Unmasking Ramsay Hunt Syndrome: Symptoms, Diagnosis, and Treatment Essentials
Doctor explains Ramsay Hunt Syndrome, a condition caused by the varicella-zoster virus, which also causes chickenpox. Learn about its symptoms, diagnosis, and treatment options to ensure timely recovery.
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Topic Breakdown
In today's discussion, we delve into a condition known as Ramsay Hunt Syndrome. This condition is caused by the same virus responsible for chickenpox, the varicella-zoster virus. After chickenpox clears up, the virus can remain dormant in your nerves for years, only to reactivate later and affect your facial nerves. You might hear the terms Ramsay Hunt Syndrome and herpes zoster oticus used interchangeably; they essentially mean the same thing.
Ramsay Hunt Syndrome occurs when the varicella-zoster virus outbreak impacts the facial nerve near one of your ears. Understanding the symptoms is crucial for early diagnosis and treatment. The two main signs are a painful red rash with fluid-filled blisters on, in, or around one ear and facial weakness or drooping on the same side as the affected ear. Typically, the rash and facial paralysis occur simultaneously, but sometimes one can precede the other, or the rash may never appear at all.
Patients often report additional symptoms, including ear pain (otalgia), hearing loss, ringing in the ears (tinnitus), difficulty closing one eye, vertigo (a sensation of the room spinning), and a change in taste perception. The facial nerve innervates part of the tongue, which explains the altered taste sensation.
For healthcare professionals, examining the eye is imperative if it doesn't close fully. Ensure the patient has eye protection and seek advice from an ophthalmology team. Inadequate eye closure can lead to the surface of the eyeball drying out, causing inflammation of the cornea, known as keratoconjunctivitis sicca. During your examination, you might also notice a rash on the anterior two-thirds of the tongue or the hard palate, areas innervated by the facial nerve.
A thorough cranial nerve exam is essential. Ask the patient to raise their eyebrows; in a facial nerve palsy, they typically can't wrinkle their forehead on the affected side due to a lower motor neuron problem, unlike an upper motor neuron issue such as a stroke. You might observe Bell's phenomenon, where the eye moves upward and outward when the patient attempts to close their eyes, a defensive mechanism to protect the eyes.
Healthcare professionals may also use the House-Brackmann scale to grade the extent of facial paralysis. For those interested, I've included a link to this scale in the description box of the video for further reading.
Diagnosing Ramsay Hunt Syndrome usually involves a thorough history and a good clinical examination. When it comes to treatment, immediate management involves a combination of antivirals, steroids, gastric protection due to high-dose steroids, and pain relief. Oral acyclovir, taken five times a day for seven days, and oral prednisolone (steroids) for the same duration are commonly prescribed. Omeprazole is used for gastric protection, also for seven days.
Timely intervention with steroids and antivirals can significantly influence prognosis. Although evidence is limited, early recognition and commencement of therapy within the first 72 hours are believed to maximize the chance of a good recovery, potentially leading to a 70% timely recovery versus 50% if treatment is delayed.
Eye protection is crucial if the patient can't fully close their eye. Administer artificial tears, such as Visco Tears, at least four times a day, and use Lacri-Lube or VitA-POS ointment at night. The eye should be taped closed at night to prevent drying out. Ensure the patient has an ENT clinic follow-up around two weeks after the initial problem for an audiogram and possibly a tympanogram.
Ramsay Hunt Syndrome can affect anyone who has had chickenpox, though it is more common in older adults, typically those over 60. While the syndrome itself isn't contagious, reactivation of the varicella-zoster virus can cause chickenpox in people who haven't had it or been vaccinated. The infection can be serious for individuals with immune system problems. Until the rash scabs over, those with Ramsay Hunt should avoid contact with anyone who hasn't had chickenpox or the vaccine, those with weak immune systems, newborns, and pregnant women.
For healthcare professionals, be aware of red flag features in patients presenting with facial nerve palsy. These include facial nerve palsy associated with trauma, which may need urgent decompression and surgical involvement; facial nerve palsy due to otitis media or mastoiditis, requiring urgent ENT input; facial nerve palsy with parotid swelling, raising the possibility of cancer; and deep ear pain (otalgia) with granulations in the ear canal, suggesting a skull-based infection or osteomyelitis.
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