Advanced Practice - "Ow, my ear hurts!" Ramsay Hunt Syndrome


• Reactivation of varicella zoster virus in the geniculate ganglion

• Major otologic complication of herpes zoster


  • Classic Triad: Ipsilateral facial paralysis, ear pain, vesicles in auditory canal and auricle
  • Facial paralysis results from CN7 involvement, however can also involve CN8 (tinnitus, hearing loss, nausea, vertigo)
  • Rarer complications:  fever, cervical adenopathy, headache, gait ataxia

Top Tip

• Ear pain usually precedes rash by hours to days - Consider empiric therapy in patients with severe otalgia and sensitivity to touch of the auricle without a discrete rash


  •  Antivirals (acyclovir, valacyclovir, or famciclovir), prednisone, analgesics 
  •  Corneal eye protection w/ CN7 paralysis (patching at night, artificial tears, ophthalmic ointment)
  •  Poor Prognostic Indicators: age > 50 y/o, complete facial paralysis, immunocompromised patient




Ryu EW, Lee HY, Lee SY, Park MS, Yeo SG. “Clinical manifestations and prognosis of patients with Ramsay Hunt syndrome.” American Journal of Otolaryngology. Nov 8 2011