10.

5005/jp-journals-10011-1263
S Karthiga Kannan et al
CASE REPORT

Ramsay Hunt Syndrome (Herpes Zoster Oticus)

S Karthiga Kannan, J Eugenia Sherubin, S Sajesh, KP Gopakumar

ABSTRACT CASE REPORT

Ramsay Hunt syndrome (RHS) is defined as an acute peripheral
facial neuropathy caused by the reactivated latent varicella
zoster virus (VZV) in the geniculate ganglion; characterized with
erythematous vesicular rash of the skin of the ear canal, auricle,
facial skin, oral mucosa and facial palsy (also known as herpes
zoster oticus). This article reports a case of Ramsay Hunt
Syndrome (RHS) in a 37-year-old male patient depicting the
classical signs.
Keywords: Varicella zoster, Geniculate ganglion, Vesicles,
Facial palsy.
How to cite this article: Kannan SK, Sherubin JE, Sajesh S,
Gopakumar KP. Ramsay Hunt Syndrome (Herpes Zoster
Oticus). J Indian Aca Oral Med Radiol 2012;24(1):70-72.
Source of support: Nil
Conflict of interest: None declared
INTRODUCTION
Here, we present a 37-year-old male patient who reported
with clusters of vesicles in the skin over the left side of the
face, following removal of carious left mandibular third
molar (38). Patient also complained of fever, fatigue,
myalgia, facial and ear pain, altered taste perception. The
vesicles were present unilaterally in the facial skin along
the left mandibular dermatome (Fig. 1). External auditory
canal and tragus of left ear also showed similar lesions.
Intraorally multiple ulcers of varying size distributed over
the left buccal mucosa, left half of the labial mucosa, tongue
and palate (Fig. 2) The case was provisionally diagnosed
as herpes zoster involving mandibular and maxillary (palate)
dermatome. Patient was prescribed tablet acyclovir 800 mg
five times a day for 5 days, tablet paracetamol 500 mg sixth
hourly for 3 days, chlorhexidine mouthwash and topical

Ramsay Hunt syndrome (RHS) is defined as an acute

peripheral facial neuropathy associated with erythematous
vesicular rash of the skin of the ear canal, auricle (also
termed herpes zoster oticus), and/or mucous membrane of
the oropharynx. RHS was first described in 1907 by James
Ramsay Hunt in a patient who had otalgia associated with
cutaneous and mucosal rashes, which he ascribed to the
infection of geniculate ganglion by human herpes virus 3
(i.e. varicella zoster virus [VZV]).1,3,7 This syndrome is also
known as geniculate neuralgia or nervus intermedius
neuralgia. Primary infection of VZV, also known as varicella
or chickenpox, is a common pediatric erythematous disease.3
VZV remain latent in neurons of cranial nerve and dorsal
root ganglia, subsequent reactivation can result in prodromal Fig. 1: Extraoral view: Front and lateral profile of face showing the
period of severe pain followed by localized vesicular rash, unilateral distribution of clusters of vesicles on the left side of the
known as herpes zoster (HZ). face and tragus of the ear

Classic RHS usually present with paroxysmal pain deep

within the ear, often radiates outward into the pinna and
may be associated with a more constant, diffuse and dull
background pain. The onset of pain usually precedes the
rash by several hours and even days. Vesiculation and
ulceration of the external ear and ipsilateral anterior two-
thirds of the tongue and soft palate are common (as many
as 80% of cases).4 The rash might precede the onset of facial
paresis/palsy; other manifestations include vertigo and
ipsilateral hearing loss (CN VII), tinnitus, otalgia,
Fig. 2: Intraoral view: Oral mucosa showing the unilateral distribution
headaches, dysarthria, gait ataxia, fever, cervical of clusters of ulcers on the buccal mucosa, labial mucosa, tongue
adenopathy.5-7 and palate on the left side

70
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Ramsay Hunt Syndrome (Herpes Zoster Oticus)

10% benzocaine four times a day. On the seventh day,

patient reported with inability to wrinkle the left half of
forehead, inability to raise the left eyebrow, inability to close
left eyelid and deviation of angle of the mouth to the normal
(right) side suggestive of left peripheral facial nerve
paralysis and healed lesions in skin showed
hyperpigmentation (Fig. 3). The diagnosis was revised as
RHS. Patient was advised physiotherapy for facial palsy
and showed good recovery.

