Advanced Practice: Ramsay Hunt Syndrome

What is it?

  • Reactivation of varicella zoster virus in the geniculate ganglion 
  • Major otologic complication of herpes zoster
  • Can result in permanent facial weakness/paralysis and deafness: early treatment reduces this risk

How does it present?

  • Classic Triad: ipsilateral facial paralysis, ear pain, vesicles in auditory canal and auricle 
  • Facial paralysis results from CN7 involvement, however can also involve CN8 (tinnitus, hearing loss, nausea, vertigo)
  • Ear pain usually precedes rash by hours to days
  • Other: fever, cervical adenopathy, headache, gait ataxia

So what do I do about it?

  • Tx: Antivirals (acyclovir, valacyclovir, or famciclovir), prednisone, analgesics 
  • Cornea eye protection w/ CN7 paralysis (artificial tears, ophthalmic ointment, etc.)
  • Poor Prognostic Indicators: age > 50 y/o, complete facial paralysis, immunocompromised patient  


  • Albrecht, MA. “Treatment of Herpes Zoster in the Immunocompetent Patient.” UpToDate.  21 July 2016 < >
  • Ryu EW, Lee HY, Lee SY, Park MS, Yeo SG. “Clinical manifestations and prognosis of patients with Ramsay Hunt syndrome.” American Journal of Otolaryngology. Nov 8 2011
  • Tintinalli, JE. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education LLC, 2016.