We report a patient with significant weakness of the left soft palate, paralysis of the left vocal cord, and left facial nerve palsy. Although the patient showed no herpetic eruption in the pharyngolaryngeal mucosa and auricle skin, reactivation of varicella zoster virus (VZV) was confirmed by serological examination. She was diagnosed with zoster sine herpete. After treatment with antiviral drugs and corticosteroids, her neurological disorder improved completely. When we encounter a patient with associated laryngeal paralysis, we should consider the possibility of reactivation of VZV even when no typical herpetic eruption is observed. 1. Introduction Ramsay Hunt syndrome (RHS) is caused by reactivation of varicella zoster virus (VZV) [1]. Typically, RHS is characterized by zoster oticus, facial nerve palsy, and cochleovestibular symptoms. However, eruption is not observed in all cases, with the cases not presenting with eruption being defined as zoster sine herpete (ZSH) [2]. Distinguishing ZSH from Bell’s palsy can be difficult. To diagnose ZSH accurately, detection of VZV DNA by polymerase chain reaction (PCR) or a significant elevation in serum anti-VZV antibody titer using a complement fixation test or enzyme-linked immune sorbent assay (ELISA) is needed. Associated laryngeal paralysis is a clinical condition merged with other cranial nerve disorders associated with vocal cord paralysis. Recently, it has been speculated that a proportion of idiopathic associated laryngeal paralysis are due to VZV [3]. Most cases might be misdiagnosed as idiopathic laryngeal paralysis due to lack of appropriate serological tests. Although there are some reports on laryngeal zoster and associated laryngeal paralysis with mucosal eruption [4, 5], cases of associated laryngeal paralysis due to VZV without eruption are rare [6]. Here, we report a case of ZSH presenting with associated laryngeal paralysis and facial nerve palsy. 2. Case Presentation A 50-year-old female presented with hoarseness, dysphagia, and left ear pain on February 10. She was diagnosed with a common cold and received medication from a clinic. Her symptoms did not improve and she visited our hospital on February 14. Physical examination demonstrated significant weakness of the left soft palate with a deviation to the right side during phonation. There was no sign of herpetic eruption within the region surrounding her ear, face, and oral cavity. Her facial sensation was normal and no facial weakness was observed. Laryngoscopy revealed paralysis of the left vocal cord and saliva pooling in the left
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