Journal of Dentistry Indonesia

Volume 30 Number 1 Article 8

4-28-2023

Ramsay Hunt Syndrome with Oral Findings: A Rare Case

İlknur Eninanç
Department of Oral and Maxillofacial, Faculty of Dentistry, Sivas Cumhuriyet University, Sivas, Turkey,
i.eninanc2@gmail.com

Büşra Şahin
Department of Oral and Maxillofacial, Faculty of Dentistry, Sivas Cumhuriyet University, Sivas, Turkey,
bbusrashn@outlook.com

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Recommended Citation
Eninanç, İ., & Şahin, B. Ramsay Hunt Syndrome with Oral Findings: A Rare Case. J Dent Indones.
2023;30(1): 62-66

This Case Report is brought to you for free and open access by the Faculty of Dentistry at UI Scholars Hub. It has
been accepted for inclusion in Journal of Dentistry Indonesia by an authorized editor of UI Scholars Hub.
Ramsay Hunt Syndrome with Oral Findings: A Rare Case

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CONFLICT OF INTEREST None declared.

This case report is available in Journal of Dentistry Indonesia: https://scholarhub.ui.ac.id/jdi/vol30/iss1/8

Journal of Dentistry Indonesia 2023, Vol. 30, No. 1, 62-66
doi: 10.14693/jdi.v30i1.1367

CASE REPORT

Ramsay Hunt Syndrome with Oral Findings: A Rare Case

İlknur Eninanç*, Büşra Şahin

Department of Oral and Maxillofacial, Faculty of Dentistry, Sivas Cumhuriyet University, Sivas, Turkey
*Correspondence e-mail to: i.eninanc2@gmail.com

ABSTRACT
Ramsay Hunt syndrome (RHS) is a disease that is caused by the varicella-zoster virus and is characterized by
severe ear pain, auricular vesicular eruptions, and peripheral facial paralysis. Objective: The aim of this case
report is to provide information about the clinical findings and treatment process of RHS, which is a rare case and
may have oral findings and stress the importance of early diagnosis. Case Report: A 60-year-old male patient
had previously consulted an otolaryngologist and a family physician with complaints of vesicular eruptions in
the right ear auricle and on the mandible. The patient in whom a diagnosis could not be established presented to
the Department of Oral and Maxillofacial Radiology after exacerbated lesions. White plaque-like and ruptured
vesicular lesions were observed in the intraoral examination. All vesicular lesions were on one side of the face,
and the patient was referred to the dermatology clinic with the diagnosis of RHS. Facial paralysis fully recovered
in a short time after early diagnosis and treatment. It should be kept in mind that there may also be oral findings
in RHS, and a patient’s intraoral and extraoral examination findings should be evaluated together. Conclusion:
Early diagnosis and treatment are highly important in preventing complications such as permanent facial paralysis,
vestibulocochlear dysfunction, and hearing loss

Key words: facial paralysis, Ramsay Hunt syndrome, varicella-zoster virus, vesicular eruptions
How to cite this article: Eninanç İ, Şahin B. Ramsay Hunt Syndrome with oral findings: A rare case. J Dent
Indones. 2023;30(1):62-66

