Prognostic value of electroneurography using the midline method for predicting the development of synkinesis after peripheral facial palsy

OBJECTIVE

The prognostic value of electroneurography (ENoG) for predicting the incidence of synkinesis is reportedly about 40 % using the formal standard method (ENoG-SM). However, the prognostic value of ENoG using the newly developed midline method (ENoG-MM) has not been determined. The aim of this study was to demonstrate the optimal prognostic value and advantages of ENoG-MM for predicting the incidence of synkinesis.

METHODS

Participants were 573 patients treated for peripheral facial palsy including Bell's palsy or Ramsay Hunt syndrome. We investigated the clinical presence of any oral-ocular or ocular-oral synkinesis from the medical records. ENoG-MM and ENoG-SM were performed 10-14 days after symptom onset. In ENoG-MM, compound muscle action potentials were recorded by placing the anode on the mental protuberance and the cathode on the philtrum. In ENoG-SM, electrodes were placed on the nasolabial fold. Synkinesis was clinically assessed at the end of follow-up or at >1 year after onset. The sensitivity and specificity of ENoG values for predicting the incidence of synkinesis were compared between ENoG-MM and ENoG-SM at every 5 % around 40 % (range, 30-50 %).

RESULTS

At every 5 % of ENoG values around 40 %, ENoG-MM provided higher sensitivity and lower specificity for predicting the incidence of synkinesis compared with ENoG-SM. In particular, when the cut-off value was set at 45 %, sensitivity was 100 % and 95.3 % with ENoG-MM and ENoG-SM, respectively.

CONCLUSION

In peripheral facial palsy, ENoG-MM offered higher sensitivity than ENoG-SM for predicting synkinesis. ENoG-MM is useful for screening patients at risk of developing synkinesis. In clinical practice, an ENoG-MM cut-off value of 45 % must be the optimal prognostic value because of the 100 % sensitivity.

The Impact of the COVID-19 Pandemic on Bell's Palsy and Ramsay-Hunt Syndrome: A Multicenter Retrospective Study

BACKGROUND

This article presents a comprehensive review of data on the impact of facial palsy during the coronavirus disease 2019 (COVID-19) pandemic. The possible causes and pathophysiological mechanisms of changes in the epidemiology of facial palsy during the COVID-19 pandemic are also discussed.

METHODS

This multicenter retrospective cohort study included 943 patients diagnosed with Bell's palsy or Ramsay Hunt syndrome. This study compared patient demographics, comorbidities, symptoms, and treatments before the COVID-19 pandemic (from 2017 to 2019) and during the COVID-19 pandemic, from 2020 to 2022).

RESULTS

Following the COVID-19 outbreak, there has been a significant increase in the number of cases of Bell's palsy, particularly among elderly individuals with diabetes. Bell's palsy increased after the COVID-19 outbreak, rising from 75.3% in the pre-COVID-19 era to 83.6% after the COVID-19 outbreak. The complete recovery rate decreased from 88.2% to 73.9%, and the rate of recurrence increased from 2.9% to 7.5% in patients with Bell's palsy. Ramsay Hunt syndrome showed fewer changes in clinical outcomes.

CONCLUSION

This study highlights the impact of the COVID-19 pandemic on the presentation and management of facial palsy, and suggests potential associations with COVID-19. Notably, the observed increase in Bell's palsy cases among elderly individuals with diabetes emphasizes the impact of the pandemic. Identifying the epidemiological changes in facial palsy during the COVID-19 pandemic has important implications for assessing its etiology and pathological mechanisms of facial palsy disease.

Ramsay Hunt Syndrome Associated with Varicella-Zoster Virus Encephalitis in a Child

Ramsay Hunt syndrome (RHS) is a triad of peri-auricular pain, ipsilateral facial nerve palsy and vesicular rash around the ear pinna. It is caused by reactivation of varicella-zoster virus (VZV) that lies dormant in the geniculate ganglia. It can be complicated by VZV encephalitis rarely. We report the case of an 8-year-old previously healthy boy who presented to a tertiary care hospital in Muscat, Oman in 2021 with fever, progressive left ear pain, vesicular rash around his ear pinna and left-sided facial nerve palsy. His course was complicated by VZV encephalitis where he was managed with intravenous (IV) acyclovir and IV corticosteroids. He improved significantly and was asymptomatic with a normal neurology examination at the 6-months follow-up.

