Thank you for the invitation to respond to the valuable comments from Dr. Nisa. I appreciate the fact that the apparent point of the letter converges well with the intended message of my case series . I read with great interest the article titled “Pharyngolaryngeal involvement by Varicella-Zoster virus” by Dr. Nisa et al. and the other article written by Kim et al. , which have been recommended by Dr. Nisa.

As Dr. Nisa’s comment states, concomitant involvement of cranial nerves IX and X by Varicella-Zoster virus (VZV) has been reported. However, I would like to remind myself that in a condition of the absence of herpes zoster oticus-related manifestation, such as vesicular lesion, the diagnosis of VZV infection may tend to be missed initially. More specifically, oropharyngeal discomfort and complaints became the initial symptoms which turned into significant pharyngeal and laryngeal mucosal eruptions, making it difficult to diagnose.

Dr. Nisa also states that three facts which are not evident in the “Discussion” section of my article. However, I have already clearly pointed out those facts in my article.

The first issue is vesicle and diagnosis. As I mentioned before, there are some comments about this issue in my article. Furthermore, in the “Conclusion” section, I state that “herpetic mucosal eruptions showing involvement in the pharynx and larynx tend to be missed or tend to disappear on examination. VZV infection should be considered even when skin eruptions are absent. Furthermore, repeated serial serology is advisable to avoid missing a delayed rise in titers” .

The second issue is antiviral therapy. Dr. Nisa et al. did not find any differences in terms of the outcome of antiviral therapy. However, the authors missed the consideration of time in the initial therapy. Antiviral agents should be started, preferably within 72 hours of onset, in order to reduce the severity and duration of the eruptive phase as well as to reduce the intensity of acute pain .

The final issue is poor prognosis. Many articles stated that multiple involvements of cranial nerves are more severe and intractable than without it; hence, they should be managed with great clinical care. I agree with Dr. Nisa of the importance of early re-education.

I hope the fairness of these comments restore the justice.

To this end, I am grateful to Dr. Nisa for reinforcing my message.

Yours sincerely,