Ramsay Hunt Syndrome Patients Research Articles

Presence of Varicella Zoster Virus DNA in Saliva May Be Associated with the Severity of Ramsay Hunt Syndrome.

Background: The relationship between varicella zoster virus (VZV) collected from saliva and Ramsay Hunt syndrome (RHS) remains unclear. Therefore, this study aimed to investigate whether VZV DNA in saliva alters the clinical symptoms and prognosis of RHS. Methods: To measure the severity of clinical symptoms of 100 RHS patients, the initial House–Brackmann (HB) grade and associated symptoms were evaluated. The final HB grade at the end of treatment was measured to determine the prognosis. Electroneurography (ENoG) was performed on four facial muscles, including the frontalis, oculi, nasalis, and oris. Results: Salivary VZV DNA was isolated from 72 patients with RHS. The VZV DNA-positive group was 34.023 times more likely to have severe initial HB grade than the control group (95% CI, 3.21–359.68; p = 0.003). There were no significant differences in final HB grade. All ENoG values of the VZV DNA-positive group were significantly higher than those of the control group (frontalis, p = 0.003; oculi, p = 0.001; nasalis, p < 0.001; oris, p = 0.037). Conclusions: RHS patients with salivary VZV DNA have more severe clinical symptoms than the control group. There were no differences in prognosis and associated symptoms. A VZV DNA test using saliva samples of patients with RHS can evaluate the clinical symptoms and provide early confirmation of VZV infection, enabling timely treatment in a non-invasive way.

Mastoid effusion on temporal bone MRI in patients with Bell\u2019s palsy and Ramsay Hunt syndrome

This study aimed to investigate the incidence of mastoid effusion on temporal bone magnetic resonance imaging (MRI) in patients with Bell’s palsy (BP) and Ramsay Hunt syndrome (RHS), and evaluate the usefulness of mastoid effusion in early differential diagnosis between BP and RHS. The incidence of mastoid effusion on 3.0 T—temporal bone MRI, which was conducted within 10 days after the onset of acute facial nerve palsy, was compared between 131 patients with BP and 33 patients with RHS. Findings of mastoid cavity on temporal bone MRI were classified into three groups as normal mastoid, mastoid effusion, and sclerotic change, and the incidence of ipsilesional mastoid effusion was significantly higher in RHS than BP (P < 0.001). Tympanic membrane was normal in 7 of 14 RHS patients with mastoid effusion, and injected without middle ear effusion in 7 patients. This study highlights significantly higher incidence of ipsilesional mastoid effusion in RHS than BP, and suggests that the presence of mastoid effusion may provide additional information for differential diagnosis between RHS and BP.

Vestibular and cochlear nerve enhancement on MRI and its correlation with vestibulocochlear functional deficits in patients with Ramsay Hunt syndrome

ObjectiveThe correlation between enhancement of the vestibulocochlear nerves on gadolinium-enhanced magnetic resonance imaging (MRI) and vestibulocochlear functional deficits was examined in patients with Ramsay Hunt syndrome (RHS). MethodsNineteen patients with RHS who showed herpes zoster oticus, peripheral facial palsy, and vertigo were enrolled. Canal paresis (CP) in the caloric test, abnormal response to ocular and cervical vestibular myogenic potentials (oVEMP and cVEMP), and refractory sensorineural hearing loss were evaluated. MRI images perpendicular to the internal auditory canal were reconstructed to identify the superior (SVN) and inferior vestibular nerves (IVN) and the cochlear nerve (CV). The signal intensity increase (SIinc) of the four-nerve enhancement was calculated as an index. ResultsAmong RHS patients, 79%, 53%, 17% and 26% showed CP in the caloric test, abnormal responses to oVEMP and cVEMP, and refractory sensorineural hearing loss, respectively. SIinc rates of the SVN were significantly increased in RHS patients with CP in the caloric test, and with abnormal responses to oVEMP and cVEMP. SIinc rates of the SVN tended to increase in RHS patients with refractory sensorineural hearing loss (p = 0.052). SIinc rates of the IVN were significantly increased in RHS patients with abnormal responses to oVEMP and cVEMP, and refractory sensorineural hearing loss, but not in those with CP in the caloric test. SIinc rates of the CN were significantly increased in RHS patients with CP in the caloric test, abnormal response to oVEMP and refractory sensorineural hearing loss, but not in those with abnormal response to cVEMP. ConclusionIn patients with RHS, the origin of vertigo may be superior vestibular neuritis, which is affected by reactive varicella-zoster virus from the geniculate ganglion of the facial nerve through the faciovestibular anastomosis. The results also suggested that in some RHS patients, inferior vestibular neuritis contributes to the development of vertigo and that the origin of refractory sensorineural hearing loss is cochlear neuritis.