Bilateral sequential Ramsay Hunt syndrome in an immunocompromised adult: a rare entity

Bilateral Ramsay Hunt syndrome is a rare clinical entity. We present a case of bilateral Ramsay Hunt syndrome in an immunocompromised adult, with sequential symptom onset. It is important to consider this as a differential diagnosis in patients presenting with bilateral lower motor neuron facial weakness.

Vestibular mapping in Ramsay-Hunt syndrome and idiopathic sudden sensorineural hearing loss

PURPOSE

To observe vestibular impairment patterns in patients with Ramsay Hunt syndrome with dizziness (RHS_D) and sudden sensorineural hearing loss with dizziness (SSNHL_D) using hierarchical cluster analysis (HCA) to interpret results with possible mechanisms.

METHODS

The data of 30 RHS_D and 81 SSNHL_D patients from January 2017 to August 2022 in a single tertiary referral center were retrospectively analyzed. Video head impulse test (vHIT) and vestibular evoked myogenic potential (VEMP) were used for vestibular analysis of peripheral vestibular organs, and the results of vHIT and VEMP were analyzed. HCA was used to analyze vestibular impairment patterns.

RESULTS

In RHS_D patients, the lateral semicircular canal (LSCC) was the most impaired semicircular canal (SCC), followed by the anterior semicircular canal (ASCC) and the posterior semicircular canal (PSCC), and the utricle was more impaired than the saccule. In SSNHL_D patients, the PSCC was the most impaired SCC, followed by the LSCC and the ASCC, and the utricle was more impaired than the saccule. In HCA of RHS_D patients, the ASCC and utricle were initially clustered, followed by the LSCC, PSCC and saccule in order. In the HCA of SSNHL_D patients, the PSCC was solely merged and independently clustered.

CONCLUSION

There were different patterns of vestibular impairments between RHS_D and SSNHL_D patients. The vestibular analysis and HCA results of SSNHL_D showed tendency of skip lesion, which could be explained by vascular pathophysiology.

Ramsay Hunt syndrome and concurrent varicella-zoster virus meningitis in Denmark: A nationwide cohort study

Ramsay Hunt syndrome (RHS) is a manifestation of reactivated varicella-zoster virus (VZV) from the geniculate ganglion. Data on clinical features and outcomes of patients with RHS and concurrent VZV meningitis (henceforth RHS meningitis) are limited. Thus, we conducted a nationwide population-based cohort study of all adults hospitalized for RHS meningitis at the departments of infectious diseases in Denmark from 2015 to 2020. Patients with VZV meningitis without cranial nerve palsies were included for comparison. In total, 37 patients with RHS meningitis (mean annual incidence: 1.6/1 000 000 adults) and 162 with VZV meningitis without cranial nerve palsies were included. In RHS meningitis, the median age was 52 years (interquartile range: 35-64), and in addition to peripheral facial nerve palsy (100%), dizziness (46%), and hearing loss (35%) were common symptoms. The triad of headache, neck stiffness, and photophobia/hyperacusis was less common in RHS meningitis than in VZV meningitis without cranial nerve palsies (0/27 [0%] vs. 24/143 [17%]; p = 0.02). At 30 days after discharge, 18/36 (50%) patients with RHS meningitis had persistent peripheral facial nerve palsy, with no statistically significant difference between those treated with and without adjuvant glucocorticoids (6/16 [38%] vs. 12/20 [60%]; p = 0.18). Additional sequelae of RHS meningitis included dizziness (29%), neuralgia (14%), tinnitus/hyperacusis (11%), hearing loss (9%), headache (9%), fatigue (6%), and concentration difficulties (3%). In conclusion, clinical features and outcomes of RHS meningitis were primarily related to cranial neuropathies.

Diabetes Mellitus and Acute Facial Palsy: A Nationwide Population-Based Study

INTRODUCTION

Acute facial palsy, characterized by sudden hemifacial weakness, significantly impacts an individual's quality of life. Despite several predisposing factors identified for acute facial palsy, the specific relationship between diabetes mellitus (DM) and acute facial palsy has not been comprehensively explored in recent studies. The aim of the study was to assess the risk of acute facial palsy in patients with DM using a nationwide population sample cohort.

