Bell’s Palsy & Ramsay Hunt Syndrome

Pathophysiology

Bell’s Palsy is generally considered idiopathic but is commonly linked to reactivation of herpes simplex virus (HSV). Ramsay Hunt Syndrome arises from reactivation of varicella-zoster virus (VZV) in the geniculate ganglion.

History – Bell’s Palsy

• Loss of taste

• Hyperacusis (noise sensitivity)

• Impaired blinking and forehead weakness

• Dry eyes (↓ tearing), potential blurred vision

• Drooling and difficulty with mouth movement

• May see ear canal vesicles (rarely)

Presentation

• Bell’s Palsy: Lower motor neurone (LMN) facial weakness involving the forehead, onset over minutes to hours. Patients cannot close the eye, show an asymmetric smile, and have no forehead wrinkling on the affected side.

• Ramsay Hunt Syndrome: Ear pain, vesicles in the external auditory canal (EAC), and can present with vertigo or hearing loss.

Differentials (Facial Weakness)

Examination

• Otoscopy to look for vesicles in EAC (Ramsay Hunt) or signs of otitis media.

• Assess corneal reflex and ability to close the eye (risk of corneal injury if incomplete closure).

Investigations

• MRI if atypical presentation (bilateral facial weakness, no improvement, or additional neurological signs).

• Bell’s Palsy is largely a diagnosis of exclusion.

Management

• If within 72 hours:

  • Prednisolone 1 mg/kg (max 75 mg/day) for 5 days (both Bell’s & Ramsay Hunt)

  • Antivirals (e.g. aciclovir/valaciclovir) in Ramsay Hunt; optional in severe Bell’s

• Eye Protection:

  • Lubricating eye drops, taping eyelid shut overnight, sunglasses outdoors

  • Return promptly if pain or vision changes occur

• Supportive Measures:

  • Physiotherapy or gentle facial massage if needed

• Referral (ENT/Neuro) if:

  • No improvement at 3 months

  • Ocular symptoms (e.g., diplopia), dysphagia, numbness, dizziness

  • Worsening neurological signs

• Psychological Support if facial weakness affects mental wellbeing

Additional Notes

• Most Bell’s Palsy cases resolve or significantly improve.

• Ramsay Hunt Syndrome requires prednisolone plus antiviral therapy for best outcomes.

• Regular review is advised to assess improvement and prevent complications (e.g. corneal damage).