INTRODUCTION

Ramsay Hunt syndrome is a disease, which was
defined by James Ramsay Hunt in 1907 and is
characterized by severe otalgia, vesicular eruptions
around the ear, peripheral facial paralysis, and frequent
vestibulocochlear dysfunction.1,2 This disease is also
known as herpes zoster oticus, and the varicella-
zoster virus, a member of the herpes virus family,
is responsible for it. Ramsay Hunt syndrome (RHS)
emerges with facial nerve involvement of the varicella-
zoster virus by 1% ,3 and only 8% of these cases have
been stated to have vesicles both around the ears and
inside the mouth.4 Pain and vesicular eruptions occur
along the nerve that is affected by the reactivation
of the virus.3 Chronic diseases that reduce immune
resistance, diabetes mellitus, hypertension, and the use
of immunosuppressive drugs cause the reactivation of
the virus.5,6 It can be seen at any age, but its incidence
increases over 60 years of age. This increase has been
reported to be proportional to the increase in the
incidence of the deficiency associated with the cellular
immune system over 60 years of age.7,8 Patients with
RHS have weakened functions, such as wrinkling their
forehead, raising their eyebrows, and closing their eyes,
because of the weakening of the facial motor muscles
on the affected side.9 When patients are requested
to laugh or show their teeth, these movements are
impossible on the affected side, and the face moves
toward the healthy side.9 Oral lesions are in the regions
of trigeminal nerve involvement and mobile areas such
as the buccal mucosa. The lesions progress toward
the midline, and the overlying skin is also involved.
Sometimes it can lead to the devitalization of teeth and
related bone necrosis.10
With this case report, it is aimed to provide information
about the clinical findings and treatment process of
RHS, which may also produce oral findings, and stress
the importance of early diagnosis and treatment in
preventing permanent damage.

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Journal of Dentistry Indonesia 2023, Vol. 30, No. 1, 62-66

CASE REPORT

A 60-year-old male patient with diabetes mellitus

presented to the Oral and Maxillofacial Radiology
Department due to lesions in his mouth and vesicular
eruptions on the skin tissue of his lower jaw. It was
learned from his anamnesis that the patient had
presented to the Department of Ear-Nose-Throat
(ENT) with a complaint of ear pain 4 days before and
that an ENT specialist had prescribed ciprofloxacin-
derived antibiotics (ciprof loxacin hydrochloride 1
g – 3 times a day 2 tablets) and corticosteroid ear
drops (dexamethasone 1 g – 3 times a day 1 tablet) Figure 1. Vesicular eruptions in the patient’s ear auricle and
upon diagnosing an external auditory canal infection. on his lower jaw.
After using drugs for two days, lesions appeared in the
patient’s mouth and on his face. Then, the patient was
referred to the dentist by the family physician, and the
general dental practitioner prescribed oral antiseptic
mouthwash (chlorhexidine gluconate) and analgesic.
The patient, whose complaints did not disappear and
whose lesions gradually intensified, presented to our
department as a last resort.

From the patient’s detailed anamnesis, it was learned

that he had pain in the ear and eye. In the patient’s
Figure 2. Lesions in the patient’s oral mucosa and on
extraoral examination, vesicular eruptions and local
his tongue.
crusts were seen in the right ear auricle, preauricular
region, external auditory canal and zygomatic region
in the right half of his head and on the right side of his
lower jaw (Figure 1).

In the intraoral examination of the patient with poor

oral hygiene, white plaque-like lesions on the right
lateral of the tongue and edema in the tongue papillae
were observed. There were ruptured vesicular lesions
in the right sublingual region, alveolar mucosa of the
lower jaw and the lower lip mucosa, and significant
edema on the right side of the lower lip. Lesions of the
entire mucosa and skin of the examined patient were
unilateral (Figure 2). Apart from the ear, all lesions
covering the right side of the mandible and the intraoral
region were asymptomatic.
The patient, who could perform eye movements and
mouth opening and closing functions completely, had
limitations in his tongue movements. The patient did
not have any complaints such as nausea, vomiting, and
dizziness and did not use diabetes drugs. The patient
had no such family history, but he was a smoker.
The patient was referred to the Dermatology Clinic
with the preliminary diagnosis of RHS and then was
hospitalized in the Dermatology Clinic on the same day.
In the laboratory findings, the patient‘s fasting blood
sugar (161 mg/dL) and white blood cell (WBC - 11.76
109/L) and C-Reactive protein (CRP- 111.36 mg/L)
values from hemogram tests were high, whereas his
sedimentation rate was normal (2 mm/h). His HIV,
HBV, and HCV serology tests were negative.
Figure 3. Crusts that occurred in the ear, face, and on the
right side of the lower jaw on the fourth day of treatment.
Oral valacyclovir (1g - 3x1) therapy was started
and administered for 7 days. First, his previous
corticosteroid dose (dexamethasone 1 g - 3 times a
day 1 tablet) was increased, and then vitamins B1,
B6, B12 (1g – 1 time a day 1 tablet) and non-steroidal
anti-inflammatory drugs were added to his treatment.
Moreover, vesicular eruptions decreased after four
days, and crusts started to occur in the patient to whom
insulin therapy started to be administered (Figure 3).
The patient was discharged after one week, and facial
paralysis emerged on the 12th day. The patient, who
had mild asymmetry at the lower lip corner on the
right side and limited tongue movements, also had
difficulty and pain in moving the right eyelid. The
patient could fully close his eyes. He was assessed
as grade 2 according to the House-Brackmann facial
paralysis grading system.11 In his examinations, HSV

