Ramsay Hunt Syndrome

Clinical Image A 37-year-old female reported to casualty department with complained of giddiness and loss of balance while walking, unable to close the left eye, dropping of saliva from the corner of left angle of mouth and difficult to swallow. She had continuous severe shooting pain like electric current from left ear and around it since last three days reduced in hearing from left ear last one week. No history of chicken pox in the past, acute febrile illness and body ache, diabetes, hypertension, chronic illness in the past. She consumed herbal and homeopathic medicine, Unani and locally applied some ayurvedic preparation. On examination young lady, thin built, with left infra-nuclear seventh cranial nerve palsy. While attempting to close the eyes the left eyeballs rotate upward called bells phenomenon (Figure 1A). There were herpes zoster vesicles over the left mastoid process and edema with diffuse conglomeration of vesicles over left ear and edema of left ear (Figure 1B), there were similar vesicles noted over the left half palate (Figure 1C) and left half of dorsal and ventral side of tongue (Figure 1D). There was no involvement of other cranial nerves. Her MRI of brain was normal. Fundoscopic examination of both eyes was normal. She was HIV negative, Hb 13.1 gms/ dl, White blood cells count 5140 cu.mm (normal 4000-10000), serum B12 498 pg/ml (187-883), random blood sugar 89.4 mg/dl. She was given oral famciclovin 500 mg 8 hourly, prednisolone 1mg/kg and tapered over two weeks, along with regular facial physiotherapy. Her symptoms progressively regressed and there were scaring over skin of left mastoid and in the ear (Figure 1E). She was seen after one year there was no improvement in facial palsy. Ramsay hunt syndrome is viral diseases caused by reactivation of latent varicella-zoster virus often in an immunesuppression, old age, and diabetes or malignancy infection in the geniculate ganglion. Characterized by lower motor neuron seventh cranial nerve palsy accompanied with pain in ear and vesicular lesion on auricle, external auditory meatus and pre-auricular region (Figure 1B). It is more serious and carries poor prognosis. Glucocorticoid is the treatment of choice. Famciclovier for seven days if there is new skin eruption, however there is controversies regarding use of antiviral agents. Keywords: Hunt syndrome; Unani; Physiotherapy