Ramsay Hunt syndrome: Symptoms and treatment

Up until a few years ago, most of us probably hadn’t heard of Ramsay Hunt syndrome, a condition first described by the American neurologist James Ramsay Hunt in 1907. However in June 2022, the Canadian musician Justin Bieber – who was aged 28 at the time – announced he’d been diagnosed with it, and that he was cancelling some of his performances to rest and recover. And so it is largely thanks to Bieber and the power of social media that more of us are now aware of this condition at all.     
 

What is Ramsay Hunt syndrome?

Also called herpes zoster oticus, Ramsay Hunt syndrome is caused by an outbreak of shingles. It develops when the shingles virus affects the facial nerve (also called the seventh cranial nerve) near one of the ears, causing inflammation in a mass of nerve tissue found along the facial nerve called the geniculate ganglion. Symptoms can include a painful red rash and weakness or paralysis on one side of the face.
 

How common is Ramsay Hunt syndrome?

About 30 per cent of people will have shingles at some stage in their lives but the facial nerve is thought to be affected in only one per cent of cases (i). This makes Ramsay Hunt syndrome fairly rare, with as little as five people in every 100,000 affected (ii). However the condition may be somewhat under-diagnosed or delayed because of a lack of awareness, with most doctors never seeing a single case of Ramsay Hunt syndrome during their entire working life.
 

What is shingles?

Ramsay Hunt syndrome is caused by shingles, but what is shingles exactly and what causes it?
 
Shingles is caused by the varicella-zoster virus, the same virus that causes chickenpox. Once you’ve had chickenpox, the virus travels up a nerve root near the spine and lays dormant. In some people the virus reactivates later in life, causing shingles.
 
The main symptom of shingles is a blister-producing rash that forms on one side of the body, usually part of the upper body. Like the chickenpox rash it can be very itchy, but it also tends to cause a dull or burning pain that can be severe in some people, along with tingling and numbness.
 
If you develop shingles you may also experience flu-like symptoms such as a headache and high temperature, with symptoms often lasting up to four weeks. Some people – particularly those who are elderly or have a weakened immune system – can develop another condition after having shingles. Called post-herpetic neuralgia, this can cause severe nerve pain and itching for months or even years after the rash has disappeared.
 
Shingles is generally considered a condition that affects people aged 60 and older, though it can affect anyone of any age (it is, however, rare in children). If you’re aged between 70 and 78 you’re eligible for a shingles vaccine on the NHS. This can help prevent the reactivation of the virus that causes shingles, or it could make your symptoms milder and shorter if you develop shingles. If you’re in this age group and haven’t been invited for the vaccine yet, ask your doctor for details.
 

Ramsay Hunt syndrome symptoms

Ramsay Hunt syndrome symptoms typically emerge in stages, not all at once. A common initial sign is intermittent ear pain, which later becomes constant and spreads from deep within the ear to the external part (i). A rash with fluid-filled blisters usually follows, affecting areas like the inside or outside of one ear, your scalp, hairline, or mouth. In about 10 per cent of cases, a rash doesn't develop at all. This is referred to as zoster sine herpete (ii).

Facial weakness or paralysis on one side is another significant symptom, though it is sometimes not immediately obvious. This may cause droopiness, difficulty closing the eye, impaired blinking, and trouble with facial expressions like smiling or frowning. Eating and speaking difficulties, even slurred speech, can also arise if the mouth is affected.
 
Other common symptoms that can affect people with Ramsay Hunt syndrome include:

• Dizziness/vertigo 

• Tinnitus (buzzing, hissing or ringing in the ear) on the affected side 

• Hyperacusis (increased sensitivity to sound) on the affected side

• Hearing loss on the affected side

• Balance problems

• Loss of taste or altered taste on the affected side of the tongue 

• Dry eyes and/or dry mouth 

• Hoarse voice

 

Ramsay Hunt syndrome vs Bell’s palsy

Ramsay Hunt syndrome itself isn’t contagious, but the virus that causes shingles is. It can spread if someone comes into contact with the fluid inside the blisters of the rash, causing chickenpox in people who haven’t had chickenpox before.
 
If you have Ramsay Hunt syndrome it’s a good idea to prevent spreading the virus by avoiding contact with others until your blisters have dried out and scabbed over, especially people who haven’t already had chickenpox, pregnant women, newborn babies and people with weakened immune systems.
 

Are you at risk of developing Ramsay Hunt syndrome?

Anyone who has ever had chickenpox at any point in their life is at risk of developing shingles – and if the shingles virus affects the facial nerve, they will develop Ramsay Hunt syndrome.
 
Experts aren’t really sure why the shingles virus reactivates in some people and not others. According to the charity Facial Palsy UK you may become more vulnerable to the reactivation of the virus if your immune system becomes depressed and less able to fight off infection (iii) (this can happen if you have HIV, for instance, or you’re having chemotherapy or taking other medicines that suppress the immune system). Stress and malnutrition may leave you more vulnerable to developing Ramsay Hunt syndrome (or indeed shingles) too.
 
However it’s also not clear why some people develop shingles near their facial nerve while others find other parts of their bodies are affected. 
 

