Herpes zoster oticus, also known as Ramsay Hunt syndrome type I, is a reactivation of the varicella zoster virus in the geniculate ganglion of the facial nerve and spiral and vestibular ganglia of the VIII nerve, causing a vesicular rash on the ear and facial nerve palsy on the same side. It often causes ear pain and can also involve the eighth nerve resulting in hearing loss, tinnitus, or vertigo. Early treatment within three days with oral acyclovir and prednisone improves outcomes and reduces complications like post-herpetic neuralgia, though elderly patients and those with complete facial palsy have a poorer prognosis.

1. Herpes zoster oticus
Definition : Herpes zoster oticus is definied as a herpetic vesicular rash on the concha, external
auditory canal or pinna with a lower motor neuron palsy of the ipsilateral facial nerve.
Nomenclature
Commonly known as Ramsay hunt syndrome. To be more accurate, herpes zoster oticus should
actually be called Ramsay hunt syndrome type I, as Ramsay hunt actually describe three neurological
syndrome – only one of which involved the facial nerve & the ear.
Pathology
The disease is a reactivated varicella zoster infection from dormant viral particles resident in the
geniculate ganglion of the facial nerve& spiral & vestibular ganglia of the VIII nerve.
Diagnosis
The diagnosis is essentially still a clinical one.
It almost always affect VIII nerve.The eight nerve may be involved to a variable degree resulting in
hearing loss,tinnitus, and /or vertigo.
Auricular pain is often the first symptom & other cranial nerve may be involved. Rash is not present
initially but develops several days after the onset of pain & facial palsy.
In some cases, rash may present on the tongue, mouth or pharyngeal mucosa & never present on
ear.
Spread from facial nerve to VIII & other cranial nerves via vasa nervorum.
A facial palsy (3%) without a cutaneous or mucosal rash may still be due to varicella zoster , this
condition is known as zoster sine herpete (no rash).
Management options
If treatment starts within three days of onset of symptoms, improves outcome.
Oral acyclovir (800×5 days)&predisolone(1mg/kg/day). 75% of the patients will recover with early
treatment. Early treatment with antiviral agents significantly reduce the prevalence of post-herpetic
neuralgia.
Complete facial palsy have a poor prognosis if not treated early.Elderly have a poor prognosis for
return of facial nerve function.