Cough after laryngeal herpes zoster: a new aspect of post-herpetic sensory disturbance B LING 1 , D NOVAKOVIC 2 , L SULICA 3 1 Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand, 2 ENT, Northern Clinical School, University of Sydney, NSW, Australia, and 3 Department of Otolaryngology – Head and Neck Surgery, Weill Cornell Medical College, New York, New York, USA Abstract Objective: Although neurogenic cough is increasingly recognised, its pathophysiology remains obscure. We describe two cases of chronic cough following laryngeal herpes zoster, a rarely described manifestation of varicella-zoster virus reactivation, and suggest that this may be analogous to post-herpetic neuralgia. The same mechanisms may cause both phenomena. Case reports: We describe two cases of chronic cough persisting for more than three months following an acute attack of laryngeal herpes zoster. Conclusion: Neuronal damage by varicella-zoster virus results in irritable nociceptors and deafferentation, mechanisms known to cause post-herpetic neuralgia. When the vagus nerve is affected, as in laryngeal herpes zoster, the result may be a chronic cough. Similar damage may underlie chronic neurogenic cough in other contexts. Key words: Herpes Zoster; Laryngeal Diseases; Vagus Nerve Diseases; Cough; Neuralgia, Postherpetic Introduction Herpes zoster represents a reactivation of varicella-zoster virus dormant in sensory nerve ganglia after acute infection. Typically, it presents with vesicular eruptions in the skin of the affected dermatome. Neurogenic sequelae, particularly pain, are well documented. Mucosal manifestations of herpes zoster are rarely reported and vagal nerve manifesta- tions still more so. We describe two cases of vagal nerve herpes zoster with characteristic presentations and clinical courses. Both devel- oped cough as a post-herpetic sequela, an aspect heretofore not described. We follow this with a discussion on the pro- posed pathophysiology of this phenomenon, likening it to the more common post-herpetic neuralgia. Case reports Patient one A 66-year-old female smoker complained of six days of hoarseness, progressive odynophagia and intense, unilateral throat pain. Flexible, transnasal laryngoscopy revealed numerous ulcers with purulent exudate on the left half of the epiglottis, the left supraglottic area, and the left lateral and posterior pharyngeal wall (Figure 1). The left vocal fold was markedly oedematous, but vocal fold mobility was intact bilaterally. An empirical diagnosis of laryngeal zoster was made based on examination findings, and the patient was started on a 7-day course of valaciclovir. A week later, her symptoms had largely resolved. She was able to tolerate liquids and some foods by mouth. Flexible laryngoscopy showed complete resolution of the ulcers, with some areas of patchy erythema but complete re-mucoli- sation. Vocal fold oedema was much reduced, and it became clear the patient had mild Reinke’s oedema at baseline. Eleven months later, she returned to the clinic complain- ing of easily provoked, non-productive cough and a persist- ent foreign body sensation since the acute episode. Rigid, peroral laryngoscopy revealed bilateral Reinke’s oedema and raised the possibility of laryngopharyngeal reflux. She was advised to stop smoking and was prescribed omeprazole 40 mg daily. Eight months later, the patient reported no improvement to her cough. She declined treatment with amitriptyline or gabapentin. She was subsequently lost to follow up. Patient two A 62-year-old man presented to a laryngologist in Australia with a 1-week history of left-sided, progressive throat pain, radiating to the neck and ear, with an associated feeling of a lump at the base of the tongue. Three days prior to the onset of the pain, he had noted a metallic taste on intake of food and beer. Flexible laryngoscopy showed vesicles on the left side of his pharynx, vallecula and supraglottis (Figure 2). The ear and the laryngeal and facial movements were normal. There were no motor symptoms or signs. An empiric- al diagnosis of herpes zoster was made. Antivirals were not prescribed as they are not funded for the treatment of herpes zoster in Australia beyond 72 hours of symptom onset. The patient’s pain increased over the next three days, with associated malaise and the development of aural fullness and Accepted for publication 21 September 2013 First published online 30 January 2014 The Journal of Laryngology & Otology (2014), 128, 209–211. CLINICAL RECORD © JLO (1984) Limited, 2014 doi:10.1017/S0022215113003642