Clinical Features, Diagnosis, and Management of Herpes Zoster Oticus: A Narrative Review
DOI:
https://doi.org/10.52221/jvnus.v7i2.901Keywords:
herpes zoster oticus, ramsay hunt syndrome, facial palsy, varicella-zoster virus, narrative reviewAbstract
Herpes Zoster Oticus (HZO) is a neurological disorder caused by reactivation of the varicella-zoster virus in the geniculate ganglion, resulting in facial paralysis and, in severe cases, auditory or vestibular impairment. This narrative review summarizes current evidence regarding the clinical features, diagnostic approaches, and management of HZO. A literature search was conducted in PubMed for articles published between 2015 and 2025 using the keywords “herpes zoster oticus,” “Ramsay Hunt syndrome,” “facial palsy,” and “varicella-zoster virus.” Only English-language, full-text case reports discussing the clinical presentation of HZO were included. Of the 38 articles initially identified, 18 met the inclusion criteria after screening titles, abstracts, and full manuscripts. The synthesized findings highlight recent advancements in understanding VZV pathogenesis, improved diagnostic accuracy, and refinement of treatment strategies. Evidence consistently indicates that early initiation of antiviral therapy, combined with corticosteroids, is associated with better facial nerve recovery and reduced long-term complications. Furthermore, the variability of clinical manifestations including atypical presentations such as zoster sine herpete underscores the importance of maintaining a high index of suspicion and adopting a multidisciplinary approach to care. Early diagnosis and timely treatment remain key determinants of patient outcomes. Future research should aim to identify reliable prognostic biomarkers, develop rapid diagnostic tools for atypical cases, and conduct randomized controlled trials to optimize therapeutic regimens, particularly regarding the role of corticosteroids and emerging antiviral agents
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Al-Ani, R. M. (2022). Ramsay Hunt syndrome with cranial polyneuropathy and delayed facial nerve palsy: A case report. Cureus, 14(7), e27434. https://doi.org/10.7759/cureus.27434
Bardach, A. E., Palermo, C., Alconada, T., Sandoval, M., Balan, D. J., Nieto Guevara, J., Gómez, J., & Ciapponi, A. (2021). Herpes zoster epidemiology in Latin America: A systematic review and meta-analysis. PLOS ONE, 16(8), e0255877. https://doi.org/10.1371/journal.pone.0255877
Cavalcante, M. de S. M., Rodríguez, K. L., Diéguez, J. A. L., Santos, L. M. dos, Guerra, M. D. G. V. B., & Guerra, J. A. de O. (2020). Ramsay Hunt syndrome after antimonial treatment for American cutaneous leishmaniasis. Revista da Sociedade Brasileira de Medicina Tropical, 54, 1–3. https://doi.org/10.1590/0037-8682-0012-2020
Crouch, A. E., Hohman, M. H., Moody, M. P., & Andaloro, C. (2023). Ramsay Hunt syndrome. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK557409/
Cunniffe, H. A., & Cunniffe, N. G. (2019). Herpes zoster oticus with meningitis masquerading as malignant otitis externa. BMJ Case Reports, 12(6), e229569. https://doi.org/10.1136/bcr-2019-229569
Dai, S., Huang, X., Chen, Y., Wang, M., Zheng, H., Zeng, K., & Li, L. (2020). Bilateral asymmetrical herpes zoster with Ramsay Hunt syndrome in an immunocompetent adult. Virology Journal, 17(1), 123. https://doi.org/10.1186/s12985-020-01392-0
Fader, F., Gendeh, H. S., & Goh, B. S. (2022). Where are the vesicles? A case report of Ramsay Hunt syndrome. Malaysian Family Physician, 17(1), 90–93. https://doi.org/10.51866/cr1351
Gaudêncio, M., Bertão, M. I., Carvalho, A., Pena, G., Bessa, I., & Gonçalves, A. (2021). Ramsay Hunt syndrome in a patient with ulcerative colitis treated with infliximab. European Journal of Case Reports in Internal Medicine, 8(12), 003032. https://doi.org/10.12890/2021_003032
Gillette, B. T., & Heilbronn, C. M. (2023). A rare case of vocal cord paralysis in the setting of Ramsay Hunt syndrome. Cureus, 15(3), e36027. https://doi.org/10.7759/cureus.36027
