What is the diagnosis for a patient presenting with severe right ear pain, a ruptured right tympanic membrane, and mild right-sided facial asymmetry, with a history of Botox (Botulinum toxin) injection to the face 2 months ago?

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Differential Diagnosis

  • Single most likely diagnosis
    • Herpes Zoster Oticus (Ramsay Hunt Syndrome): This diagnosis is likely due to the patient's severe ear pain, ruptured tympanic membrane, and subtle right-sided facial asymmetry (mild mouth droop). The absence of fever, otorrhea, and recent URTI symptoms also supports this diagnosis.
  • Other Likely diagnoses
    • Temporomandibular Joint (TMJ) Disorder: The patient's severe ear pain and tenderness over the right ear could be related to a TMJ disorder, especially considering the recent Botox injection to the face.
    • Otalgia due to Referred Pain: Referred pain from the face or neck could be causing the patient's ear pain, and the mild mouth droop could be related to the Botox injection.
  • Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
    • Cerebellopontine Angle (CPA) Tumor: Although unlikely, a CPA tumor could cause facial weakness, ear pain, and hearing loss (although the patient does not have hearing loss). It is essential to consider this diagnosis to avoid missing a potentially life-threatening condition.
    • Stroke or Transient Ischemic Attack (TIA): The patient's mild mouth droop could be a sign of a stroke or TIA, and it is crucial to rule out this diagnosis to prevent further complications.
  • Rare diagnoses
    • Lyme Disease: Although rare, Lyme disease could cause facial palsy and ear pain, especially if the patient has been exposed to ticks.
    • Sarcoidosis: This condition could cause facial weakness, ear pain, and other systemic symptoms, although it is a rare diagnosis.
    • Multiple Sclerosis: Although unlikely, multiple sclerosis could cause facial weakness, ear pain, and other neurological symptoms, and it is essential to consider this diagnosis in the differential.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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