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Journal of Dentistry Indonesia 2023, Vol. 30, No. 1, 62-66
Figure 4. Facial paralysis that developed 12 days after
vesicular eruptions in the ear.
IgG and VZV (varicella-zoster virus) IgM antibodies
were positive (Figure 4).
The patient was again hospitalized in the Department
of ENT, and the IV administration of corticosteroid
(methylprednisolone 40 mg - 1 time a day 2 tablets)
and antibiotic (sulbactam 1gr - 4 times a day 1 tablet),
vitamins B1, B6, B12, and eye drops (0.5%/15 ml) with
a moisturizing effect were started. The patient was
discharged again after seven days, and his crusts and
peripheral facial paralysis disappeared completely at
his next-month follow-up.
DISCUSSION
In RHS, the time of vesicular eruptions is important in
prognostic terms. According to the retrospective study
conducted by Coulson et al. on 101 patients,4 the first
symptom was ear pain in 55% of patients, whereas
vesicles and facial paralysis occurred 2-3 days later.
In 2% of patients, vesicles appeared first. Twenty-three
percent first had facial paralysis. Furthermore, vesicles
were observed on the auricle in 86% of patients, inside
the mouth in 7%, and both around the ear and inside
the mouth in 8%.10
Another study stated that 46.5% of the vesicles in the
ear occurred together with facial paralysis, 19.3%
before paralysis, and 34.2% after paralysis. The
eruption of vesicles before paralysis was reported to
affect the prognosis of facial paralysis positively.12 In
the same study, the sense of taste and lacrimation were
reported to be impaired.12
In this case, who first had ear pain, vesicular lesions
inside the mouth emerged a few days after the eruptions
64
around the ear. Twelve days after the onset of eruptions
around the ear, facial paralysis occurred on the same
side, although valacyclovir was used. The occurrence of
paralysis after vesicular eruptions is a good prognostic
sign, and the antiviral drug use probably delayed facial
paralysis and reduced the House-Brackmann grade of
facial paralysis.
In patients with RHS, erythematous eruptions are
rarely observed in the ipsilateral anterior two-thirds of
the tongue or palate. The chorda tympani is a sensory
branch of the facial nerve related to taste in the anterior
two-thirds of the tongue.
This nerve anastomoses with the lingual and maxillary
nerves that enable the distribution of Ramsay Hunt
lesions. A damaged chorda tympani leads to taste
impairment in the anterior two-thirds of the affected
half of the tongue and reduction in tear, nose, and
salivary secretions. Patients with oral lesions report
a burning sense or numbness in the relevant mucosal
areas.13 In this case, in which intraoral findings
were rarely observed, the patient did not have taste
impairment and numbness. There were edemas in the
tongue papillae on the right tongue lateral, and the
patient’s tongue and alveolar mucosal surface were
covered with a plaque-like white layer. Ruptured
vesicular lesions were observed in the sublingual
region, the lower lip mucosa, and the alveolar mucosa.
The patient had a significant edema on the right side
of the lower lip. These oral findings show that dentists
should also have information about patients with RHS.
In addition to vesicular lesions observed in RHS,
which are helpful for establishing a diagnosis, various
neurological disorders such as tinnitus, hearing
loss, nausea and vomiting, vertigo, and nystagmus
may also emerge.1,13 The factors that worsen the
prognosis of the disease include stress, chemotherapy,
immunodeficiency, malnutrition, infection, diabetes,
hypertension, and advanced age.14 In this case, it is
thought that the reduced immunity of the patient who
did not use diabetes drugs prepared the ground for
secondary infection, with the effect of advanced age.
In addition to the antiviral therapy administered to the
patient, the patient‘s blood sugar was also taken under
