[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Conditions](https://durgical.com/en/conditions/) › Ramsay Hunt syndrome (herpes zoster oticus)

# Ramsay Hunt syndrome (herpes zoster oticus)

Shingles of the [facial nerve](https://durgical.com/en/anatomy/facial-nerve/) near the ear: painful blisters on the ear and facial paralysis on one side, sometimes with hearing loss and vertigo.

Updated Nov 5, 2026

## Quick facts

**Key signs**
Intense ear pain · Vertigo with nausea and nystagmus

**Diagnosis**
PCR for varicella-zoster virus from vesicle fluid

Red flags ↓ No doses: the clinician sets them by the current guideline.

On this page

- The basics What it is
- Who gets it
- Causes
- Risk factors
- Classification
- In ENT

- Clinical Symptoms and signs
- Red flags
- Diagnosis
- Differential diagnosis
- Complications
- Prognosis

- Treatment Treatment

- Study Test yourself

- Connections Connections

## What it is

Reactivation of the varicella-zoster virus in the geniculate ganglion of the facial nerve. It causes peripheral facial palsy with ear pain and a vesicular rash on the ear, and often involves the [vestibulocochlear nerve](https://durgical.com/en/anatomy/vestibulocochlear-nerve/).

See it in 3D

- [Facial nerve (VII)](https://durgical.com/en/anatomy/facial-nerve/)
- [Vestibulocochlear nerve (VIII)](https://durgical.com/en/anatomy/vestibulocochlear-nerve/)
- [Facial nerve branches](https://durgical.com/en/anatomy/temporal-branches-of-facial-nerve/)
- [Internal acoustic meatus](https://durgical.com/en/anatomy/internal-acoustic-meatus/)

## +6

- [Auricle](https://durgical.com/en/anatomy/auricle/)
- [Ear canal](https://durgical.com/en/anatomy/external-acoustic-meatus/)
- [Cochlea](https://durgical.com/en/anatomy/cochlea/)
- [Vestibule](https://durgical.com/en/anatomy/vestibule/)
- [Semicircular canals](https://durgical.com/en/anatomy/semicircular-canals/)
- [Tongue](https://durgical.com/en/anatomy/tongue/)

## Who gets it

It is the second most common cause of atraumatic peripheral facial palsy after Bell palsy. It is more frequent after the age of 60 and in immunosuppressed people. Varicella vaccination is part of Colombia's national schedule, and zoster vaccines can reduce reactivation in older adults.

## Causes

- Reactivation of latent varicella-zoster virus in the geniculate ganglion
- Spread of inflammation to the vestibulocochlear nerve in the internal acoustic canal
- Waning cell-mediated immunity with age or immunosuppression

## Risk factors

- Age over 60
- Immunosuppression: HIV, cancer, chemotherapy, transplant, corticosteroids
- Previous chickenpox
- Physical or emotional stress
- Diabetes mellitus

## Classification

- Classic: facial palsy, otalgia and vesicles on the ear
- With vestibulocochlear involvement: hearing loss, tinnitus, vertigo
- Zoster sine herpete: facial palsy without a visible rash
- Severity of facial palsy graded with the House-Brackmann scale (I to VI)

## Symptoms and signs

- Intense ear pain, which may come before the rash
- Vesicles on the [auricle](https://durgical.com/en/anatomy/auricle/) and [ear canal](https://durgical.com/en/anatomy/external-acoustic-meatus/), and sometimes on the anterior [tongue](https://durgical.com/en/anatomy/tongue/) or palate
- Sudden peripheral facial palsy on the same side, including the forehead
- Sensorineural hearing loss and tinnitus
- Vertigo with nausea and nystagmus
- Loss of taste, dry eye or tearing, and hyperacusis

## Red flags

- Inability to close the eye (risk of corneal ulcer)
- Involvement of other cranial nerves or limb weakness
- Headache, confusion, seizures or neck stiffness (meningoencephalitis)
- Immunosuppressed patient or disseminated rash
- Rash on the tip of the nose or eye symptoms (ophthalmic zoster)

## Diagnosis

**Clinical**
Clinical: peripheral facial palsy with otalgia and vesicles on the ear. Examination includes otoscopy, the other cranial nerves, the eye and a bedside hearing and balance test; the palsy is graded with House-Brackmann.