Nystagmus in Ramsay Hunt syndrome with or without dizziness.

The presence of dizziness has been reported as a negative prognostic factor for recovery of facial palsy in Ramsay Hunt syndrome (RHS). The aim of this study was to investigate the incidence and patterns of nystagmus in RHS patients without dizziness, and discuss possible mechanisms. We also compared the severity and prognosis of facial palsy between RHS patients with and without dizziness. From January 2014 to January 2019, 36 patients diagnosed with RHS (27 with dizziness and 9 without dizziness) were included. Patterns of nystagmus were examined and categorized using video-nystagmography. House-Brackmann(HB) grade of facial palsy was compared between RHS patients with and without dizziness. Not only RHS patients with dizziness exhibited nystagmus in most cases (96%, 26 of 27) but also as many as 67% (6 of 9) of RHS patients without dizziness exhibited nystagmus, though the intensity was remarkably weak. In both groups of RHS with and without dizziness, direction-fixed nystagmus and direction-changing positional nystagmus were observed. Initial HB grade and recovery of facial palsy after treatment were not significantly different between RHS with and without dizziness. Various patterns of nystagmus including direction-fixed and positional direction-changing nystagmus were observed in RHS patients, and inflammation of the vestibular nerve and inner ear end organs may be responsible for the production of nystagmus in these patients. The results support that the evaluation of vestibular function may be necessary even in RHS patients who do not complain of dizziness or vertigo.

Herpes zoster oticus among pediatric patients: Our experiences at a tertiary care teaching hospital

Introduction: Herpes zoster oticus (HZO) occurs due to the reactivation of the varicella zoster virus (VZV) in the geniculate ganglion of the facial nerve. It is characterized by erythematous vesicular eruptions on the pinna and external auditory canal with severe otalgia. When it is associated with ipsilateral facial nerve paralysis, a diagnosis of Ramsay Hunt syndrome (RHS) can be made. It is rare in the pediatric age group but with low immunity, so prone for increased risk of disseminated infections, neurological complications, and recurrence of infections. Objective: The aim of this study was to evaluate the clinical profile and management of the HZO among pediatric patients at a tertiary care teaching hospital. Materials and Methods: In this prospective study, 24 pediatric patients of HZO were reviewed those presented during the period of December 2015–January 2020. All pediatric patients underwent thorough clinical examinations before getting the diagnosis. All the participants also underwent thorough neuro-otological and otolaryngological examinations. Results: Out of 24 pediatric patients, 15 were boys and 9 were girls. All were in the pediatric age group with age ranging from 5 years to 16 years. After the diagnosis of HZO/RHS, all were treated with acyclovir for 10 days along with tapering dose of deflazacort, labyrinthine sedatives, and eye care in case of facial palsy. All the pediatric patients were recovered by our treatment protocol except 3 cases those are still in follow-up with facial weakness. Conclusions: Adequate awareness for the HZO in pediatric patients is required, and the management of RHS patients is paramount among pediatrician or pediatric otorhinolaryngologists.

Atypical clinical manifestations of herpes zoster oticus: diagnostic usefulness of magnetic resonance imaging

