Typical or Atypical Ramsay-Hunt Syndrome in Delayed Facial Palsy After Stapedectomy?

Abstract

Original ArticleIntroduction Delayed facial palsy (DFP) is an uncommon complication after middle ear surgery; it occurs after >72 hours of an uneventful ear surgery [1] . Shea described this phenomenon as "five and a half day syndrome, " meaning that all his personal observations shared the same time lag from surgery.[2] DFP after stapedectomy is a very rare event (0.22%) [3] . Its incidence in the literature ranges between 0.07% and 1.4%. [4][5][6] While immediate facial palsy is easily explained by the use of local anesthetics (if transient) or by intraoperative severe surgical trauma (if permanent), many hypotheses have been proposed about the late facial nerve dysfunctions, including reactivation of a quiescent virus colonizing the nerve ganglion. According to Shea et al.[4] the most probable etio-pathogenetic mechanism for DFP is the activation of a latent herpesvirus in the geniculate ganglion, induced by mechanical stimulation or reactive inflammation of the facial nerve during middle ear surgery. This hypothesis has been supported by many other observations after otological surgical procedures [7][8][9][10][11][12][13][14][15][16][17][18] and preventive antiviral therapy has been proposed in patients with positive history to varicella zoster virus and herpes simplex virus 1 and 2. However, serological search of a viral etiology is often inconclusive, not always identifying which virus (HSV type 1, 2, or VZV) is involved; the proposed use of preventive therapy with antivirals in all stapedectomy patients is still debated and often not applied in clinical practice [4][5][6][7] .The purpose of this work is to review the relevant literature on DFP after stapedectomy, aiming at properly assessing the viral etiology and at identifying factors that might influence the prognosis or the recovery time or the choice of therapies, and describe a very unusual case of DFP characterized by VZV reactivation showed by the eruption of typical RH lesions. MATERIALS and METHODSA PubMed search encompassing all publications over the last 40 years was initially performed searching for "facial palsy OR paralysis OR paresis" AND "stapedectomy OR stapedotomy OR stapes surgery" using Boolean combinations; Further, the terms "delayed OR late" were added to the search. The date of last search was 18 th March 2018. After screening all the articles abstracts, full-text works pertinentTypical or Atypical Ramsay-Hunt Syndrome in Delayed Facial Palsy After Stapedectomy?OBJECTIVES: The aim of this study was to define the typical pattern for varicella zoster virus (VZV) reactivation in delayed facial palsy (DFP) after stapedectomy for otosclerosis. MATERIALS and METHODS:Review of the relevant literature, personal casistics, and case-report RESULTS:In total, 48 cases of DFP after stapes surgery have been described so far, including the reported case with exclusive manifestation of atypical Ramsay Hunt syndrome (RH); in the personal series of 1253 stapedectomies, DFP occurred in only one case (0.08%). Complete DFP (House-Brackmann grade VI) ...

Postoperative Delayed Facial Nerve Palsy: A Surgeon's Nightmare

“…However, we could not conduct this test due to its unavailability at our center at the present moment as well as due to financial constraint of the patient. Surgical trauma, along with the induced immunosuppression post-surgery and the administration of exogenous steroids, can create a predisposition to the reactivation of viruses that typically remain dormant in the geniculate ganglion [ 11 ].…”

Clinical Features and Prognosis of Facial Palsy and Hearing Loss in Patients With Ramsay Hunt Syndrome

“…The risk of VZV reactivation should be raised if acute otalgia occurs before DFP [46]. After the progression of VZV, cochlear neuritis might result in persistent hearing loss in Ramsay Hunt syndrome patients [47].…”

“…Following middle ear surgery, delayed facial palsy (DFP), a rare complication that rarely lasts longer than 72 hours, can develop. The risk of VZV reactivation should be raised if acute otalgia occurs before DFP [ 46 ]. After the progression of VZV, cochlear neuritis might result in persistent hearing loss in Ramsay Hunt syndrome patients [ 47 ].…”