Anesth Pain Med 2012; 7: 16～21 ￭Case Report￭ Auriculotemporal and greater auricular nerve blocks have roles in patients with Ramsay Hunt syndrome with trigeminal nerve involvement -A report of two cases- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Hyun Seung Jin, Woo-Seok Sim, and Hee-Jin Roe Ramsay Hunt syndrome (RHS) refers to herpes zoster infection of CN VIII or cervical spinal nerves are also involved in the the geniculate ganglion of the facial nerve. Cases complicated by disease process, in which symptoms and the clinical course are multicranial nerve involvement in the process of reactivation of the heavier and the prognosis worse, emphasizing the greater need virus, which are known to show virulent clinical course and worse prognosis, are not common in literature as in practice, and there for appropriate and earlier treatment. Although pain physicians has been only one reported case of suspected co-involvement of may actually encounter cases with multicranial nerve invol- the trigeminal nerve in Korean literature. Therefore, in cases of vement in RHS once in a while in practice, there has been RHS with severe rash over the face and neck, it is pertinent to give consideration to such multiple involvement in their early presen- only one such case report in Korean literature, where the tation. Facial nerve palsy and herpes related pain are the two authors finally concluded RHS was mistaken for a trigeminal worrisome complication, which could be alleviated by early treatment herpes zoster, rather than co-involement [1]. In search for with neural blockade in addition to oral medication. Especially, foreign literature related to Koreans, one article reported of a nerve blocks are known to decrease the extent of nerve infla- mmation or damage, thereby facilitating recovery and probably Korean patient with concurrent involvement of trigeminal and preventing postherpetic neuralgia. We report two rare cases of facial nerve, and another report by Korean authors evaluated Ramsay Hunt syndrome with trigeminal nerve involvement, where the clinical characteristics and prognosis of over 300 patients early implementation of blockade of somatic peripheral nerve with RHS and multicranial nerve involvement [2], but none of branches, in addition to the conventional treatment, promoted early recovery. (Anesth Pain Med 2012; 7: 16∼21) the articles discussed about the optimal treatment in such cases, especially related to somatic peripheral nerve blocks. Key Words: Herpes zoster, Polyneuropathy, Ramsay Hunt The goals of all treatment modalities of acute herpes zoster syndrome, Somatic peripheral nerve branch block. infection including RHS, are to reduce edema and infla- mmation of the involved nerves and associated pain, thus Ramsay Hunt syndrome (RHS) is herpes zoster infection of reducing central sensitization and thereby preventing posther- the geniculate ganglion, characterized by vesicular skin lesions petic neuralgia (PHN) or nerve palsy. Especially, the usefulness in the auricle of ear, external ear, palatal and tongue mucosa of neural blockade with local anesthetics with or without and associated pain, usually accompanied by facial nerve palsy. steroids, has been proven in numerous studies [3,4]. Cranial nerve (CN) VIII, and rarely cranial nerves other than The authors are presenting, with review of literature, two rare cases of RHS with co-involvement of the trigeminal Received: October 20, 2011. nerve, where early suspicion and diagnosis of multicranial Revised: October 24, 2011. nerve involvement, and early institution of blockade of specific Accepted: November 18, 2011. somatic peripheral nerve branches in the involved dermatome Corresponding author: Woo-Seok Sim, M.D., Ph.D., Department of Anesthesiology and Pain Medicine, Samsung Medical Center, combined with conventional treatments, were associated with Sungkyunkwan University School of Medicine, 50, Irwon-dong, good prognosis. Gangnam-gu, Seoul 135-710, Korea. Tel: 82-2-3410-0356, Fax: 82-2-3410-0361, E-mail: [email protected] 16 Hyun Seung Jin, et al：Somatic peripheral nerve block in Ramsay Hunt syndrome 17 examination revealed no specific abnormalities, and was CASE REPORTS prescribed with oral valacyclovir 1 g daily for 1 week under the impression of recurrent herpes zoster virus infection of the Case 1 trigeminal nerve. The skin lesion seemed to improve after the A 64-year-old man presented with a 3-day history of initiation of such treatment, but the pain did not subside, and right-sided headache and earache accompanied by vesicular starting from the 5th day of oral medication, the patient newly skin lesions. The pain was stinging in nature, and started from developed difficulty in mouth opening and lip movement on the right ear and surrounding temporal area that spread through the right side and blinking of the right eye (Fig. 1). He also the inner ear toward the mandible, and multiple papules and complained of tingling and numbness on the right side of the vesicles developed in the face along the mandibular nerve gingiva and