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What is the cause of the spots in this young man's ear?

GP Dr Oliver Starr explains how he reached the right diagnosis when this young man arrived in his surgery with painful ear lesions

 

This young man was normally healthy, but these tiny spots had appeared in his right conchal bowl over a few days. 

They were painful, and he admitted to picking away at his ear a little recently, from habit.

He asked what they were, and what I could do about them.

 

Differential diagnoses

  • Carbuncles
  • Herpes simplex
  • Herpes zoster.

Carbuncles are an infection of the hair follicle, usually by Staphylococcus aureus or other Gram-positive bacteria.

Carbuncles in the conchal bowl or ear canal are fairly common – they even have their own Read code – and were a possibility.

Herpes is usually found around the mouth (herpes simplex virus type I) or the genital area (type II).

I thought it was less likely to find it in the ear, although not entirely impossible.

Herpes zoster (shingles) is caused by the virus varicella zoster.

After the initial infection the virus lies dormant in the dorsal root ganglion, recurring typically at times of immunocompromise or stress.

Some 50% of people will have had shingles by the age of 85.

 

Getting on the right track

Things became clearer three days later.

He came back concerned about why one side of his face looked odd.

I could see what he meant – he couldn't raise his right eyebrow or the right side of his mouth. In other words, he had a right-sided lower motor neurone lesion of the facial nerve.

This was Ramsay Hunt syndrome – essentially, shingles of the facial nerve. I was seeing him in the very early stages, so prescribed aciclovir and prednisolone. 

 

Within two weeks his eye closure had improved and within a month his mouth and forehead had gone back to normal.

 

Dr Oliver Starr is a GP in Stevenage, Hertfordshire

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