**Tests**
PCR for varicella-zoster virus from vesicle fluid confirms it in atypical cases; pure-tone audiometry for hearing; electroneurography in complete palsy to estimate prognosis; HIV testing when indicated.

**Imaging**
Not needed in typical cases. MRI with contrast in atypical cases, other cranial nerve deficits or no recovery, to exclude a tumour or stroke; it may show enhancement of the facial and vestibulocochlear nerves.

## Differential diagnosis

- Bell palsy
- Acute otitis media or cholesteatoma with facial palsy
- Necrotising otitis externa
- Stroke (central palsy spares the forehead)
- Parotid tumour, Lyme disease and Guillain-Barré syndrome

## Treatment

**Medical**
Oral antivirals (acyclovir, valacyclovir or famciclovir) started as early as possible, ideally within 72 hours of onset; intravenous acyclovir in immunosuppressed patients or complicated cases.

**Medical**
Oral corticosteroids together with the antiviral, unless contraindicated, to reduce nerve swelling.

**Conservative**
Eye protection: lubricating drops and ointment, and taping or an eye patch at night when the eye does not close.

**Medical**
Pain relief, short courses of vestibular suppressants for vertigo, and treatment of postherpetic neuralgia if it appears.

**Rehabilitation**
Facial physiotherapy and follow-up; referral to otolaryngology for hearing loss, vertigo or incomplete recovery.

**Surgical**
Facial reanimation or eyelid procedures for permanent palsy.

## Complications

- Permanent facial weakness
- Synkinesis and crocodile tears (gustatory tearing)
- Permanent sensorineural hearing loss and tinnitus
- Exposure keratitis and corneal ulcer
- Postherpetic neuralgia
- Meningoencephalitis, rarely

## Prognosis

Worse than Bell palsy: about 70% regain normal or near-normal facial function with early treatment, compared with more than 90% in Bell palsy. Complete palsy, older age and late treatment worsen the outcome; hearing loss may be permanent.

## Test yourself

Think of the answer, then tap the question to see it.

## What is the classic triad of Ramsay Hunt syndrome?

Ipsilateral peripheral facial palsy, ear pain and vesicles on the auricle or ear canal.

## Where does the varicella-zoster virus reactivate?

In the geniculate ganglion of the facial nerve.

## Which nerve is often also involved, and how does it present?

The vestibulocochlear nerve: sensorineural hearing loss, tinnitus and vertigo.

## How does its prognosis compare with Bell palsy?

Worse: fewer patients recover full facial function, so early antiviral plus corticosteroid treatment matters.

## What is zoster sine herpete?

Facial palsy from varicella-zoster reactivation without a visible rash.

[Add to my cards (5)](https://durgical.app/estudiar/?add=/en/conditions/ramsay-hunt-syndrome/)

## In ENT

- [External ear problems: wax, otomycosis, furuncle, perichondritis, exostoses and keratosis obturans](https://durgical.com/en/ent/external-ear-problems-wax-otomycosis-furuncle-perichondritis-exostoses-and-kerat/)

## Connections

## Related conditions 7

- [Herpes zoster (shingles)](https://durgical.com/en/conditions/herpes-zoster/)
- [Varicella (chickenpox)](https://durgical.com/en/conditions/varicella/)
- [Bell palsy](https://durgical.com/en/conditions/bell-palsy/)
- [Herpes zoster ophthalmicus](https://durgical.com/en/conditions/herpes-zoster-ophthalmicus/)
- [Hearing loss (conductive and sensorineural, including sudden hearing loss)](https://durgical.com/en/conditions/hearing-loss/)
- [Vestibular neuritis and labyrinthitis](https://durgical.com/en/conditions/vestibular-neuritis-and-labyrinthitis/)
- [Otitis externa](https://durgical.com/en/conditions/otitis-externa/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Ramsay Hunt Syndrome](https://www.ncbi.nlm.nih.gov/books/NBK557409/) (StatPearls (NCBI Bookshelf), 2023).

[← All conditions](https://durgical.com/en/conditions/)

## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake

Representative model, for educational purposes only.

---
Source: https://durgical.com/en/conditions/ramsay-hunt-syndrome/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/ramsay-hunt-syndrome/