Multidisciplinary Management and Physical Therapy Outcomes in a Patient with Ramsay Hunt Syndrome: A Case Report

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Original abstract

Introduction: Ramsay Hunt syndrome (RHS) is an uncommon peripheral facial neuropathy caused by reactivation of latent varicella-zoster virus (VZV) within the geniculate ganglion, and it carries a worse prognosis for facial nerve recovery than idiopathic Bell's palsy1,2. Few reports detail the specific physical therapy decision-making - including the staged use of facial neuromuscular re-education and the deliberate avoidance of aggressive stimulation to prevent synkinesis - that accompanies pharmacological treatment of this condition. This case adds a structured, outcome-measure-driven account of physiotherapy management across the acute, paretic, and synkinesis-prevention phases of recovery. Main Symptoms and Important Clinical Findings: A 54-year-old male presented with a 3-day history of severe right-sided otalgia followed by acute right peripheral facial palsy, incomplete eye closure, and vesicular eruptions over the right pinna. Examination revealed House-Brackmann Grade V facial palsy with absent voluntary movement of the frontalis, orbicularis oculi, orbicularis oris, and zygomaticus major, accompanied by reduced taste sensation and diminished lacrimation on the affected side. Main Diagnoses, Therapeutic Interventions, and Outcomes: The clinical triad of otalgia, vesicular rash, and lower motor neuron facial palsy, supported by VZV-positive vesicle fluid PCR and MRI enhancement of the facial nerve, confirmed the diagnosis of Ramsay Hunt syndrome. Management combined oral antiviral therapy, corticosteroids, and ocular protection with a phased physiotherapy protocol progressing from gentle circulatory massage and eye protection in the acute flaccid phase to mirror-guided neuromuscular re-education and EMG biofeedback as paresis resolved. Conclusion: Early antiviral and corticosteroid therapy combined with a carefully staged, low-effort facial re-education program — rather than early aggressive stimulation — may support functional recovery while minimizing the risk of synkinesis in patients with Ramsay Hunt syndrome. Keywords: Ramsay Hunt syndrome; facial nerve palsy; varicella-zoster virus; facial neuromuscular re-education; EMG biofeedback

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