METHODS

DM cohort and non-DM cohort were built using the Korean National Health Insurance Service-Sample Cohort which represents the entire population of the Republic of Korea from January 2002 to December 2019. The DM cohort comprised 92,872 patients with a record of medication and a diagnosis of DM. Individuals who had facial palsy before the diagnosis of DM were excluded. A comparison cohort comprised 1,012,021 individuals without DM matched sociodemographically in a 1:4 ratio. The incidence of Bell's palsy (BP) and Ramsay Hunt syndrome (RHS) were evaluated in both cohorts. The risk factors for acute facial palsy were also assessed.

RESULTS

Among the 92,868 patients in the DM cohort, the incidence rate (IR) of BP and RHS were 31.42 (confidence interval [CI], 30.24-32.63) and 4.58 per 10,000 person-years (CI, 4.14-5.05), respectively. Among the 371,392 individuals in the non-DM cohort, the IR of BP was 22.11 per 10,000 person-years (CI, 21.62-22.59) and the IR of RHS was 2.85 per 10,000 person-years (CI, 2.68-3.02). IR ratios for BP and RHS were 1.42 (CI, 1.36-1.48) and 1.61 (CI, 1.43-1.80). In multivariate analysis, DM (hazard ratio [HR] 1.428), age (HR 1.008), and high comorbidity score (HR 1.051) were associated with increased risk of BP, and male (HR 0.803) and living in metropolis (HR 0.966) decreased the risk of BP. And DM (HR 1.615), high comorbidity score (HR 1.078), and living in metropolis (HR 1.201) were associated with increased risk for RHS.

CONCLUSION

This study suggests that patients with DM had an increased risk of acute facial palsy including BP and RHS.

Clinical Analysis of 3D-Fluid Attenuated Inversion Recovery and T1volume interpolated body examination Sequences on Delayed Gadolinium-Enhanced Scanning in Ramsay Hunt Syndrome

BACKGROUND

Through the clinical analysis of 4 clinically confirmed cases of delayed gadolinium enhancement of Ramsay Hunt syndrome 3D-Fluid Attenated Inversion Recovery'and 'T1volume interpolated body examination (3D-FLAIR and T1VIBE) sequences, the more suitable sequences and pathologically damaged tissue sites of deep tissues of Ramsay Hunt syndrome by magnetic resonance imaging gadolinium enhancement were preliminarily explored.

METHODS

From October 2020 to March 2021, 4 clinically confirmed patients with Ramsay Hunt syndrome, 2 males and 2 females, aged 27-63, were continuously collected in the hospital otology clinic. Siemens Avento 1.5T magnetic resonance imaging 3D-FLAIR and T1VIBE sequencedelayed gadolinium enhancement scans and serological laboratory tests were performed, respectively, and corresponding antiviral and antiinflammatory therapy was given.

RESULTS

The magnetic resonance imaging gadolinium enhancement of 4 cases of Ramsay Hunt syndrome was as follows: 3D-FLAIR sequence delay of 4.5 hours scanning 4 patients labyrinthine and/or middle ear signal was enhanced at the same time as the healthy side; T1VIBE sequence scanning disease in 3 cases of vestibular nerve development was enhanced than the healthy side, 2 cases of facial nerve development was enhanced than the healthy side, and 2 cases of cochlear nerve development was enhanced than the healthy side. All 4 patients were cured with related treatment.

CONCLUSION

Through the comparison of 3D-FAIR and T1VIBE sequence of 4.5 hours delay before intravenous gadolinium injection and 4.5 hours delay after intravenous gadolinium injection in 4 patients with Ramsay Hunt syndrome, it was found that (i) 3D-FLAIR sequence delay of 4.5 hours scan was more likely to show whether the inner ear labyrinth barrier permeability increased and (ii) Ramsay Hunt syndrome deep ear tissue damage can be manifested as labyrinthitis, vestibular cochlear neuritis, facial neuritis, and otitis media.

Multiple cranial neuropathy due to varicella zoster virus reactivation without vesicular rash: a challenging diagnosis

Ramsay Hunt syndrome is due to reactivation of varicella zoster virus (VZV) dormant in the geniculate ganglion of the facial nerve. The diagnosis is typically based on clinical triad of ipsilateral facial paralysis, otalgia, and vesicles in the auditory canal or the auricle. However, Ramsay Hunt syndrome may occur without skin eruption in up to one third of patients. Moreover, the involvement of other cranial nerves in addition to the facial nerve has been also reported. Herein, we reported a case report of a man who developed a multiple cranial neuropathy caused by VZV reactivation without skin vesicular eruption. The present case underlines a possible diagnostic challenge that clinicians may hit when facing a common disorder such as peripheral facial palsy. Indeed, clinicians must be aware that Ramsay Hunt syndrome may develop without skin vesicular eruption as well it may be complicated by multiple cranial nerve involvement. Antiviral therapy is effective in VZV reactivation for recovery of nerve function.

