Uncommon presentation and complications of herpes zoster infection involving the cervical, vagus and accessory nerves which caused a delay in diagnosis and treatment.

A 70-year-old man with a history of invasive anal squamous cell carcinoma treated with excision and chemoradiation presented to the emergency department with right-sided neck pain and submandibular lymphadenopathy. CT imaging of the head and neck was unrevealing. The patient eventually developed cranial nerves X and XI dysfunction, manifesting as severe vocal cord paralysis (dysphonia), dysphagia, asymmetric palate elevation/deviation and trapezius muscle atrophy, in addition to scalene muscle atrophy. After an extensive workup, the patient's symptoms were determined to be due to sequelae of varicella zoster infection, which was confirmed with antibody titers. The patient's dysphagia and dysphonia eventually improved with vocal cord medialisation injection and Botox injection. However, despite delayed treatment with acyclovir and valacyclovir, the patient continued to have neuropathic pain and exhibit signs of CN X and CN XI paresis, in addition to scalene muscle atrophy.