Ramsay Hunt syndrome is caused by reactivation of the varicella zoster virus in the geniculate ganglion, resulting in a peripheral facial nerve palsy accompanied by a rash on the ear or in the mouth. Other cranial nerves are commonly involved as well. The prognosis is worse than Bell's palsy, with persistent weakness observed in 30-50% of untreated patients. Treatment involves a combination of steroids and antiviral agents for longer periods of 2-3 weeks to reduce complications.

1. Varicella zoster virus infection(Ramsay
Hunt syndrome)
The strict definition of Ramsay Hunt syndrome is a peripheral facial nerve palsy accompanied by an
erythaematous vesicular rash on the ear(zoster oticus) or in the mouth. It is due to the reactivation
of the latent VZV virus in the geniculate ganglion. Other cranial nerve are commomly involved. The
onset of palsy is preceded by pain which may persist & may be excruciating. In a small proportion of
cases, the facial palsy is accompanied by a sensorineural hearing loss.
It has been demonstrated that a small proportion of patients diagnosed as Bell’s palsy may in fact
have a VZV infection.
In 15% of case vesicles may appear after the onset of palsy & the diagnosis may be missed.
Another reason for missing the diagnosis is the Ramsay Hunt syndrome zoster sine herpete.
-This is characterised by peripheral facial paralysis without ear or mouth rash.
-Four fold rise in antibody to varicella zoster virus( VZV) or
- detection of VZV DNA in the skin, blood monocyte or middle ear fluid.
The prognosis for Ramsay hunt is worse than bell’s palsy. Persistent weakness observed in 30-50%
of patients & only 10% recover completely after complete loss of function without treatment.
Most authors advocate a combination of steroids & antiviral agents but for a longer period of time(2
to 3 weeks).
The combination of steroids & acyclovir also seems to reduce otalgia, vertigo, & post-herpetic
neuralgia. Surgical decompression is not indicated.
Other viral causes
1. Guillain –barre syndrome( acute inflammatory demyelinating polyneuropathy) presents
typically 2 to3 weeks after an upper respiratory infection probably caused by an abnormal T-cell
response against myelin components.
2. Epstein-barr infection ( infectious mononucleosis) is clinically characterized by generalised
lymphadenopathy , fever, & sore throat & may be associated with facial palsy. 40% are
bilateral palsy.
3. Human immune deficiency virus(HIV) can cause facial palsy at any stage of disease.
a. The presumed mechanisms include local infection of facial nerve or ganglion by the
HIV,
b. inflammatory demyelinating neuropathy or

2. c. secondary infection precipitated by immunosuppression with agents such as VZV,
HSV or EBV.