Varicella zoster virus associated-polyradiculoneuritis in an elderly woman: A new subtype of varicella zoster virus neuropathy

An 82-year-old Japanese woman without underlying disease was admitted to our hospital 3 days after she noticed lower-limb weakness. At presentation, she had lower-leg motor paralysis with mild upper-limb paresis and left Ramsay Hunt syndrome. Cerebrospinal fluid (CSF) findings revealed moderate pleocytosis. A polymerase chain reaction for varicella zoster virus (VZV) DNA in CSF was positive. MRI using 3D Nerve-VIEW (Philips) and contrast T₁ images showed high-intensity lesions on the L2-5 and S1-2 spinal roots. A new subtype of VZV-associated polyradiculoneuritis was diagnosed in this patient. We provide the case details and compare three similar reported cases.

Distribution of Medical Service Use for Facial Palsy Between Medicine and Traditional Korean Medicine Based on Population-Based Data of Korea

We investigated the distribution of medical service uses for Bell's palsy and Ramsay Hunt syndrome between medicine and traditional Korean medicine using the National Health Insurance Service National Sample Cohort data of Korea from 2006 to 2015. Patients were identified with diagnostic codes and medication or treatment claim codes. For Bell's palsy, there were 5,970 (68.8%) patients who used traditional Korean medical service only, whereas for Ramsay Hunt syndrome, there were 749 (93.6%) patients who used medical service only. The proportion of traditional Korean medical service use was higher than that of medical service use in patients with Bell's palsy, while the opposite was found in patients with Ramsay Hunt syndrome.

[Clinical and therapeutic features of herpes zoster oticus: a case report]

Ear shingles, also called herpes zoster oticus, are a viral infection of the outer, middle and/or inner ear due to varicella zoster virus (VZV). Patients with ear involvement associated with facial palsy are clinically diagnosed with Ramsay-Hunt´s syndrome. We here report the case of a 25-year-old patient with herpes zoster oticus associated with peripheral facial palsy, without other associated signs. This study and literature review investigate the various clinical, para-clinical and evolutionary features of herpes zoster oticus and the therapeutic approaches.

Ramsay-Hunt syndrome: Report of two cases with identification of the varicella zoster virus genome in cerebrospinal fluid

Like other alpha-herpesviruses, the varicella-zoster virus (VZV) remains latent in the neural ganglia following the primary varicella infection. The reactivation of the VZV in the dorsal root ganglia results in herpes zoster. Herpes zoster eruption is characterized by localized cutaneous lesions and neuralgic pain mostly in older and immunocompromised persons, especially those living with the human immunodeficiency virus (HIV). The most commonly reported complications include VZV pneumonia, meningitis, encephalitis, and hepatitis. Several neurologic syndromes have been described associated with herpes zoster localized in cranial areas including peripheral nerve palsies and the Ramsay-Hunt syndrome, which has a varied clinical presentation and is the second most common cause of peripheral facial paralysis. Facial paralysis in this syndrome occurs in 60 to 90% of cases and it may precede or appear after the cutaneous lesions with a worse prognosis than idiopathic Bell paralysis. Here we present two cases of herpes zoster from the geniculate ganglia with peripheral facial paralysis that appeared simultaneously with vesicular herpetic otic lesions (multimetameric Ramsay-Hunt syndrome). In the two cases, amplifiable varicella-zoster viral DNA was found in the cerebrospinal fluid by RT-PCR Multiplex.

