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Updated: Jan 23, 2026
Plaquing of Herpes Simplex Viruses
Published on: November 5, 2021
Herpes zoster oticus with meningitis masquerading as malignant otitis externa
Harriet A Cunniffe1,2, Nicholas G Cunniffe3
1ENT, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.
Abstract:
This is a case of an 85-year-old woman whom was admitted with otalgia and an abducens nerve palsy alongside a Pseudomonas otitis externa; she was presumed to have malignant otitis externa. However, despite optimum treatment and resolution of her otitis externa, she went on to develop an ipsilateral facial nerve palsy and sensorineural hearing loss. After further investigation, it was discovered that varicella-zoster meningitis was causing her polyneuropathy. She eventually responded to antivirals and steroids and, at follow-up, her sixth and seventh cranial nerve palsies had completely resolved, though a hearing deficit remained. This case highlights the importance of keeping a diagnosis under review, with the help of the multidisciplinary team, when the clinical course is not progressing as expected.
Insights
An elderly woman initially treated for malignant otitis externa developed cranial nerve palsies due to varicella-zoster meningitis. Prompt antiviral and steroid treatment led to recovery, emphasizing diagnostic reassessment for atypical presentations.
Area of Science:
- Neurology
- Infectious Diseases
- Otolaryngology
Background:
- Malignant otitis externa (MOE) is a severe infection typically seen in elderly patients with diabetes.
- Early diagnosis and treatment are crucial for favorable outcomes.
Observation:
- An 85-year-old woman presented with otalgia, abducens nerve palsy, and Pseudomonas otitis externa, initially presumed to be MOE.
- Despite treatment for otitis externa, she developed facial nerve palsy and sensorineural hearing loss.
- Further investigations revealed varicella-zoster meningitis as the cause of her polyneuropathy.
Findings:
- Varicella-zoster virus (VZV) meningitis can mimic other conditions, including MOE.
- Cranial nerve palsies (VI and VII) and hearing loss are potential neurological manifestations of VZV meningitis.
- Antiviral therapy and corticosteroids are effective in treating VZV meningitis and its neurological sequelae.
Implications:
- This case underscores the importance of considering infectious etiologies, such as VZV meningitis, in patients with cranial nerve palsies, even with concurrent otitis externa.
- A multidisciplinary approach is vital for re-evaluating diagnoses when clinical progression deviates from the expected course.
- Timely diagnosis and management of VZV meningitis can lead to significant neurological recovery, although residual deficits like hearing impairment may persist.