Is Ramsay Hunt syndrome caused by stress?

Being under a lot of stress may raise your risk of shingles which can then lead to Ramsay Hunt syndrome, since stress is thought to affect immunity.      
 

Other types of Ramsay Hunt syndrome

Herpes zoster oticus is the second of three syndromes discovered by James Ramsay Hunt. The first – Ramsay Hunt syndrome type 1 (or Ramsay Hunt cerebellar syndrome) – is a rare neurological disorder that causes seizures, tremors, cognitive impairment and progressive ataxia (a degenerative disease of the nervous system). The other – Ramsay Hunt syndrome type 3 – affects the nerves in the wrist and hand.
 

Ramsay Hunt syndrome treatment 

 

Antiviral medication

Since it’s caused by the shingles virus, Ramsay Hunt syndrome is treated with antiviral medication      which helps treat the infection and reduce its symptoms. Taking antiviral medicines within 72 hours of the onset of symptoms is thought to be helpful if you have shingles – it may also be beneficial for people with Ramsay Hunt syndrome and increase the chances of a full recovery (according to Facial Palsy UK people with the condition have a 70 per cent chance of recovering virtually fully if they take antiviral medicines promptly after their symptoms start – though this drops to 50 per cent if antivirals aren’t taken within 72 hours (iii)). 
 

Steroid medicines

Steroid medicines are also often prescribed for Ramsay Hunt syndrome – this is usually in the form of a short course of high-dose medicines. These can help reduce inflammation of the facial nerve.
 

Other medicines

Other medicines include painkillers (including special painkillers to help with nerve pain) and drugs to help treat vertigo, where needed.
 

Treatments for eye symptoms

You may also need eye drops if you’re having difficulties closing or blinking with one eye, as this can help prevent your eye becoming too dry. Some people may also have to tape their affected eye to close it, for example while sleeping. Others find wearing sunglasses or even an eye patch can help when they’re out and about, as well as avoiding bright sunlight and environments where the air is dry (buildings with air conditioning, for instance).
 

How long does Ramsay Hunt syndrome last?

The good news is that people with a mild case of Ramsay Hunt syndrome should recover well within a few weeks. But the more severe your symptoms, the longer you will usually take to recover – and the lower your chances will be of recovering fully. If you experienced hearing difficulties you should also recover well, with only five per cent of people affected experiencing lasting problems with their hearing (i).
 
Meanwhile those who are more likely to experience a less positive outcome after having Ramsay Hunt syndrome include older people, people with diabetes and people with high blood pressure, as well as those who develop vertigo with the condition (iv).
 

Are there any complications from Ramsay Hunt syndrome?

While getting prompt treatment for Ramsay Hunt syndrome increases your chances of recovering fully, there is still a very small risk you could develop complications such as:
 

• Permanent facial weakness or paralysis

• Permanent hearing loss

• Synkinesis (unwanted facial movements – for instance, when you smile your eye may close; this is thought to be caused by the facial nerves growing back incorrectly)

• Vision problems caused by extreme dryness such as corneal ulcers, abrasions and infections

• Chronic tinnitus

• Post-herpetic neuralgia (see above, What is shingles?)

• Chronic vestibular dysfunction (disturbance in the body’s balance system caused by a problem in the inner ear)

Not getting the proper treatment in time (or at all) can mean you have an even higher risk of developing one or more of these complications.
 

Self-help for Ramsay Hunt syndrome

Apply a cold compress to the affected area to help reduce pain. Keeping the rash clean is also a good idea, as it can help reduce the risk of a blister becoming infected which can lead to scarring. Facial exercises can retrain your facial nerve if you’re having problems with facial weakness – however these are best practised by following the advice of a health professional such as a physiotherapist or other specialist.
 
Unfortunately good-quality human research into nutritional supplements and how they may benefit people with Ramsay Hunt syndrome is almost non-existent. Nevertheless many natural health practitioners recommend nutrients that may help with nerve support, inflammation relief and pain relief, including:

B complex  

A good-quality vitamin B complex supplement that includes vitamin B12 may help support the production of myelin, which is essential for the formation of a protective fatty layer called the myelin sheath that covers the spinal, cranial (including facial) and peripheral nerves. Indeed, vitamin B12 deficiency is known to cause myelin sheath damage, which may lead to neurological problems (v).
      

High-strength fish oils  

The omega-3 fatty acids found in oily fish are widely thought to help reduce inflammation, which can be a factor in some types of facial nerve disorders including Ramsay Hunt syndrome. Oily fish include salmon, sardines, mackerel and herring, but you can also get a supply of omega-3s by taking a high-strength fish oil supplement. If you’re vegetarian or vegan, you can get the same beneficial omega-3s in a supplement sourced from marine algae instead of fish.
 

Magnesium  

This essential mineral is important for a range of body functions, including nerve health. For instance magnesium is essential for healthy nerve transmission and neuromuscular conduction, and has been implicated in several nerve-related disorders (vii). You can find magnesium in foods including spinach, nuts, wholemeal bread, pumpkin seeds, cocoa powder and soya milk, as well as in nutritional supplements.
 