Zoster Cranial Polyneuropathy in a COVID-19 Patient

BACKGROUND Ramsay Hunt syndrome is a rare form of herpes zoster caused by the reactivation of the varicella-zoster virus in the geniculate ganglion. The main clinical manifestations are peripheral facial palsy, vesicular rash in the ear, and ipsilateral auricular pain, and sometimes vertigo. COVID-19 is a new multisystemic infectious disease that, in addition to common respiratory manifestations, it is known to affect the immune system, primarily depressing cellular immunity. CASE REPORT A 54-year-old woman was admitted to our hospital with an acute vestibular syndrome and diplopia. She had been diagnosed 3 years prior with interstitial lung disease for which she was taking methylprednisolone. At admission, she tested positive for SARS-CoV-2. In the following days, she developed a sixth nerve palsy on the left side and a right peripheral facial palsy on the right side, followed by a typical zoster rash on the ipsilateral ear. One month later, she developed acute severe hearing loss on the right side. There were no COVID-19 symptoms during her stay in our hospital. The MRI showed Gd enhancement of both facial nerves. Under antiviral and corticoid treatment, the evolution was favorable, with marked improvement at 6 months. CONCLUSIONS COVID-19 increases the risk for herpes zoster infection, probably through induced depression of the cellular immunity. Our case suggests Ramsay Hunt syndrome can be the presenting symptom and sometimes the only symptom of COVID-19. This also seems to be true for other cranial neuropathies, and we recommend testing these patients even if there are no other manifestations.

Herpes zoster oticus

BACKGROUND

Herpes zoster oticus is a rare neurological disease caused by reactivation of varicella-zoster virus in the facial nerve.

CASE PRESENTATION

A woman in her 60 s presented with left-sided seventh and eighth cranial neuropathy. A vesicular rash in her left ear and palate appeared one week after symptom onset. Lumbar puncture revealed cerebrospinal fluid (CSF) pleocytosis, mononuclear cells only, with PCR positive for varicella zoster virus. Inflammation of the cochlear and vestibular systems and along the facial nerve was detected by MRI. Antiviral treatment with valacyclovir in combination with prednisolone was initiated. After one month with outpatient rehabilitation, the vertigo had ceased, but hearing loss and facial paralysis persisted.

INTERPRETATION

Early diagnosis and treatment of herpes zoster oticus as a cause of facial palsy when accompanied by ear rash, pain or signs of other cranial nerve involvement may improve overall prognosis.

[Ramsay Hunt syndrome can present with vesicular elements on the tongue, facial nerve palsy and meningitis]

Ramsay Hunt syndrome (RHS) is caused by a reactivation of the varicella zoster virus (VZV). It normally involves the triad of earache, peripheral facial nerve palsy and ipsilateral rash but can present without/with minimal visible rashes. In this case report, a 53-year-old male was admitted to hospital after a week-long headache, right-sided earache and peripheral facial nerve palsy. Vesicular elements were observed on the right side of the tongue. Cerebrospinal fluid (CSF) analysis showed 195 monocytes/mm3, and PCR verified VZV in the CSF. To avoid misdiagnosis, early recognition of the symptoms of RHS and diagnostic workup is advised.

A CASE OF MRI-NEGATIVE HERPES VIRUS ENCEPHALITIS PRESENTED BY RAMSAY HUNT SYNDROME

Ramsay Hunt syndrome (RHS) occurs due to reactivation of latent Varicella Zoster Virus (VZV) infection in the geniculate ganglion of the facial nerve. Major clinical symptoms include ipsilateral facial paralysis, otic pain, and herpetic vesicles (rashes) along the nerve with accompanying ear pain. Rarely clinical findings include retrograde transaxonal spread of the virus from the ganglion into the brain parenchyma with developing the encephalitis or multiple cranial nerve involvement. We describe here a patient with both RHS along with complicating brainstem encephalitis developed due to the coinfection of VZV and EBV.

Meningitis and Ramsay-Hunt syndrome in a 17-year old girl

INTRODUCTION

Ramsay Hunt syndrome (RHS) is a rare manifestation of varicella-zoster virus (VZV) reactivation in geniculate ganglion. It usually manifests with a characteristic triad of symptoms including ipsilateral ear pain, vesicles in the external auditory canal, and facial nerve palsy.

CASE

We present a case report showing RHS additionally manifested by meningitis and involvement of VIII cranial nerve. Clinical course was complicated by acute kidney injury induced by acyclovir therapy.

RESULTS

Despite the involvement of the geniculate ganglion and vestibulocochlear nerve in the course of herpes zoster, and the occurrence of acute kidney injury, the patient fully recovered.

CONCLUSIONS

A complete recovery of cranial nerves VII and VIII in the course of RHS can be achieved.

