Imaging manifestations on sequential magnetic resonance imaging in pharyngolaryngeal involvement by varicella zoster virus


Clarifying temporal changes in magnetic resonance imaging (MRI) offers a good chance to understand the pathology of neural lesions; however, such information is scarce in varicella zoster virus (VZV) neuropathies for the glossopharyngeal and vagus nerves. Here, we present the changes in sequential MR images of such a pathology over a period of 12 months from symptom onset.

A 27-year-old woman with difficulty in swallowing and hoarseness due to a palatal palsy and arytenoid fixation on the left presented 2 days after onset. MRI revealed a lesion which largely filled the left jugular foramen on T2-weighted images (T2-WI) with high diffusion-weighted imaging (DWI) signals, which has never been previously described, on the 3rd day after onset. The DWI signals were highest on day 3, then deteriorated over 2 months until the signal was only detectable at the intracranial level, but not in the jugular foramen. The glossopharyngeal nerve had returned to normal by 2 months.

The time course of the glossopharyngeal and vagus nerve swelling detected on T2-WI suggests that nerve swelling reduces over several months, even though the paralytic symptoms persist. Furthermore, the high DWI signal suggests that nerve swelling was caused by edematous swelling of the nerve fibers, rather than fiber disruption with water displacement in the extracellular space. These findings may provide good clues to speculate on the dynamically changing pathology of VZV neuropathies of the glossopharyngeal and vagus nerves.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3


  1. Adachi M (2008) A case of Varicella zoster virus polyneuropathy: involvement of the glossopharyngeal and vagus nerves mimicking a tumor. Am J Neuroradiol 29:1743–1745

    CAS  Article  Google Scholar 

  2. Bond JD, Zhang M (2020) Compartmental subdivisions of the jugular foramen: a review of the current models. World Neurosurg 136:49–57

    Article  Google Scholar 

  3. Cao D-H, Xie Y-N, Ji Y, Han J-Z, Zhu J-G (2019) A case of varicella zoster encephalitis with glossopharyngeal and vagus nerve injury as primary manifestation combined with medulla lesion. J Int Med Res 47:2256–2261

    Article  Google Scholar 

  4. Chitose S, Umeno H, Hamakawa S, Nakashima T, Shoji H (2008) Unilateral associated laryngeal paralysis due to varicella-zoster virus: virus antibody testing and videofluoroscopic findings. J Laryngol Otol 122:170–176

    Article  Google Scholar 

  5. Choi JH (2013) Two cases of pharyngolaryngeal zoster advanced to multiple cranial neuropathy. Am J Otolaryngol 34:369–372

    Article  Google Scholar 

  6. Cohen JI (2013) Herpes zoster. N Engl J Med 369:255–263

    CAS  Article  Google Scholar 

  7. Hoshino C, Yamabe A (2012). Where is reactivation after a long latency? BMJ Case Reports 2012: bcr0120125538.

  8. Kennedy PG, Mogensen TH (2020) Determinants of neurological syndromes caused by varicella zoster virus (VZV). J Neurovirology 26(4):482–495

    Article  Google Scholar 

  9. Kuroda T, Kobayashi Z, Inokuchi N, Nakamura K, Michizaki H, Katayama Y, Ishihara S, Tomimitsu H, Shintani S (2019) Unilateral oropharyngeal mucosal lesions as a clue to the pathogen of encephalitis. J Neurol Sci 397:22–23

    Article  Google Scholar 

  10. Nakagawa H, Nagasao M, Kusuyama T, Fukuda H, Ogawa K (2007) A case of glossopharyngeal zoster diagnosed by detecting viral specific antigen in the pharyngeal mucous membrane. J Laryngol Otol 121:163–165

    CAS  Article  Google Scholar 

  11. Nisa L, Landis BN, Giger R, Leuchter I (2013) Pharyngolaryngeal involvement by varicella-zoster virus. J Voice 27:636–641

    Article  Google Scholar 

  12. Noguerol TM, Barousse R, Socolovsky M, Luna A (2017) Quantitative magnetic resonance (MR) neurography for evaluation of peripheral nerves and plexus injuries. Quant Imaging Med Surg 7:398

    Article  Google Scholar 

  13. Ong CK, Chong VFH (2010) The glossopharyngeal, vagus and spinal accessory nerves. Eur J Radiol 74:359–367

    Article  Google Scholar 

  14. Tsau P-W, Liao M-F, Hsu J-L, Hsu H-C, Peng C-H, Lin Y-C, Kuo H-C, Ro L-S (2020) Clinical presentations and outcome studies of cranial nerve involvement in herpes zoster infection: a retrospective single-center analysis. J Clin Med 9:946

    Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Akira Inagaki.

Ethics declarations

Ethics approval and consent to participate

The patient provided written informed consent, and the institutional review board at Nagoya City University approved this retrospective study.

Conflict of interest

The authors declare that they have no conflicts of interest. 

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 22 KB)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Inagaki, A., Kojima, A., Ogawa, M. et al. Imaging manifestations on sequential magnetic resonance imaging in pharyngolaryngeal involvement by varicella zoster virus. J. Neurovirol. (2021).

Download citation


  • Varicella zoster virus
  • Pharyngolaryngeal involvement
  • MRI
  • jugular foramen