A middle aged woman was well until she developed a painful lesion in her right ear. This gradually worsened, the ear became swollen, and she developed vertigo, hearing loss and weakness of the right side of her face. She was ultimately treated with steroids and acyclovir.
At 2 months after onset, she was constantly dizzy, had partial hearing loss on the right, and strong spontaneous nystagmus, head-shaking nystagmus. There was a small amount of residual facial weakness on the right side.
An MRI done close to onset showed enhancement of the R 8th nerve.
Testing showed a modest decline in sweep OAE on the right side, consistent with a nerve injury rather than cochlear hearing loss.
Rotatory chair testing was very abnormal with low gain, high phase and strong asymmetry. The gain_TC product was 3.3 (normal is 11.5).
VHIT testing was also very abnormal to the right side.
This patient likely had Ramsay Hunt as she had a painful ear infection, with skin lesions, and clinical signs suggesting a combination of damage to both the 7th and 8th nerves. While her MRI might be thought to be due to a tumor, the strong signs of infection make this highly unlikely.
In our experience, patients with Ramsay Hunt generally have a prolonged recovery time.
Some of these patients (after a year), if still not able to return to work, benefit from vestibular nerve section. This drastic procedure eliminates abnormal firing of the 8th nerve. This is very much a last resort procedure. Low dose gentamicin would be irrational in a nerve lesion.