[Ramsey-Hunt syndrome with initial syndrome of hoarseness: a case report]

Summary Ramsey-Hunt syndrome is caused by the varicella zoster virus, which mainly affects the facial nerve. The typical clinical features of Ramsey-Hunt syndrome are peripheral facial paralysis and ear herpes. In this case, initial symptoms were hoarseness and coughing, afterwards typical symptom occurred 5 days later which were earache, late-onset herpes, and facial paralysis. Ramsey-Hunt syndrome are difficult to diagnose because of its seemingly unrelated initial symptoms.

A case study of Ramsay Hunt Syndrome in conjunction with cranial polyneuritis

RATIONALE

Ramsay Hunt syndrome in conjunction with cranial polyneuritis is not extensively documented, and is very easily misdiagnosed.

PATIENT CONCERNS

A case of a 53-year-old male with Ramsay Hunt syndrome in conjunction with cranial polyneuritis is presented with early symptoms of vertigo, cephalalgia, and facial palsy, followed by zoster oticus 10 days later.

DIAGNOSES

Diagnosis was challenging as this condition presents with multiple neuropathies, and attempting to diagnose based on clinical symptoms was often misleading. Polymerase chain reaction can be used to test for presence of the virus in the cerebrospinal fluid, followed by targeted drug therapy.

INTERVENTIONS

Acupuncture, in conjunction with fire cupping, bloodletting around the afflicted region on the face, as well as oral consumption of herbal medicine and vitamins for nerve nourishment was given to treat this disease.

OUTCOMES

Due to misdiagnosis resulting in delayed treatment, peripheral facial paralysis was left as the main sequelae, while other symptoms responded quickly to treatment. After a 6-month follow-up, facial palsy was still present.

LESSONS

Considering that targeted antiviral therapy can be used to increase the effectiveness of treatment, early diagnosis, and timely use of medication is critical.

Characteristics of hearing loss in patients with herpes zoster oticus

Patients with herpes zoster oticus (HZO) may commonly show symptoms associated with 7th and 8th cranial nerve (CN VII and CN VIII) dysfunction. The aim of this study is to investigate the characteristics of hearing loss in patients with HZO and discuss possible mechanisms.Ninety-five HZO patients who showed at least one of the symptoms of CN VII and CN VIII dysfunction between January 2007 and October 2014 were included in this study. Hearing loss was defined when the mean thresholds of pure tone audiometry (PTA) in speech frequency (0.5 kHz + 1 kHz + 2 kHz/3) or isolated high frequency (4 kHz + 8 kHz/2) were greater than 10 dB in the affected ear compared with the healthy ear, and a total of 72 patients were classified as the hearing loss group.The difference of mean PTA thresholds between affected and healthy ears was significantly greater in the high frequency range than in low range (20.0 ± 11.5 dB vs. 12.9 ± 15.7 dB, P = 0.0026) in patients with hearing loss (n = 72). The difference between affected and healthy ear was significantly greater in patients with vertigo (n = 34) than those without vertigo (n = 38) in both the high (P = 0.033) and low (P = 0.024) frequency ranges. In contrast, the differences between affected and healthy ears were not significantly different between patients with facial palsy (n = 50) and those without facial palsy (n = 22) in both the high (P = 0.921) and low (P = 0.382) frequency ranges.In patients with HZO, hearing loss is more severe in the high frequency range than in the low frequency range. Hearing impairment is more severe in patients with vertigo than in those without vertigo in both the high and low frequency ranges, even though the degree of hearing impairment is not significantly different between patients with and without facial palsy. These findings indicate that the mechanisms of viral spread from CN VII to CN VIII may differ between vestibular and audiologic deficits.

Sore throat and left ear pain

This elderly patient's unilateral pattern of symptoms was key to the diagnosis.

[Facial palsy]

Facial palsy is a daily challenge for the clinicians. Determining whether facial nerve palsy is peripheral or central is a key step in the diagnosis. Central nervous lesions can give facial palsy which may be easily differentiated from peripheral palsy. The next question is the peripheral facial paralysis idiopathic or symptomatic. A good knowledge of anatomy of facial nerve is helpful. A structure approach is given to identify additional features that distinguish symptomatic facial palsy from idiopathic one. The main cause of peripheral facial palsies is idiopathic one, or Bell's palsy, which remains a diagnosis of exclusion. The most common cause of symptomatic peripheral facial palsy is Ramsay-Hunt syndrome. Early identification of symptomatic facial palsy is important because of often worst outcome and different management. The prognosis of Bell's palsy is on the whole favorable and is improved with a prompt tapering course of prednisone. In Ramsay-Hunt syndrome, an antiviral therapy is added along with prednisone. We also discussed of current treatment recommendations. We will review short and long term complications of peripheral facial palsy.