tongue, and visited the neurology department, dermatome. The patient immediately visited otolaryngology and where Bell’s palsy due to herpes zoster virus, RHS was dermatology outpatient clinic, but the otolaryngological physical diagnosed. He was admitted to the neurology department, and the laboratory examination on admission showed slightly increase in neutrophil count and ESR, and right facial nerve lesion was observed in both nerve conduction and corneal reflex test. The aggravation of pain and development of new clinical symptoms such as facial nerve palsy seemed to be a sign of progression of the inflammation even after the previous 7-day oral valacyclovir treatment. This raised the possibility of zoster meningitis, encephalitis or multiple cranial nerve involvement including the trigeminal nerve, and a 7-day intravenous treatment with 650 mg of acyclovir every 8 hr was initiated. The cranial nerve magnetic resonance imaging (MRI) showed multiple enhancement around the fundus of internal auditory canal, labyrinth segment of the facial nerve, geniculate fossa, which were all compatible with his clinical RHS with right facial nerve involvement (Fig. 2). Steroid therapy was commenced with oral prednisolone 60 mg daily for 3 days and maintained on 50 mg daily for another 3 days. Fig. 1. This picture shows the skin lesion and facial paralysis on admission in the first patient. On hospital day 5, the movement of the right eyelid began to Fig. 2. This picture shows the two sections of cranial nerve MRI of the first patient, showing enhancement around the fundus of right internal auditory canal, the labyrinthine segment of facial nerve, and geniculate fossa. Arrows indicate the lesion. 18 Anesth Pain Med Vol. 7, No. 1, 2012 show improvement, whereas the persisting severe pain his admission. However, he had a history of hearing loss necessitated supplementation with carbamazepine 200 mg/d and immediately after admission, and the otolaryngologic exami- gabapentin 300 mg/d. After his discharge on hospital day 8, nation revealed a mild unilateral sensorineural hearing loss, prednisolone was tapered off, while oral carbamazepine and which improved quickly and returned to normal within 5 days gabapentin was maintained. However, the patient came to our of admission. Although the possibility of RHS could not be outpatient clinic due to unrelenting pain. At his first visit, totally ruled out, no further radiologic examination was taken, facial muscle movement and skin sensation had both improved and the treatment was focused on reducing the skin lesions to grade 4/5 by Medical Research Council (MRC) scale, and accompanying pain with antivirals and analgesics, since whereas his pain intensity was describe as 70−80/100 mm by apparent facial nerve palsy was absent throughout the course visual analogue scale (VAS). The most painful area was and the cochlear symptoms resolved. He was discharged after around the right side cheek and chin, which included intravenous injection treatment for 7 days with improvement of electric-shock like pain spreading from the auricle forward acute skin lesions, and was maintained thereafter on ibuprofen, Ⓡ accompanied by dull ache with pruritis of the same area, acetaminophen and codein (Mypol cap , Sungwon Adcock stabbing pain of the tongue, dull ache of the teeth and Pharm., Korea) every 8 h. He visited our clinic due to gingiva. Spontaneous pain and hyperalgesia was observed in all remaining pain, and at his first visit, his pain score on areas. He was taking carbamazepine 600 mg/d, amitriptylin 10 aggravation reached VAS 80−90/100 mm, and its relief of mg/day, pregabalin 150 mg/d, without a significant about 50% after the medication, was only transient. There was improvement in his pain. A stellate ganglion block (SGB) was no observable facial nerve palsy, while skin pigmentation given using 8 ml of 1% lidocaine, which resulted in a relief without vesicles were diffusely scattered around the ear auricle of pain to VAS 50/100 mm at 1-week follow up. Pain and right mandibular nerve dermatome, and crusted skin lesion persisting around the area ahead of the auricle, and below the remained in the external auditory canal. The most severe pain lower lip, raised suspicion of the involvement of the trigeminal was the earache, and all the above mentioned skin areas were nerve, and the cranial nerve MRI findings were reassessed, to accompanied by spontaneous pain and hyperalgesia. Concu- reveal an ill-defined signal change along the spinal nucleus of rrence of the trigeminal nerve lesion with RHS was suspected, trigeminal nerve suggesting a change following viral infection. and somatic and sympathetic nerve blocks were given During the following month, he was given 4 times of SGBs, alternatively, including a right SGB, a right greater auricular twice each of auriculotemporal nerve block (ATNB) and nerve block (GANB) using a mixture of 20 mg of triam- mental nerve block (MNB), to report a decreased pain score of cinolone in 5 ml of 0.375% ropivacaine, and a right mental VAS 30/100 mm.