Herpes Zoster Oticus (Ramsay–Hunt Syndrome)

📌 Also known as: Ramsay–Hunt Syndrome

Definition: A viral infection characterized by a vesicular rash in the external auditory canal and pinna, often accompanied by facial paralysis.

Clinical Features

The condition typically presents with a triad of symptoms:

• Vesicular Rash: Small tense blisters with surrounding erythema.
  • Sites: Tympanic membrane, meatal skin, concha, and postauricular groove.
  • Pain: Severe ear pain usually precedes the rash by several days.
• Facial Nerve Palsy: Paralysis of the face (LMN type) along with the rash.
• Vestibulo-Cochlear Symptoms:
  • Sensorineural Hearing Loss (SNHL) due to VIIIth nerve involvement.
  • Giddiness/Vestibular disturbance.
• Anaesthesia: May involve Vth (Trigeminal) nerve causing facial numbness.

Medical Management

1. Corticosteroids

Drug of Choice: Prednisolone.

Utility:

• Prevents synkinesis and "crocodile tears".
• Shortens recovery time of facial paralysis.

Dosing Regimen (Adults):

Timeframe	Action/Dose
Start (First 5 Days)	1 mg/kg/day (divided morning & evening). *Start within 1 week of onset.
Day 5 Review	If Recovering: Taper over next 5 days. If Complete Paralysis: Continue same dose for 10 days, then taper over 5 days.
Total Duration	Max 20 days (for complete paralysis).

2. Antivirals

• Acyclovir: Can be combined with steroids for Herpes Zoster Oticus or Bell's Palsy.

3. Ineffective Drugs

The following have not been found useful:

• Vasodilators & Vitamins.
• Mast cell inhibitors & Antihistaminics.

Surgical Treatment

Procedure: Nerve Decompression.

• Mechanism: Relieves pressure on nerve fibers → improves micro-circulation.
• Sites Decompressed: Vertical and tympanic segments.
• Approaches: Postaural or Middle Fossa approach (suggested for total decompression including labyrinthine segment).

Differential: Bell's Palsy vs Ramsay Hunt

While both cause LMN Facial Paralysis, Ramsay Hunt is more severe.

Feature	Bell's Palsy	Ramsay Hunt Syndrome
Aetiology	Idiopathic (likely HSV-1).	VZV (Varicella Zoster Virus).
Cutaneous Signs	None (Normal Ear Canal).	Vesicular Rash (Pinna/EAC/Palate).
Pain	Mild post-auricular ache (50%).	Severe, deep boring pain.
Associated Nerves	Usually only VII.	VII + VIII (Hearing/Balance) + V, IX, X.
Prognosis	Good (85-90% recovery).	Poor (<50% full recovery).