68 year old male with L ear pain and facial paraesthesia.
This patient is a 68 year old male whose chief complaint is "My left cheek has a 'pins and needles' sensation and I have L ear pain, decreased hearing and bleeding from my ear"
Approximately 3 days ago, the patient noticed some vesicles on his chin, which coalesced then scabbed. He also noted a 'pins and needles' sensation on his left cheek, in the V3 distribution, and then extending to his ear and into the external auditory canal. Late this evening he describes a worsening of the sensation in his Left ear as well as hearing loss and bleeding. He denies fever, chills, vertigo, lightheadedness, tinnitus, eye pain, or discharge. He had chickenpox as a child.
Physical exam:
Vitals: No fever, Pulse, respirations and blood pressure are wnl
Skin: There is a diffuse papular rash extending from the left chin onto his cheek and along the mandible, into the ear. There is a 2 cm in diameter crusted area on his left chin. There is a single vesicle on the left side of his forehead above his eye.
HEENT: Eye exam with dye revealed no abnormality. No pain on palpation. EOMs are intact. External auditory canal reveals small vesicles and bright red blood. Left TM is not visualized due to cerumen and blood. Right EAC is filled with cerumen. Neck skin is normal, no adenopathy.
Neuro: Facial wrinkles appear symmetric. There is mild weakness in the facial muscles, including the forehead, on the Left side of his face.
Discussion: This patient has symptoms consistent with herpes zoster, or shingles. It is a rare occurrence, however, on the face. When the zoster extends into the ear canal, and is accompanied by facial paralysis, it is called Herpes Zoster Oticus. It is also called Ramsey Hunt Syndrome. The incidence is 0.2%. Apparently the orgin of the virus is the geniculate ganglion and involves the facial nerve as well as the trigeminal nerve. If the eye is involved and not treated, it can cause disability. The patient was counseled regarding the viral cause. He was instructed to avoid pregnant women, chemotherapy patients, and neonates until the symptoms cleared. He was instructed on keeping his ear dry until he could follow up with an ENT. He was started on acyclovir and given ibuprofen and lorcet for pain. He was also instructed to return to the ER should the symptoms worsen, or if he began to experience eye pain or visual difficulties.
Approximately 3 days ago, the patient noticed some vesicles on his chin, which coalesced then scabbed. He also noted a 'pins and needles' sensation on his left cheek, in the V3 distribution, and then extending to his ear and into the external auditory canal. Late this evening he describes a worsening of the sensation in his Left ear as well as hearing loss and bleeding. He denies fever, chills, vertigo, lightheadedness, tinnitus, eye pain, or discharge. He had chickenpox as a child.
Physical exam:
Vitals: No fever, Pulse, respirations and blood pressure are wnl
Skin: There is a diffuse papular rash extending from the left chin onto his cheek and along the mandible, into the ear. There is a 2 cm in diameter crusted area on his left chin. There is a single vesicle on the left side of his forehead above his eye.
HEENT: Eye exam with dye revealed no abnormality. No pain on palpation. EOMs are intact. External auditory canal reveals small vesicles and bright red blood. Left TM is not visualized due to cerumen and blood. Right EAC is filled with cerumen. Neck skin is normal, no adenopathy.
Neuro: Facial wrinkles appear symmetric. There is mild weakness in the facial muscles, including the forehead, on the Left side of his face.
Discussion: This patient has symptoms consistent with herpes zoster, or shingles. It is a rare occurrence, however, on the face. When the zoster extends into the ear canal, and is accompanied by facial paralysis, it is called Herpes Zoster Oticus. It is also called Ramsey Hunt Syndrome. The incidence is 0.2%. Apparently the orgin of the virus is the geniculate ganglion and involves the facial nerve as well as the trigeminal nerve. If the eye is involved and not treated, it can cause disability. The patient was counseled regarding the viral cause. He was instructed to avoid pregnant women, chemotherapy patients, and neonates until the symptoms cleared. He was instructed on keeping his ear dry until he could follow up with an ENT. He was started on acyclovir and given ibuprofen and lorcet for pain. He was also instructed to return to the ER should the symptoms worsen, or if he began to experience eye pain or visual difficulties.
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