control during the treatment. Moreover, except for
vesicular lesions, the patient had pain in the eye only
when he had otalgia and facial paralysis. However, the
patient did not experience hearing loss and vertigo.
This situation can be explained by the fact that the 8th
cranial nerve and vestibulocochlear system were not
affected owing to early treatment.
Bell‘s paralysis is the most frequent cause of facial
paralysis and is an acute-onset, idiopathic and short-
term paralysis. RHS is the second most frequent cause
of acute peripheral facial paralysis following Bell‘s
paralysis.15 Facial paralysis in RHS is more severe
compared to Bell‘s paralysis, and the recovery rate is
Journal of Dentistry Indonesia 2023, Vol. 30, No. 1, 62-66
lower. Of patients, 71% recover from Bell‘s paralysis
fully. In RHS, on the other hand, only 21% of patients
with complete loss of facial functions recover fully. In
patients with RHS, this rate was 25% for mild sequelae
and 26% for moderate sequelae.15 It is crucial to start
antiviral agents such as acyclovir, valacyclovir, and
famciclovir, particularly in the first 72 hours, in terms
of the efficiency of the treatment.16,17 Along with
these drugs, non-steroidal anti-inflammatory drugs,
corticosteroids or tricyclic antidepressants can be used
to relieve herpetic neuralgia.18 In the patient diagnosed
with RHS, the aim of the treatment was to enable quick
recovery, ensure the least tissue sequestration, and stop
the pain.18  1. Hunt JR. On herpetic inf lammations of the
In the literature, there are studies on the efficiency of
acyclovir and steroid treatment, and the combination of
antiviral and steroid treatments has been proven to be
significantly superior to steroid use alone. Murakami
et al. observed complete recovery in 80 patients with
RHS who were administered acyclovir and steroid
(prednisone) in combination.19 Facial paralysis
disappeared in 21 (75%) patients who started treatment
in the first three days, 14 (48%) patients who started
treatment in 4–7 days, and 7 (30%) patients who started
treatment after the seventh day. Steroids have a strong
anti-inflammatory effect that reduces inflammation
and edema in the nerves linked with herpes zoster
and ensures quicker recovery of the affected nerves.20
Kanerva et al. achieved good recovery (complete
recovery or recovery with only mild sequelae) in more
than 80% of patients receiving antiviral therapy within
72 hours of the onset of RHS. Half of these patients
received corticosteroid therapy concurrently with
antiviral therapy.16
In this case, steroid therapy was started in addition to
valacyclovir antiviral therapy before facial paralysis,
and nonsteroidal anti-inf lammatory, vitamin B,
ciprofloxacin group antibiotic therapy was administered
in combination. The above studies show that the
complete recovery rate is considerably lower in cases
with delayed treatment. In this case, which started
late and had a low degree of House-Brackmann facial
paralysis, the complete recovery of the paralysis within
a month is thought to result from early diagnosis and,
thus, the early initiation of antiviral treatment.
CONCLUSION
The presented case had oral involvement, which
is rare, unlike the classic effect of RHS. As seen
in this case, it should not be forgotten that oral
findings may be observed in RHS, and intraoral and
extraoral examinations of the patient should be carried
out together. Early diagnosis is important for the
recovery of damaged nerves. Accordingly, permanent
complications can be prevented. Moreover, starting
65
antiviral and steroid therapies as soon as possible in
elderly patients and patients with a chronic disease such
as diabetes will prevent permanent facial paralysis,
vestibulocochlear dysfunction, and hearing loss.
CONFLICT OF INTEREST
None declared.
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(Received May 22, 2022; Accepted February 7, 2023)