Imaging Case of the Month
Visualizing Affected Nerve Bundles of Cranial
Nerves VII and VIII in Herpes Zoster Oticus
Yen-Hui Lee, Yi-Ho Young, and Yi-Tsen Lin
Departments of Otolaryngology–Head and Neck Surgery, National Taiwan
University Hospital, Taipei, Taiwan
A 66-year-old man presented with odynophagia for
7 days, followed by the sudden onset of vertiginous
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attack and facial weakness. On physical examination,
the patient had complete right facial nerve paralysis
(House – Brackmann grade VI/VI), spontaneous left
beating nystagmus, and vesicular eruptions on the
right auricle and external auditory canal. Based on
this history and physical examination, herpes zoster
oticus was suspected and he was admitted. Audiome-
try showed profound deafness on the right ear. The
ocular vestibular-evoked muscle potential (oVEMP),
cervical VEMP (cVEMP), and caloric tests identified
absent responses on the right ear, while the left ear
showed normal responses in all above testing. Thus,
four nerve bundles inside the internal auditory canal
(IAC), namely facial, cochlear, superior vestibular,
and inferior vestibular nerves were thoroughly
affected. Subsequently, axial view of gadolinium
(Gd)-enhanced T1 weighted MR imaging demon-
strated enhancement over all four nerve bundles
inside the IAC (Fig. 1A, B). Reformatted oblique
sagittal view of T2-weighted MR imaging revealed
diffuse swelling of all four nerve bundles of the IAC
on the lesion ear (Fig. 2A), compatible with deficits in
cranial nerves (CNs) VII and VIII test battery. Mean-
while, serological assay confirmed the reactivation of
varicella-zoster virus.
Six months after treatment by acyclovir and tapering
corticosteroid for 2 weeks, follow-up MR imaging
demonstrated reduced enhancement in all four nerve
bundles in the IAC (Fig. 1 C, D). Although CN VII
paralysis had resolved and returned to normal function,
CN VIII deficits assessed by test battery remained
unchanged.
Address correspondence and reprint requests to Yi-Tsen Lin, M.D.,
Department of Otolaryngology, National Taiwan University Hospital,
7, Chung-Shan South Road, Taipei, Taiwan; E-mail: yitsenlin@ntu.
edu.tw
Financial disclosure: Nil.
The authors disclose no conflicts of interest.
DOI: 10.1097/MAO.0000000000002740
ß 2020, Otology & Neurotology, Inc.
Copyright © 2020 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
DISCUSSION
Herpes zoster oticus, also termed Ramsay Hunt
syndrome, manifests as otalgia, vesicular eruptions,
facial palsy, and/or hearing loss. With the aid of CN
VII and VIII test battery comprising clinical grading of
facial nerve function, audiometry, caloric, oVEMP, and
cVEMP tests, the clinicians are able to assess how
many nerve bundles inside the IAC are affected. Then,
the affected nerve bundles could be confirmed by
enhancement on T1 weighted Gd-MR images
(Fig. 1A, B), likely because the varicella-zoster virus
breaks down the blood-labyrinth barrier and increases
the permeability of contrast media (1). Additionally,
inflammatory nerve edema in the IAC can be compre-
hensively visualized on reformatted oblique view of
T2-weighted image (Fig. 2), which is perpendicular to
the long axis of IAC, allowing higher resolution on each
nerve bundle inside the IAC.
Notably, when visualizing a linear, non-mass like
enhancement on MR images without significant
expansion of the nerve in the IAC, differential diag-
noses such as Bell’s palsy, meningitis, sarcoidosis,
and metastatic/perineural tumor should be taken into
consideration. First, Bell’s palsy can be neglected
because it generally affects facial nerve solely. Next,
lack of systemic symptoms such as fever, headache,
neck stiffness, lung, or heart problem in this patient
helps exclude the possibility of meningitis and sar-
coidosis. Finally, perineural spread from a neoplasm
deserves our concern. Since this patient denied history
of head and neck malignancy, and characteristic find-
ings of MR image, i.e., replacement of normal peri-
neural fat with tumor, increased size of the nerve, or
enlargement of the IAC were not shown (2), possibil-
ity of a space-occupied lesion was thus excluded.
Taken together, inflammatory process rather than
neoplastic lesion was suspected, which was further
confirmed by serological assay and diagnosed as
herpes zoster oticus. As the number of affected nerve
bundles evidenced by both test battery and MR imag-
ing, severity of involvement is therefore decided,
 HERPES ZOSTER OTICUS e1175

FIG. 1. Axial view of gadolinium-enhanced MR images at the level of geniculate ganglion (A) and 1 mm below (B) demonstrates
enhancement of all four nerve bundles before treatment (1, facial nerve; 2, superior vestibular nerve; 3, inferior vestibular nerve; 4, cochlear
nerve). Six months after treatment, reduced enhancement of all four nerve bundles is shown (C, D).

which helps predict the outcome of herpes zoster
oticus (3).
Six months later, follow-up MR imaging demon-
strated reduced enhancement of all four nerve bundles
in the IAC (Fig. 1C, D), likely because healing of the
blood-labyrinth barrier did not allow leakage of contrast
media (4). Clinically, function of CN VII has returned to
normal in this patient, whereas CN VIII deficits
remained unchanged 6 months after treatment, indicat-
ing that function of CN VIII is less likely to recover than
CN VII. Restated, resolution of MR imaging fails to
match the functional recovery in CNs VII and VIII test
battery. The reason is probably because the recovery
process comprises not only the healing of blood-laby-
rinth barrier, but also the regeneration and restoration of
nerve circuits (5).
In sum, test battery of CNs VII and VIII correlates well
with the radiological evidence to indicate the affected
nerve bundles in cases of herpes zoster oticus before
treatment, but not posttreatment.

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e1176 Y. -H LEE ET AL.

FIG. 2. Reformatted oblique sagittal view of T2 weighted MR images demonstrates diffuse swelling of all four nerve bundles inside the
internal auditory canal on the lesion ear (A, right ear) in comparison with those on the control ear (B, left ear) (1, facial nerve; 2, superior
vestibular nerve; 3, inferior vestibular nerve; 4, cochlear nerve).

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