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Clinical Summary

Herpes zoster oticus (HZO), or Ramsay Hunt syndrome, is the second most common cause of facial paralysis, representing 3% to 12% of cases. The syndrome consists of facial and neck pain, auditory symptoms, and facial palsy associated with the reactivation of latent varicella-zoster virus in the facial nerve and geniculate ganglion. Patients first note pruritus, followed by pain out of proportion to the physical examination over the face and ear. Patients may also experience vertigo, hearing loss from involvement of the 8th cranial nerve, tinnitus, rapid onset of facial paralysis, decrease in salivation, loss of taste sensation over the posterolateral tongue, and vesicles on the ear, EAC, and face.

Management and Disposition

The diagnosis of HZO is based largely on history and physical examination. Tzanck preparations may be difficult because of the vesicles’ location. Magnetic resonance imaging (MRI) with contrast, if performed, may show enhancement of the geniculate ganglion and facial nerve.


Herpes Zoster Oticus. Facial palsy in a young adult. Note the vesicular eruptions on the neck. (Photo contributor: Frank Birinyi, MD.)

Oral antivirals and steroids are mainstays of treatment; earlier initiation is associated with the highest rates of improvement. As with Bell palsy, it is important to protect the involved eye from corneal abrasions and ulcerations by using lubricating drops. Referral to a specialist should be made for follow-up care.


  1. The prognosis for facial paralysis due to HZO is worse than that for Bell palsy. Approximately 10% and 66% of patients with full and partial facial paralysis, respectively, recover fully. The prognosis improves if the symptoms of HZO are preceded by the vesicular eruption.

  2. The combination of antivirals with steroids produces better outcomes than with either agent alone.


Herpes Zoster Oticus. On closer examination, the vesicles extend up the neck to the external auditory canal. (Photo contributor: Frank Birinyi, MD.)


Herpes Zoster Oticus. Erythema and drainage coming from the EAC are seen in this patient with herpes zoster oticus. Otitis externa can have a similar appearance but does not have vesicles, as seen in this patient. (Photo contributor: David Effron, MD.)


Herpes Zoster Oticus. Vesicles of zoster are clearly seen in this patient. (Photo contributor: Lawrence B. Stack, MD.)

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