I read with interest the case series on pharyngolaryngeal zoster by Dr. Choi . This article has appeared a few weeks before the recent publication of a systematic review on this subject written in collaboration by two Swiss clinics, of which I am co-author . In opposition to what is stated in the introduction, concomitant involvement of cranial nerves IX and X by varicella-zoster virus (VZV) has been reported in the past by several authors, and such clinical picture is most often accompanied by dysfunction of several other nerves (for a precise example see Kim et al. ).

I think the cases presented by Dr. Choi are nicely illustrative of the fact that, as shown in our review, most cases of pharyngolaryngeal zoster present as cranial polyneuropathies, and therefore the diagnosis is, as indicated by the author, challenging. I think it is important to stress three facts that are not evident in the discussion of Choi’s article:

• 1.
  

  The absence of vesicles does not rule out the diagnosis of zoster, and it is especially in these cases where a high suspicion index should lead to a thorough serological workup. It is important to note that, in the context of a progressive cranial polyneuropathy without any mucosal/cutaneous manifestations, patients are likely to undergo imaging studies.

  
  
• 2.
  

  The issue of antiviral therapy is a controverted issue. In our review we did not find any differences in terms of outcome in patients that were treated versus those that were not treated .

  
  
• 3.
  

  Finally, the most dreadful aspect of this disease is the low full-recovery rate, with long-term speech impairment in 30% of the patients and swallowing impairment in 20%. Other cranial nerve deficits are also found in a very substantial number of patient . Beyond diagnosis and early management, it is of utmost importance to keep in mind the role of early re-education.