On flexible laryngoscopy, multiple vesicles were found on the posterior pharyngeal wall (right side), the epiglottis (right side), the right aryepiglottic fold, the right arytenoid, and the right pyriform fossa, with a fixed right vocal cord. The left vocal cord was mobile and had a typical appearance. A sample was taken from the vesicle area of the right arytenoid eminence during direct laryngoscopy. VZV was found to be positive via polymerase chain reaction (PCR) testing, and an elevated and positive immunoglobulin M (IgM) level was also detected.
A provisional diagnosis of laryngeal herpes was suspected and confirmed by PCR testing of a swab from the right arytenoid eminence vesicle (Figs 1A to D).
Figs 1A to D: Initial laryngoscopic findings showing multiple vesicles at right side of epiglottis, right aryepiglottic fold, right arytenoid, and right pyriform fossa with right vocal cord palsy
The patient was prescribed oral prednisolone 20 mg at a tapering dose and oral valacyclovir 500 mg three times a day for 10 days, along with supportive medication (analgesics and antacids). After 2 weeks, flexible laryngoscopy showed a reduction in the number and size of vesicles, but no improvement in vocal cord palsy.
Case II
A 75-year-old female patient presented with a sore throat, hoarseness, and right facial palsy for 5 days. After 3 days, she developed vesicles over the right pinna. She also had associated complaints of difficulty in swallowing. The patient denied dyspnea and could complete sentences despite the hoarseness (Figs 2A to C).
Figs 2A to F: (A) Initial vesicles seen at right pinna; (B and C) Initial laryngoscopic findings showing multiple vesicles at right side of epiglottis, right aryepiglottic fold, right arytenoid, and right pyriform fossa with right vocal cord palsy; (E and F) Posttreatment, laryngoscopic findings showing resolution of multiple vesicles at epiglottis, aryepiglottic fold, arytenoid, and right pyriform sinus, no improvement in right vocal cord palsy; (G) Posttreatment mild resolution of vesicles over pinna
She was not a known case of any systemic illness. On examination, she had a vesicular eruption over the right pinna, right facial palsy, and paralysis of the soft palate on the right side. Flexible laryngoscopy showed vesicles on the right side of the epiglottis, right aryepiglottic fold, right arytenoid, and a paralyzed right vocal cord in the paramedian position. The left vocal cord was normal and mobile. On nerve examination, the fifth, eleventh, and twelfth nerves were found intact (Figs 2D to F).
Direct laryngoscopy was performed, and a swab was taken from the vesicle area of the right arytenoid eminence. PCR testing detected VZV, and IgM levels were positive and elevated. A provisional diagnosis of laryngeal herpes with facial nerve involvement was suspected and confirmed by PCR testing from the right arytenoid eminence vesicle. The patient was prescribed oral prednisolone 20 mg at a tapering dose, oral valacyclovir 500 mg three times a day for 10 days, and supportive medication (analgesics and antacids). After 2 weeks, the patient showed improvement with fewer vesicles and a reduction in their size, but no significant improvement in right vocal cord palsy.
DISCUSSION
As the disease may mimic typical viral laryngitis and endoscopy is rarely conducted during the brief period of typical mucosal eruption, laryngeal zoster presents a special diagnostic challenge.7 Herpes zoster laryngitis is an uncommon manifestation of VZV that can occur alone or in conjunction with other cranial neuropathies.8
The latent VZV reactivates to cause herpes zoster infection.9 Patients with herpes zoster laryngitis may experience occipital headache, pain when swallowing, voice changes, and a burning sensation on one side of the throat.10 Vocal cord paralysis can occasionally occur in patients, though it is uncommon.11
The use of fiberoptic laryngoscopy or laryngeal endoscopic examination is beneficial for direct assessment of the larynx and pharynx. It allows for determination of the precise location of lesions and the degree of pathology in the larynx. Serological tests such as IgM or IgG tests, complement fixation (CF) tests, and PCR tests are available for diagnosing these viral infections and are frequently utilized for diagnosing herpes zoster.
Antiviral medications such as intravenous acyclovir or oral valacyclovir are used to treat herpes zoster laryngitis. Additionally, steroids are administered in conjunction with antiviral therapy to reduce laryngeal edema in cases of acute respiratory distress.4
Recently, a live attenuated vaccine has demonstrated efficacy against herpes zoster infections, including herpes zoster laryngitis, and might be utilized in the future.
CONCLUSION
Laryngeal herpes is a rare clinical entity caused by VZV, characterized by isolated cranial nerve involvement, especially the 10th cranial nerve or multiple cranial nerve involvement, associated with or without skin eruptions. Even in the absence of skin eruptions, VZV infection should be considered. Therefore, whenever such cases present, we recommend a detailed examination of the larynx and pharynx, including a biopsy or laryngeal swab, and PCR testing as a preferred diagnostic approach.
This rare clinical entity should be treated with valacyclovir or acyclovir along with steroids.
ORCID
Ravindra Bansal https://orcid.org/0009-0008-5993-2423
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