DISCUSSION

RHS is estimated to account for 18% of facial palsies in

adults.2,4 Early initiation of antiviral treatment and adjuvant
steroid therapy can prevent the occurrence of facial
paralysis. Poor prognostic factors for good functional
recovery of facial nerve include patient older than 50 years,
complete facial paralysis and lack of CN VII nerve
excitability.4 Approximately 25% of patients with RHS
experience vestibular or cochlear symptoms or both;
apparently caused by the spread of inflammatory cells from
geniculate ganglion to inner ear, spiral or vestibular
ganglion. In one-fourth of patient, symptom also includes
vertigo, nystagmus, tinnitus and hearing loss. Sensorineural
hearing loss occurs in only approximately 6% of patients.
Audiograms vary and suggest primary cochlear involvement
or cochlear nerve damage.5,7 In our case, there was no
Fig. 4: Audiogram report: Normal pure tone audiogram ruling
history of deafness or vertigo. Examination revealed normal out involvement of auditory apparatus
tuning fork test and normal pure tone audiogram (Fig. 4),
thereby ruling out involvement of auditory apparatus. There presentation. Similar to our case many of the patients with
was no feature suggestive of vestibular involvement which HZ in the head and neck region undergo unnecessary
was evident by the absence of vertigo and nystagmus. This extraction/endodontic treatment for many teeth during the
case was presented for its rarity and classical clinical prodromal period with no clinical lesions.

REFERENCES
Fig. 3: Facial view before and after facial palsy: Patient face showing
features of complete peripheral facial nerve palsy of left side showing
lack of wrinkling of forehead, inability to close the left eye lid,
deviation of angle of mouth to right side
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2. Kleinschmidt-DeMasters BK, Gilden DH. The expanding
spectrum of herpesvirus infections of the nervous system. Brain
Pathol Oct 2001;11(4):440-51.
3. Sandoval CC, Nunez FA, Lizama CM, et al. Ramsay Hunt
syndrome in children: Four cases and review. Rev Chilena
Infectol 2008 Dec;25 (6): 458-64.
4. Gilchrist JM. Seventh cranial neuropathy. Semin Neurol
2009 Feb;29 (1):5-13.
5. Wayman DM, Pham HN, Byl FM, Adour KK. Audiological
manifestations of Ramsay Hunt syndrome. The Journal of
Laryngology andamp; Otology 1990;104:104-08.
6. Kaberos A, Balatsouras DG, Korres SG, Kandiloros D,
Economou C. Audiological assessment in Ramsay Hunt
syndrome. Ann Otol Rhinol Laryngol 2002 Jan;111(1):
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Journal of Indian Academy of Oral Medicine and Radiology, January-March 2012;24(1):70-72 71

S Karthiga Kannan et al
7. Flint PW, Haughey BH, Lund VJ, Niparko JK, Richardson
MA, Robbins KT, Thomas JR. Cummings Otolaryngology
Head and Neck Surgery, (5th ed), 2010 Mosby, An Imprint of
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ABOUT THE AUTHORS
S Karthiga Kannan (Corresponding Author)
Professor and Head, Department of Oral Medicine and Radiology
Sree Mookambika Institute of Dental Science, Sanker Ganesh
Dental Clinic, 5/62 B, Ist Floor, Main Road, Puthukkadai
Kanyakumari, Tamil Nadu-629171, India, Phone: 9443453725
e-mail: profdrskkomdr@yahoo.com, info@sankerganeshdental.com
Website: www.sankerganeshdental.com
72
J Eugenia Sherubin
Senior Lecturer, Department of Oral Medicine and Radiology
Sree Mookambika Institute of Dental Sciences, Kanyakumari
Tamil Nadu, India
S Sajesh
Reader, Department of Maxillofacial Surgery, Sree Mookambika
Institute of Dental Sciences, Kanyakumari, Tamil Nadu, India
KP Gopakumar
Professor, Department of ENT and Otolaryngology, Sree Mookambika
Institute of Dental Sciences, Kanyakumari, Tamil Nadu, India
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