Goswami, Y., & Gaurkar, S. S. (2023). Ramsay Hunt syndrome: An introduction, signs and symptoms, and treatment. Cureus, 15(1), e33688. https://doi.org/10.7759/cureus.33688
Guan, R., Hong, Z., Pan, L., Wang, Y., & Li, Y. (2024). Mechanism and future prospect of treatment of facial paralysis caused by herpes zoster virus infection with acupuncture combined with medicine: A review. Medicine, 103(38). https://journals.lww.com/md-journal/fulltext/2024/09200/mechanism_and_future_prospect_of_treatment_of.76.aspx
Kang, D. H., Kwak, B. O., Park, A. Y., & Kim, H. W. (2021). Clinical manifestations of herpes zoster associated with complications in children. Children, 8(10), 845. https://doi.org/10.3390/children8100845
Kim, C.-H., Choi, H., & Shin, J. E. (2016). Characteristics of hearing loss in patients with herpes zoster oticus. Medicine, 95(46), e5457. https://doi.org/10.1097/MD.0000000000005457
Kim, K. M., Yu, K., Jeon, E.-J., & Lee, H. J. (2021). Herpes zoster oticus with delayed facial palsy and multiple cranial nerve involvement. Korean Journal of Otorhinolaryngology–Head and Neck Surgery, 64(11), 839–843. https://doi.org/10.3342/kjorl-hns.2021.00157
Lee, J., Choi, J. W., & Kim, C.-H. (2022). Features of audio-vestibular deficit and 3D-FLAIR temporal bone MRI in patients with herpes zoster oticus. Viruses, 14(11), 2568. https://doi.org/10.3390/v14112568
Malhotra, R., Mudey, A., & Agrawal, I. (2022). Clinical features and prognosis of facial palsy and hearing loss in patients with Ramsay Hunt syndrome. Cureus, 14(10), e30897. https://doi.org/10.7759/cureus.30897
Montague, S. J., & Morton, A. R. (2017). Ramsay Hunt syndrome. Canadian Medical Association Journal, 189(8), E320. https://doi.org/10.1503/cmaj.160483
Pitton Rissardo, J., & Fornari Caprara, A. L. (2019). Herpes zoster oticus, ophthalmicus, and cutaneous disseminated: Case report and literature review. Neuro-Ophthalmology, 43(6), 407–410. https://doi.org/10.1080/01658107.2018.1523932
Qavi, A., Tiwari, A., Maurya, P. K., Singh, A. K., & Kumar, P. (2020). Unilateral cranial polyneuropathy in herpes zoster oticus: Infection teaching us anatomy. Nepal Journal of Neuroscience, 17(3), 59–62. https://doi.org/10.3126/njn.v17i3.33129
Rim, H. S., Chung, S. H., Kim, H. J., Yeo, S. G., & Kim, S. H. (2023). Herpes zoster oticus with concurrent hearing loss: Clinical characteristics and prognosis. Journal of Clinical Medicine, 12(20), 6476. https://doi.org/10.3390/jcm12206476
Sheik-Ali, S., Jiang, Y., Nasef, H., Sproson, E., & Tuohy, O. (2022). Bilateral sequential Ramsay Hunt syndrome in an immunocompromised adult: A rare entity. Annals of the Royal College of Surgeons of England, 106(2), 197–199. https://doi.org/10.1308/rcsann.2022.0133
Sinha, R., Kumari, P., Pallavi, U. K., & Sarkar, S. (2023). Clinical and epidemiological profile of herpes zoster and its complications in a tertiary care center of Bihar: A prospective study. Cureus, 15(8), e43560. https://doi.org/10.7759/cureus.43560
Swain, S. K., Choudhury, J., & Acharya, S. (2020). Herpes zoster oticus among pediatric patients: Our experiences at a tertiary care teaching hospital. Indian Journal of Health Sciences and Biomedical Research, 13(3), 210–214. https://journals.lww.com/kleu/fulltext/2020/13030/herpes_zoster_oticus_among_pediatric_patients__our.6.aspx
Wu, D., & Song, M. (2025). Varicella-zoster virus vasculopathy: A rare complication of Ramsay Hunt syndrome. Frontiers in Neurology, 16, 1509110. https://doi.org/10.3389/fneur.2025.1509110
Yu, C., Lee, H.-Y., & Chen, Y.-C. (2025). Early diagnosis and treatment of Ramsay Hunt syndrome: A case report. International Journal of Emergency Medicine, 18(1), 1. https://doi.org/10.1186/s12245-024-00807-x
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Copyright (c) 2025 Labid Al-Mutawakkil, Burhanuddin Ichsan, Aisha Nurindah Kusumaningtyas, Aryska Nur Hidayah, Shafira Mahira Nariswari, Shofi Rizki Anhari
This work is licensed under a Creative Commons Attribution 4.0 International License.
