1. Neurology Resident and Fellow Section
An 85 year old woman with facial weakness, ear pain, and rash
Teaching NeuroImages
Neurology
Resident and Fellow Section
© 2017 American Academy of Neurology

2. VIGNETTE
Initial presentation: left ear pain, mild left peripheral facial weakness and vertigo
Due to underlying dementia, the duration of facial weakness was unclear
Four days later she returned with worsening ear pain, facial paralysis, and vesicular rash within the auditory canal, plus left hyperacusis and persistent vertigo
Labin et al
© 2017 American Academy of Neurology

3. IMAGING Labin et al Figure legend:
Top Figure: A) Contrast enhancement of intracanalicular CN VII segment (arrowhead) and geniculate ganglion (arrow). B) Contrast enhancement of intracanicular segments of CN VII (arrowhead) and CN VIII (arrow). The contralateral CN VII and CN VIII appear normal.
Bottom Figure: Left facial paralysis with encrusted vesicular rash in the ipsilateral ear.
Labin et al
© 2017 American Academy of Neurology

4. Classic Ramsay Hunt Syndrome and Associated MRI Findings
Ramsay Hunt syndrome is caused by VZV reactivation in CN VII1
Additional CNs are often affected (usually VIII)1
The classic RHS triad involves: ear pain, facial paralysis, and vesicular rash1
Contrast enhancement of CN VII and VIII on MRI is consistent with Ramsay Hunt Syndrome (RHS)2  
Contrast enhancement of CN VII plus additional affected CNs (most commonly VIII) may allow diagnosis of RHS prior to onset of the classic vesicular rash.
References:
Hunt, J. Ramsay. "On Herpetic Inflammations Of The Geniculate Ganglion. A New Syndrome And Its Complications." The Journal of Nervous and Mental Disease 34.2 (1907):
Chung, Mi S., Jeong H. Lee, Dae Y. Kim, Young-Min Lim, Joong H. Ahn, Yu S. Sung, Young J. Choi, Ra G. Yoon, and Jung H. Baek. "The Clinical Significance of Findings Obtained on 3D-FLAIR MR Imaging in Patients with Ramsay-Hunt Syndrome." The Laryngoscope (2014):
Labin et al
© 2017 American Academy of Neurology