A 24-Year-Old Man With Ear Pain, Dizziness, and a Rash

D. Brady Pregerson, MD


December 11, 2019

Temporary relief of otalgia in geniculate neuralgia may be achieved by applying a local anesthetic to the external auditory canal. The condition is a self-limited disease and is not associated with mortality. However, it is associated with significant morbidity: Complete recovery of facial weakness occurs in less than 50% of patients. Studies have suggested improved recovery of facial strength and reduced incidence of chronic pain when antiviral and steroid treatments are used.

Because of the risk for subsequent central nervous system infection, treatment of Ramsay Hunt syndrome should include acyclovir, valacyclovir, or famciclovir. The addition of steroids or admission for intravenous acyclovir should be considered as well, especially in more severe cases or in immunocompromised hosts. Consultation with a head and neck specialist or an infectious disease specialist can be considered.

Long-term antiviral prophylaxis is not routinely used, although it should be considered in cases of recurrent herpes zoster or when cell-mediated immunity is known to be impaired. The patient should also be given lubricating eye drops to use during the day and paper tape to use at night to prevent eye drying and damage. A vestibular suppressant, such as meclizine, dimenhydrinate, or diazepam, may provide relief from vertigo or other vestibular symptoms. Such medications as tricyclic antidepressants, gabapentin, pregabalin, and carbamazepine may be beneficial in reducing the neuralgic pain associated with the syndrome.[1,6]

The patient in this case gradually improved during a 10-day course of prednisone and valacyclovir. By day 14, he had complete recovery of both his hearing and facial strength, as well as resolution of the vertigo. The favorable outcome was thought to result from early detection and treatment. His ear pain gradually improved over the next few months, but it was only after approximately 5 months that the patient felt it was no longer noticeable.


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