PEA (Palmitoylethanolamide)  

Some practitioners report that PEA may help relieve the pain of shingles, which means it could also be helpful for people with Ramsay Hunt syndrome.
 
A study, published in the journal Pain Medicine, suggests PEA may be effective and safe in the management of chronic pain in different conditions, one of which was shingles (viii). A case report published in the journal Nutrition and Health also claims PEA provided effective pain relief within 48 hours in a patient suffering with neuropathic pain caused by shingles (ix). 
 
A type of fatty acid made naturally by the body and found in all cells, tissues and fluids including the brain, PEA is also found in foods including soya beans, peanuts, eggs, flaxseed and milk. Described by scientists as an endocannabinoid-like chemical that belongs to a family of fatty acid compounds called amides (x), PEA is often mentioned as an alternative to CBD, since both substances are thought to have similar properties including the ability to reduce pain and inflammation. However, researchers suggest PEA is safer than CBD, since it has been studied more extensively and has a more robust safety profile (xi) with no known side effects (x).
 

What else might be helpful?

Two other nutrients available as supplements that are sometimes recommended for people with Ramsay Hunt syndrome are N-acetyl cysteine (NAC) and alpha-lipoic acid (ALA).
 

N-acetyl cysteine (NAC)

An antioxidant compound derived from the amino acid L-cysteine, NAC helps with the production of one of the body’s own potent antioxidants glutathione. There is one animal study that shows NAC may help with facial nerve recovery, but so far no similar human studies have been carried out.
 

Alpha-lipoic acid (ALA)       

Also an antioxidant, ALA has been used to treat the symptoms of nerve damage in people with diabetes (diabetic neuropathy), with at least one study suggesting it may well be beneficial (xii). Researchers who carried out a small-scale study also claim that muscle retraining in the form of massage therapy combined with ALA supplements represents a clinically effective treatment for people with chronic facial paralysis (xiii).
 

Need more information?

 
If you’re interested in conditions such as Ramsay Hunt syndrome you may like to know there’s more information about neurological health problems in the nervous system section of our pharmacy health library, including a guide to facial nerve damage and an article on Bell’s palsy. 

 

References:

1. Available online: https://patient.info/doctor/herpes-zoster-oticus-ramsay-hunt-syndrome

2. Available online: https://dermnetnz.org/topics/ramsay-hunt-syndrome

3. Available online: https://www.facialpalsy.org.uk/causesanddiagnoses/ramsay-hunt-syndrome/

4. Sang-won Yeo HS. et al., Analysis of prognostic factors in Bell's palsy and Ramsay Hunt syndrome. Auris Nasus Larynx. 2007 Jun;34(2):159-64. Available online: https://www.aurisnasuslarynx.com/article/S0385-8146(06)00136-2/fulltext

5. Available online: https://www.foundationforpn.org/what-is-peripheral-neuropathy/causes/vitamin-nutrition-deficiency/

6. Pereira FP. et al., Unilateral facial paralysis caused by Ramsay Hunt syndrome. J Craniofac Surg. 2011 Sep;22(5):1961-3. Available online: https://journals.lww.com/jcraniofacialsurgery/Abstract/2011/09000/Unilateral_Facial_Paralysis_Caused_by_Ramsay_Hunt.100.aspx

7. Kirkland. AE, Sarlo. GS, Holton. KF. The Role of Magnesium in Neurological Disorders. Nutrients. 2018 Jun ;10(6):730.Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024559/

8. Gatti A. et al., Palimitoylethanolamide in the Treatment of Chronic Pain Caused by Different Etiopathogenesis. Pain Med. 2021 Sep;13(9):1121-30. Available online: https://academic.oup.com/painmedicine/article/13/9/1121/1864240

9. Kamper D. et al., Palmitoylethanolamide (PEA) in the treatment of neuropathic pain: a case study. Nutr Health. 2022 Jun ;28(2):265-269. Available online: https://journals.sagepub.com/doi/10.1177/02601060211019669

10. Natural health practitioners also Clayton P. et al., Palmitoylethanolamide: A Natural Compound for Health Management. Int J Mol Sci. 2021 May;22(10): 5305. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157570/

11. Clayton P. et al., Palmitoylethanolamide: A Potential Alternative to Cannabidiol. J Diet Suppl. 2021 Nov 28;1-26. Available online: https://www.tandfonline.com/doi/full/10.1080/19390211.2021.2005733

12. Ziegler D. et al., Oral treatment with {alpha}-lipoic acid improves symptomatic diabetic polyneuropathy: The SYDNEY 2 trial. Diabetes Care. 2006;29:2365-2370. Available online: https://care.diabetesjournals.org/content/29/11/2365

13. Sánchez . DJR , Lorenzo. VRM, Aguilar. RF. Treatment of peripheral facial paralysis with alpha lipoic acid (ALA) plus muscle retraining. Plasticidad y Restauración Neurológica. 2021;8 (2).Available online: https://www.medigraphic.com/cgi-bin/new/resumenI.cgi?IDARTICULO=103084

 

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Disclaimer: The information presented by Nature's Best is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. Self-treatment is not recommended for life-threatening conditions that require medical treatment under a doctor's care. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications.

 

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