Ramsay-Hunt syndrome is caused by the herpes (or varicella) zoster virus. Like Bell's palsy, it presents with rapid onset of facial paralysis, but also with a vesicular rash (as seen with "shingles") erupting in the external ear or near it. There is almost always severe otalgia, and the virus affects other adjacent cranial nerves as well. Cranial nerve VIII is the most frequently affected, with sensorineural hearing loss and vertigo. Lesions of cranial nerves IX and X may cause pain in the pharynx, and involvement of cranial nerve V may give facial pain. The prognosis of Ramsay-Hunt syndrome is not as good as that for Bell's palsy. The clinical course is more
prolonged and the facial asymmetry is more apt to persevere. In addition, the hearing loss may be permanent. Vertigo and dysequilibrium from vestibular involvement can persist. In general, with unilateral vestibular loss, the opposite vestibule eventually compensates for most of the symptoms. However, this may take 6 months or more.
Treatment by the primary physician centers on steroids and antivirals, as with Bell's palsy. Steroids should be given over a long period, perhaps 2 weeks or more. Acyclovir is recommended as early as possible in the high-strength dosage—800 mg by mouth five times a day. Alternatively, Famvir, a newer antiviral in the same family, may be given. Total recovery, with no residual deficit, is less than 50%, with older age bringing a worse prognosis.
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