[Clinical analysis of 32 cases of Ramsay Hunt syndrome]

OBJECTIVE

To observe the clinical features and the treatment effect of 32 cases of Ramsay Hunt syndrome and explore the relationship between different clinical manifestations and the prognosis.

METHOD

Using the integrated therapy including the medication and physiotherapy of ultrashort wave, the relationship between clinical manifestations and recovery time was analyzed.

RESULT

Twenty two cases were cured, 10 cases showed improvement of the symptoms, and no patients complained ineffectiveness. The effective rate was 100%. The shortest recovery time was 13 days, and the longest recovery time was 1 year and 7 months.

CONCLUSION

The key to cure Ramsay Hunt syndrome is comprehensive treatment in time. The different clinical manifestations have something to do with the prognosis.

Vestibular and cochlear neuritis in patients with Ramsay Hunt syndrome: a Gd-enhanced MRI study

CONCLUSION

It is suggested that vertigo in patients with Ramsay Hunt syndrome is mostly induced by superior vestibular neuritis consecutive to the reactivation of varicella-zoster virus (VZV) infection from the geniculate ganglion through the faciovestibular anastomosis. Refractory hearing loss in patients with Ramsay Hunt syndrome may be due to cochlear neuritis following the spread of VZV.

OBJECTIVES

An attempt was made to selectively identify vestibulocochlear nerves in the internal auditory canal (IAC) on gadolinium (Gd)-enhanced MRI in patients with Ramsay Hunt syndrome.

METHODS

Fourteen patients with Ramsay Hunt syndrome presenting with facial palsy, herpes zoster oticus, vertigo, and/or sensorineural hearing loss were scanned on 1.5 T MRI enhanced with Gd. Perpendicular section images of the IAC were reconstructed to identify the facial, superior, and inferior vestibular nerves and the cochlear nerves separately.

RESULTS

All except one of the patients with Ramsay Hunt syndrome with vertigo showed both canal paresis on the caloric test and Gd enhancement of the superior vestibular nerve in the IAC on MRI. Among 10 patients with hearing loss, 3 patients with severe to moderate sensorineural hearing loss showed Gd enhancement of the cochlear nerve in the IAC on MRI.

The midline electroneurography method for facial palsy reflects total nerve degeneration

CONCLUSION

The midline electroneurography (ENoG) method might reflect total facial nerve degeneration.

OBJECTIVE

We compared ENoG values in patients with facial palsy using two different methods, the midline method and five electroneurogram recordings, to reveal whether the ENoG value obtained with the midline method reflects total facial nerve degeneration.

METHODS

Forty patients with facial palsy were enrolled. Compound muscle action potentials (CMAPs) were recorded using the midline method, in which the anode was placed on the mental protuberance and the cathode was placed on the philtrum. Additionally, five electroneurogram recordings were obtained by placing the anode on the skin of the parietal region and five cathodes on the skin over five facial muscles (frontalis, orbicularis oculi, nasalis, orbicularis oris, and depressor anguli oris muscles). ENoG values recorded using the two methods were compared.

RESULTS

The ENoG values of the five facial muscles did not differ from those obtained using the midline method. The total ENoG value calculated by summing five CMAPs from five facial muscles, which is considered to reflect total facial nerve degeneration, was not significantly different from that using midline methods; moreover, a strong positive correlation coefficient (r = 0.87) was found between them.

[Ramsay Hunt syndrome in a 13-year-old boy]

We describe a formerly healthy 13-year-old boy who was admitted with symptoms of epiphora from his left eye over a period of four days and of left-sided peripheral facial palsy for one day. There was no history of trauma or tick bites. Cutaneous vesicles were observed in the ipsilateral ear. Pleocytosis was found and positive polymerase chain reaction for varicella zoster virus was obtained in samples from the vesicles and the cerebrospinal fluid. A magnetic resonance imaging confirmed neuritis of the left facial nerve. The patient was treated with a combination of aciclovir and prednisolone for ten days. On follow-up one week later, full recovery had been obtained.

