Herpes oticus

Definition

Ramsay Hunt syndrome is a neurologic disorder caused by a virus (varicella zoster) that infects certain nerves in the head.

Alternative Names

Causes

The varicella zoster virus causes both Ramsay Hunt syndrome and another common cause of facial weakness, Bell's palsy (in which there is no rash).

This virus is within the family of human herpes viruses, which cause fever sores on the mouth and genital herpes. The varicella zoster virus also causes shingles and chickenpox.

In those with Ramsay Hunt syndrome, the virus is believed to infect the facial nerve near the inner ear. This results in irritation and swelling.

Symptoms

Symptoms may include:

• Facial weakness with difficulty closing one eye -- smile may look crooked
• Painful rash on the ear drum, tongue, or palate on the same side of the facial weakness
• Hearing loss on one side
• Sensation of things spinning around (vertigo)

Exams and Tests

Diagnosis is generally determined by observation of evidence of facial weakness and a vesicular rash. Occasionally, a nerve conduction study will be done to determine the extent of damage to the facial nerve and potential for recovery.

The more severe the damage, the longer it will take to recover, and the lower the chance of complete return to normal function. Occasionally, blood tests are used to determine whether or not an infection with the varicella zoster virus has occurred.

There is a promising laboratory technique called PCR, which can detect very small amounts of viral DNA in the affected skin. However, it is mostly used for research nowadays.

The use of neuroimaging (pictures of the brain), particularly MRI (magnetic resonance imaging), may sometimes show inflammation of the facial nerves and determine whether the infection has spread to other nerves or the brain. A spinal tap is used in rare cases, especially when the diagnosis is not clear.

Treatment

Treatment with anti-viral medications, such as acyclovir or famciclovir is recommended for 7 - 10 days, along with strong anti-inflammatory drugs called steroids (such as prednisone) for 3 - 5 days.

The steroids are then tapered off in about 1 week. Sometimes strong pain killers are also needed if the pain persists despite the use of the steroids. During the period of facial weakness, an eye patch should be worn to prevent corneal abrasion and damage to the eye if it does not close completely.

Outlook (Prognosis)

If damage to the nerve is minimal, then a full recovery is usually expected within a few weeks. If damage is more severe, there may not be full recovery -- even after several months.

Overall, chances of recovery are better if the treatment is started within 3 days of the onset of the symptoms. Complete recovery is achieved by 70% of patients if treatment is begun at this time.

However, when the treatment is delayed more than 3 days, the chances of complete recovery drop to about 50%. Children are more likely to have a complete recovery than adults.

Recovery may be complicated if the nerve grows back to the wrong areas (synkinesis) which may cause inappropriate responses, such as tears when laughing or chewing (croc´s tears). Some other people may experience blinking of the eye when talking or chewing food.

Possible Complications

Severe paralysis will result in incomplete or inappropriate recovery with potential for permanent facial paralysis and synkinesis.

Occasionally, the virus may spread to other nerves or even to the brain and spinal cord, causing headaches, back pain, confusion, lethargy, and limb weakness. This may prompt an admission to the hospital, where a spinal tap may help to determine whether other areas of the nervous system have been infected.

When to Contact a Medical Professional

Call your health care provider if you have facial paralysis or a rash on your face associated with facial weakness.

Prevention

There is no known prevention of Ramsay Hunt syndrome, but recovery is improved with the use of medications early in the course of the symptoms. It is important to keep the eye protected if there is incomplete eye closure due to weakness.

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