Introduction
Several cases of dysphagia cases caused by Varicella Zoster virus infection have already been reported. Among them, cases of Ramsay hunt syndrome patients can be often found. This case is different from the typical clinical features of Ramsay hunt syndrome. The patient had main problems of dysphagia and hoarseness, not facial palsy and hearing impairment. In this study, we also cover the process of dysphagia treatments and its outcomes.
Clinical presentation
A 68-year-old male visited to LMC with sore throat and Left ear pain on February 19, 2019 and took an analgesic due to suspicious acute pharyngitis, acute tonsilitis or varicella zoster infection. After 5 days, he visited KNUH emergency room with worsening sore throat and swallowing difficulty. Then, Left vocal cord hypomobility was checked. Blood test showed positive results for Herpes Simplex Virus IgG and VZV IgG, and negative results for Herpes Simplex IgM and VZV IgM. For treatment, prednisolone and acyclovir were used for 1 week. No neurological symptoms other than dysphagia were found. Because of persistent dysphagia and aspiration pneumonia, he used the Levin-tube and was admitted to the rehabilitation department on June 8, 2019. A Video fluoroscopic swallowing study conducted after admission showed dysphagia with large amounts of residue in pyriform sinus and dysfunction of upper esophageal sphincter.
Interventions
Botox injection(40IU) on Posterior cricopharyngeal muscle was performed by Gastroenterology. In addition, 11 times active UES (Upper esophageal sphincter) ballooning using foley catheter was done during the VFSS process. Then, education of the methods of UES ballooning and 10 times of self-ballooning before every meal was also done.
Outcomes
Dysphagia treatment was performed for about 12 days, and esophageal transition was better right away after doing upper esophageal sphincter UES ballooning. At the time of discharge, he was able to take oral, but there were symptoms still remained, including CPD and aspiration. After that, he continued home-based self-ballooning and followed up outpatient clinic regularly. On July 9, 2019, in VFSS study, aspiration was found on thick 6cc. On August 13, 2019, penetration was only found, on December 3rd, 2019, aspiration was found on thin 6cc. Compared to before, PAS score and subjective swallowing function were generally improved.
Discussion
This article reports a case of a patient suspected of varicella zoster viral infection on larynx. A patient complained only dysphagia and hoarseness as a sequalae. This article shows that objective or subjective improvement of dysphagia can be accomplished by botox injection on cricopharyngeal muscle and active UES ballooning treatment.
Conclusion
Suspicious Varicella zoster viral infection on larynx can induce dysphagia. Dysphagia rehabilitation treatments including botox injection on cricopharyngeal muscle and UES ballooning may help improve swallowing functions.
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