Herpes zoster oticus (Ramsay Hunt syndrome) in children: case report and literature review

INTRODUCTION

Approximately 10% of patients with peripheral facial nerve palsy are children. Facial nerve palsy is usually idiopathic. An uncommon cause is herpes zoster oticus (Ramsay Hunt syndrome). This syndrome usually affects adults and is rare in children.

METHODS

We reviewed the literature and describe the cause, clinical manifestations, and treatment of Ramsay Hunt syndrome. We also report a case of the syndrome in a 12-year-old boy.

CONCLUSION

Ramsay Hunt syndrome is characterized by peripheral facial paralysis associated with herpetic eruption on the auricula and external ear, and by vestibulocochlear dysfunction. It occurs by reactivation of latent varicella-zoster virus (VZV) in the geniculate ganglion, affecting the seventh and eighth cranial nerves. The diagnosis is based on history and physical findings. Treatment of Ramsay Hunt syndrome uses a combination of high-dose corticosteroids and acyclovir. Although the prognosis is better in children than in adults, it is not good enough.

[Ramsay Hunt syndrome and current approaches]

Ramsay Hunt syndrome (RHS) is a disease characterized by acute peripheric facial paralysis, vesicular eruptions on the auricular skin and severe ear pain caused by reactivation of latent Varicella zoster virus in the geniculate ganglion. In addition to clinical findings, the diagnosis is confirmed with the presence of viral DNA in the involved tissue and vesicular exudate, as assessed by polymerase chain reaction. Corticosteroids for their anti-inflammatory effects and antiviral agents for their anti-replicative effects on viral load are used as the first-line therapy. However, there is a limited number of studies which proved the efficacy of this treatment.

[Case of atypical Ramsay-Hunt syndrome who presented with severe vertigo and vomiting]

We herein present a case of 6-year-old female demonstrating atypical Ramsay-Hunt syndrome. She presented with an earache, severe vertigo, and vomiting at onset, and thereafter, herpes zoster oticus appeared. No facial nerve palsy was seen. She was vaccinated for varicella and had no past history of apparent varicella infection. The patient showed positive IgG and negative IgM serum antibodies for varicella-zoster virus (VZV). An analysis of VZV-DNA from the patient's ear lesion using alleric discrimination real-time PCR identified a wild-type strain of VZV. We diagnosed her to have atypical Ramsay-Hunt syndrome caused by reactivation of the VZV. Aciclovir and prednisolone were administered, and she recovered completely. This case indicates that Ramsay-Hunt syndrome could be caused by a VZV infection after vaccination, even though its frequency is low. Ramsay-Hunt syndrome may thus be considered as one of causes of sudden onset vertigo in children.

Ramsay Hunt syndrome with unilateral polyneuropathy involving cranial nerves V, VII, VIII, and XII in a diabetic patient

Ramsay Hunt syndrome is a rare complication of the varicella zoster virus, defined as a peripheral facial palsy that typically results from involvement of the facial and auditory nerves. Ramsay Hunt syndrome can be associated with cranial nerves V, VI, IX, and X but rarely with XII. We describe an atypical case of Ramsay Hunt syndrome with multiple cranial nerve involvement of nerves V, VII, VIII, and XII. Antiviral drugs, antibiotics, insulin, and traditional Chinese drugs were administered immediately after admission. After 3 months of combination therapy, the patient had recovered satisfactorily. Herpes zoster can cause severe infections in diabetic patients and should be treated as soon after detection as possible. Ramsay Hunt syndrome should be recognized as a polycranial neuritis characterized by damage to sensory and motor nerves. In addition to facial and vestibular nerve paralysis, Ramsay Hunt syndrome may also involve cranial nerves V and XII.

Acute unilateral facial nerve palsy

Mrs PS, 78 years of age, presented with acute left-sided otalgia, ear swelling and subsequent unilateral facial paralysis (Figure 1). She denied any otorrhoea or hearing loss. Past medical history relevant to the presenting complaint included: * Bell palsy diagnosed 20 years ago with no residual effect * biopsy confirmed benign parotid lump (diagnosed 3 years previously). Histopathology revealed a pleomorphic adenoma. Mrs PS declined surgical intervention at the time * chicken pox as a child * normal fasting blood glucose 1 month previously and no known immune compromise. Examination revealed yellow crusts and small vesicles on the external acoustic meatus (Figure 2). A 10 mm well defined firm and nontender nodule was palpable at the ramus of the mandible.