Related Subjects:
|Bell's (Facial Nerve) palsy
|Ramsay Hunt syndrome
|Facial nerve anatomy
🎭 About
- Ramsay Hunt syndrome is a form of facial nerve palsy caused by varicella-zoster virus (VZV), also called herpes zoster oticus.
- First described by neurologist James Ramsay Hunt in 1907.
- Prognosis for recovery is generally worse than idiopathic Bell’s palsy.
- Can involve both facial (CN VII) and auditory/vestibular nerves (CN VIII), leading to weakness, hearing loss, or vertigo.
🦠 Aetiology
- Due to VZV reactivation in the geniculate ganglion of the facial nerve.
- Characterised by:
- Unilateral facial weakness (LMN type).
- Painful vesicles in the external auditory canal, auricle, or soft palate.
- Possible vestibulocochlear nerve involvement → hearing loss, tinnitus, vertigo.
⚠️ Risk Factors for Recurrence
- Most cases are sporadic, but risks ↑ with:
- HIV or malignancy 💉
- Immunosuppressive therapy (steroids, chemo, radiotherapy) 💊
- Stress, infection, or trauma 🧠
🧑⚕️ Clinical Features
- Facial nerve palsy (LMN type): Drooping, weak smile, loss of forehead wrinkling.
- Herpes zoster oticus: Painful vesicular rash around the ear or canal.
- Vesicles may extend to the tongue or palate.
- If CN VIII involved → tinnitus, hearing loss, vertigo.
🔬 Investigations
- Clinical diagnosis usually sufficient (classic triad: facial palsy, vesicles, otalgia).
- PCR for VZV if atypical.
- HIV test if immunodeficiency suspected.
- MRI to exclude stroke, tumour, or atypical causes.
💊 Management
- Eye protection 👁️:
- Patch or tape eye if incomplete closure.
- Artificial tears & lubricants to prevent keratitis.
- Ophthalmology referral if corneal risk.
- Antivirals 🦠:
- Aciclovir 800 mg 5× daily × 7–10 days OR Famciclovir 500 mg TDS × 7 days.
- Steroids 💊:
- Prednisolone 50 mg daily for 5 days (start early with antivirals).
- Pain relief: Paracetamol, NSAIDs; neuropathic pain may require gabapentin/amitryptyline.
- Audiology: Assess if hearing loss or vertigo present.
📉 Prognosis
- Worse than Bell’s palsy → many patients have incomplete recovery.
- Early antiviral + steroid therapy improves outcomes but residual weakness, tinnitus, or hearing loss may persist.
- Recovery can take weeks–months; facial physiotherapy helps prevent contractures.
Cases — Ramsay Hunt Syndrome
- Case 1 — Classic Triad 🎯:
A 62-year-old man presents with severe right ear pain, a vesicular rash in the external ear canal, and acute right-sided facial weakness. He cannot close his eye or smile on the affected side.
Diagnosis: Ramsay Hunt syndrome (VZV reactivation in geniculate ganglion).
Management: Oral aciclovir + high-dose corticosteroids within 72 hrs; eye protection (lubricants, tape at night).
- Case 2 — With Vestibulocochlear Involvement 🎧:
A 48-year-old woman presents with left-sided facial paralysis, ear vesicles, and hearing loss. She also complains of vertigo and tinnitus.
Diagnosis: Ramsay Hunt syndrome with CN VIII involvement.
Management: Antivirals + steroids; vestibular suppressants short-term; audiology referral.
- Case 3 — Immunocompromised Patient 🧬:
A 35-year-old man with poorly controlled HIV presents with painful vesicular rash on pinna and oral mucosa, plus right-sided facial weakness. Exam: multiple cranial nerves involved (CN VII, VIII, IX).
Diagnosis: Disseminated Ramsay Hunt syndrome.
Management: IV aciclovir (immunocompromised), corticosteroids, multidisciplinary input (ENT, neurology, infectious diseases).
Teaching Commentary 🧠
Ramsay Hunt syndrome is caused by reactivation of varicella-zoster virus in the geniculate ganglion of CN VII. Classic triad:
1️⃣ Auricular vesicles,
2️⃣ Otalgia,
3️⃣ Ipsilateral LMN facial palsy.
Additional signs: hearing loss, vertigo, altered taste, dry eyes/mouth.
Differentiate from Bell’s palsy: Ramsay Hunt has rash and more severe prognosis.
Treatment = early antivirals + steroids (best if within 72 hrs) + eye care. Recovery is often incomplete compared to Bell’s palsy, especially if CN VIII is involved.