B. Ramsay Hunt Syndrome – This not the correct answer

Image courtesy of Brady Pregerson, MD

Ramsay Hunt syndrome (Herpes zoster oticus) classically features the triad of ipsilateral facial paralysis, ear pain, and vesicles in the auditory canal and auricle (Figure). This constellation of symptoms is the result of reactivation of the varicella zoster virus from the facial nerve root ganglion (geniculate ganglion).

The facial paralysis component of Ramsay Hunt Syndrome is specific to the facial nerve involvement. In this case, the patient’s initial presentation of ear pain, which was originally misdiagnosed as otitis media, was a painful varicella zoster lesion in the ear canal, which put Ramsay Hunt syndrome in the differential. The distribution of the rash fits both the trigeminal and facial nerve distribution, but the lack of facial nerve paralysis makes this diagnosis unlikely. Taste perception, hearing (tinnitus, hyperacusis), and lacrimation can also be affected in select patients with Ramsay Hunt Syndrome, which is generally considered a polycranial neuropathy with frequent involvement of cranial nerves V, IX, and X.

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