CC: Painful sores in the mouth.
HPI: Painful sores in the mouth that appeared a few days ago. Pain with eating but patient is able to swallow without difficulty. Now having some pain around his right ear today. No difficulty hearing. Denies URI symptoms. No significant PMH. Meds = SSRI.
PE: You see vesicles on the right side of the hard palate. Right pinna is swollen and red, and there are vesicles in the external auditory canal.
Herpes zoster oticus is also known as Ramsay Hunt syndrome when associated with a facial nerve palsy.
“It is caused by reactivation of the varicella-zoster virus (VZV) in the geniculate ganglion of the facial nerve. Typical symptoms include painful vesicles on one side of the palate and the ipsilateral ear. When the reactivation involves other branches of the facial nerve it can result in a unilateral facial herpetiform rash that may also involve the anterior two-thirds of the tongue, taste disturbance, and reduced lacrimation. If the nearby cochlear and vestibular nerves become involved, patients may also experience hearing loss, tinnitus, nausea, vomiting, and vertigo. The diagnosis is usually made clinically, but if confirmation is needed polymerase chain reaction testing of vesicular fluid or of a swab of the base of an ulcer may be done.
Treatment includes antivirals (acyclovir, valacyclovir) and prednisone, and is more effective when started sooner in the course of illness.” ABFM critique.
Further reading / Reference
Ear pain, vesicular rash, and facial palsy. BMJ 2014;349:g7572.
Sore throat and left ear pain. J Fam Pract 2015;64(2):117-119.