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Endgames Picture Quiz

Ear pain, vesicular rash, and facial palsy

BMJ 2014; 349 doi: (Published 10 December 2014) Cite this as: BMJ 2014;349:g7572
  1. Ali Al-Hussaini, ear, nose, and throat specialist registrar1,
  2. Farah Latif, core medical trainee2,
  3. Sandeep Berry, ear, nose, and throat consultant1
  1. 1Department of Otolaryngology, Head and Neck Surgery, Royal Glamorgan Hospital, Llantrisant CF72 8XR, UK
  2. 2Nephrology Department, University Hospital of Wales, Cardiff, UK
  1. Correspondence to: A Al-Hussaini alialhussaini{at}

A 76 year old man presented to the emergency department with a three day history of a painful rash on his right cheek, associated with right sided otalgia and sore throat. He had noticed a right sided facial droop over the past 24 hours. He had no history of other neurological disturbances, otological symptoms, or head trauma.

Ten years earlier he had received a right cochlear implant, which was still functioning, and he also had benign prostatic hypertrophy. He was on aspirin 75 mg once daily and tamsulosin 400 µg once daily and had no known allergies.

He was afebrile and had partial right facial nerve palsy with incomplete eye closure; his forehead muscles were also affected. Neurological examination was otherwise normal. Examination of the right ear identified vesicles on the external auditory canal; the right tympanic membrane was normal. The left ear was normal. A rash comprising lentil sized vesicles, in part confluent and pustular with surrounding erythema, was noted in the dermatomal distribution of the maxillary branch of the right trigeminal nerve. A vesicular rash was noted on the right side of the hard palate (figure); the oropharynx was normal. Examination of the neck showed no parotid swelling or cervical lymphadenopathy.

Vesicular rash on the right side of the hard palate


  • 1. On the basis of the history and clinical findings, what is the likely diagnosis?

  • 2. What system is usually used to grade facial nerve palsy?

  • 3. How is this condition managed?


1. On the basis of the history and examination findings, what is the likely diagnosis?

Short answer

Ramsay Hunt syndrome, which is caused by reactivation of the varicella zoster virus (VZV) in the geniculate ganglion of the facial nerve. Clinically, it usually comprises a painful vesicular rash on the external ear (herpes zoster oticus) associated with ipsilateral lower motor neurone facial nerve palsy. Because it is a cranial polyneuritis, other cranial …

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