A patient comes with complaint of... Troubling of saliva and, uh, having... Pain in the mouth. And there is upper eyelid de- deviation in the eye with previous history of viral infection. What is the diagnosis? 50 year. Yes.
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Diagnosis: Ramsay Hunt Syndrome (Herpes Zoster Oticus)
This is a classic presentation. Here is the breakdown:
Key Features in This Patient
| Symptom Reported | Clinical Correlation |
|---|---|
| Drooling / troubling of saliva | Facial nerve palsy (CN VII) - loss of orbicularis oris tone |
| Pain in the mouth | Geniculate ganglion involvement - pain radiating to oral cavity, ear, face |
| Upper eyelid deviation (ptosis-like) | Facial nerve palsy - weakness of frontalis / orbicularis oculi |
| Previous viral infection history | VZV reactivation after primary chickenpox (latent in geniculate ganglion) |
| Age 50 years | Typical age group - risk increases with age and declining cell-mediated immunity |
What Is Ramsay Hunt Syndrome?
Ramsay Hunt Syndrome is VZV (varicella-zoster virus) reactivation from its dormant state in the geniculate ganglion of CN VII. It causes:
- Peripheral facial palsy (unilateral) - the hallmark
- Otalgia / facial pain - often severe, preceding or accompanying the palsy
- Vesicular eruption - on the pinna, external auditory canal, or oral mucosa (soft palate, anterior 2/3 of tongue)
- Possible CN VIII involvement - sensorineural hearing loss, tinnitus, vertigo (in up to 50% of patients)
- Other cranial nerves (V, IX-XII) may also be affected in some cases
The "upper eyelid deviation" here reflects orbicularis oculi weakness - the eye cannot close properly (lagophthalmos), making the eye appear deviated upward (Bell's phenomenon, where the eyeball rolls up when the patient attempts to close the eye).
"Ramsay Hunt syndrome is a herpes zoster infection of the geniculate ganglion. Signs and symptoms include unilateral facial nerve palsy, severe pain, and a vesicular eruption on the face or in the auditory canal." - Tintinalli's Emergency Medicine
"Clinical characteristics include pain in and around the ear, vesicular eruption that involves the pinna and external auditory canal, and facial paralysis." - Cummings Otolaryngology
How to Differentiate from Bell's Palsy
| Feature | Bell's Palsy | Ramsay Hunt Syndrome |
|---|---|---|
| Cause | HSV-1 reactivation | VZV reactivation |
| Pain | Mild post-auricular | Severe, often prominent |
| Vesicles | Absent | Present (ear, mouth) |
| Prognosis | Better (85% recover fully) | Worse (~50% have residual palsy) |
| CN VIII involvement | Rare | Up to 50% |
Note: Ramsay Hunt can be indistinguishable from Bell's palsy if facial paralysis precedes the vesicular eruption.
Treatment
- Oral antivirals (acyclovir 800 mg 5x/day OR valacyclovir 1g TID for 7-10 days) - must start early
- Oral corticosteroids (prednisolone 1 mg/kg/day, tapering over 10 days) - Cochrane review confirms benefit
- Combination (antivirals + steroids) is superior to either alone
- Eye protection - artificial tears, lubricating ointment at night, eye patch to prevent corneal exposure keratitis (given incomplete eye closure)
- Physiotherapy for facial muscles
"Early treatment with steroid and antiviral medication has reduced the long-term sequelae." - Shambaugh Surgery of the Ear
Memory Aid
Ramsay Hunt = "Ear Zoster + Facial Palsy"
- Redness/vesicles (ear/mouth)
- Aching pain (geniculate neuralgia)
- Motor palsy (facial nerve)
- Sensory (CN VIII - hearing/balance)
- Antivirals + steroids = treatment
- Y (VZV) = the causative virus
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