Is a herpes zoster rash around the external ear the same as Ramsay Hunt syndrome (Ramsay Hunt syndrome)?

From the Guidelines

A zoster rash around the external ear is not the same as Ramsay Hunt syndrome unless it is accompanied by facial paralysis, severe otalgia, loss of taste on the anterior two-thirds of the tongue, and decreased lacrimation on the involved side. According to the clinical practice guideline on acute otitis externa 1, Herpes zoster oticus (Ramsay Hunt syndrome) is a specific condition that causes vesicles on the external ear canal and posterior surface of the auricle, along with other symptoms such as facial paralysis or paresis. If the rash is present without these additional symptoms, it may be herpes zoster oticus (shingles affecting the ear) but not full Ramsay Hunt syndrome.

Key Considerations

• The presence of facial paralysis or paresis is a key distinguishing feature of Ramsay Hunt syndrome
• Severe otalgia, loss of taste on the anterior two-thirds of the tongue, and decreased lacrimation on the involved side are also characteristic of Ramsay Hunt syndrome
• Prompt treatment with antivirals and corticosteroids is necessary to reduce the risk of permanent facial nerve damage in cases of Ramsay Hunt syndrome
• If facial weakness, drooping, or difficulty closing the eye is noticed along with the ear rash, immediate medical attention is necessary as early treatment significantly improves outcomes 1.

Management

• For Ramsay Hunt syndrome, management involves prompt systemic antiviral therapy and systemic steroids 1
• The specific antiviral and corticosteroid regimen may vary, but examples include acyclovir 800mg five times daily for 7-10 days or valacyclovir 1000mg three times daily for 7 days, and prednisone 60mg daily for 5 days with a taper.

From the Research

Zoster Rash Around External Ear and Ramsay Hunt Syndrome

• A zoster rash around the external ear can be a symptom of Ramsay Hunt syndrome, which is a type of acute herpes zoster caused by the reactivation of the varicella-zoster virus at the geniculate ganglion 2.
• Ramsay Hunt syndrome is characterized by a vesicular rash on the ear (herpes zoster oticus) or in the oral mucosa, accompanied by acute peripheral facial nerve paralysis, and often involves other cranial nerves such as V, IX, XI, and XII 2, 3.
• The clinical presentation of Ramsay Hunt syndrome can vary, with some patients experiencing atypical symptoms, making early diagnosis and treatment crucial to improve outcomes 4, 5.
• A study found that early administration of acyclovir-prednisone treatment within 3 days of the onset of facial paralysis resulted in complete recovery from paralysis in 75% of patients, highlighting the importance of prompt recognition and treatment 6.

Key Characteristics of Ramsay Hunt Syndrome

• Painful vesicular lesions in the ear or oral mucosa
• Facial nerve palsy
• Hearing loss
• Involvement of other cranial nerves (V, IX, XI, and XII)
• Atypical clinical manifestations can occur, making diagnosis challenging

Diagnostic Tools and Treatment

• Magnetic resonance imaging (MRI) can be useful in diagnosing Ramsay Hunt syndrome, especially in cases with atypical clinical manifestations 5.
• Combination treatment containing anti-viral agents and steroids is recommended for the treatment of Ramsay Hunt syndrome 2, 6.