Typical symptoms of Ramsay Hunt syndrome (RHS) consist of painful vesicular eruptions in the external ear, unilateral facial palsy, and/or vestibulocochlear deficit. When RHS patients show atypical clinical manifestations, correct diagnosis can be delayed, and ideal treatment timing for antiviral therapy may be missed. The aim of this study is to describe RHS patients with atypical clinical manifestations and evaluate the usefulness of magnetic resonance imaging (MRI) for early differential diagnosis. We retrospectively reviewed the clinical data and investigated the findings of internal auditory canal (IAC) MRI of seven patients diagnosed with RHS presenting "atypical" clinical manifestations between January 2013 and December 2016. "Typical" symptoms of RHS consist of herpetic vesicular eruption and facial palsy with or without vestibulocochlear deficit. Regardless of symptomatic presentations, IAC MRI demonstrated post-contrast enhancement of cranial nerve (CN) VII, CN VIII, and IAC dura in patients with atypical clinical manifestations. In cases with multiple lower CN palsy, enhancement along the involved nerve was observed on IAC MRI. When RHS was complicated by acute parotiditis, diffuse enhancement of the parotid gland was demonstrated. The present study shows that in IAC MRI of RHS patients with atypical clinical manifestations, post-contrast enhancement was not confined to the facial nerve but also observed in CN VIII and IAC dura regardless of the symptoms, which may facilitate early diagnosis of RHS.

Delayed transmastoid facial nerve decompression surgery in patients with Ramsay-Hunt syndrome presenting with neurophysiologically complete paralysis

Objectives: To determine the efficacy of delayed transmastoid facial nerve decompression in patients with Ramsay Hunt Syndrome (RHS) presenting with complete facial paralysis.Methods: Twenty-five RHS patients with complete facial nerve paralysis presenting electroneuronographic (ENoG) degeneration ≥90% underwent transmastoid facial nerve decompression more than 3 weeks after the onset of paralysis. The principal features measured were 12 months pre- and post-operative House-Brackmann (HB) grades and the presence of a direct intraoperative neural response (INR) prior to decompression procedure. Correlations between these parameters, and the time between symptom onset and surgery (within or later than 30 and 50 d) were statistically analyzed.Results: Of the 25 patients 13 (52%) exhibited good recovery (HB grade I or II) at 12 months-post-operatively. The timing of decompression generally did not significantly influence outcome but patients treated within 50 d of symptom onset enjoyed better outcomes than those treated later (p = .047). The presence of an INR significantly influenced outcomes (p = .0003).Conclusions: The success of delayed transmastoid facial nerve decompression in RHS patients was not affected between 25–30 and 30–40 d from symptom onset but was compromised when the delay was >50 d. The presence or absence of an INR was a good predictor of post-operative prognosis.

Vestibular Restoration and Adaptation in Vestibular Neuritis and Ramsay Hunt Syndrome With Vertigo.

To evaluate vestibular restoration and the evolution of the compensatory saccades in acute severe inflammatory vestibular nerve paralysis, including vestibular neuritis and Ramsay Hunt syndrome with vertigo. Prospective. Tertiary referral center. Vestibular neuritis (n = 18) and Ramsay Hunt syndrome patients with vertigo (n = 13) were enrolled. After treatment with oral corticosteroids, patients were followed up for 6 months. Functional recovery of the facial nerve was scored according to the House-Brackman grading system. Caloric and video head impulse tests were performed in every patient at the time of enrolment. Subsequently, successive video head impulse test (vHIT) exploration was performed at the 1, 3, and 6-month follow-up. Eighteen patients with vestibular neuritis and 13 with Ramsay Hunt syndrome and associated vertigo were included. Vestibular function was significantly worse in patients with Ramsay Hunt syndrome than in those with vestibular neuritis. Similar compensatory saccades velocity and latency values were observed in both groups, in both the caloric and initial vHIT tests. Successive vHIT results showed a significantly higher vestibulo-ocular reflex gain recovery in vestibular neuritis patients than in Ramsay Hunt syndrome patients. A significantly faster reduction in the latency, velocity, and organization of the compensatory saccades was observed in neuritis than in Ramsay Hunt syndrome patients. In addition to the recovery of the vestibulo-ocular reflex, the reduction of latency, velocity and the organization of compensatory saccades play a role in vestibular compensation.

Prognostic factors of Bell's palsy and Ramsay Hunt syndrome.

The aim of this study was to compare clinical characteristics, electroneurography (ENoG) results, and functional outcomes of patients with Bell's palsy (BP) and Ramsay Hunt syndrome (RHS).Around 57 patients with BP and 23 patients with RHS were enrolled in this study from January 2010 and September 2015. Both clinical characteristics and ENoG results were recorded at hospital admission. The evaluations of functional outcomes were conducted with House–Brackmann (H-B) grading system at 6-month follow-up.There were no significant differences in age, gender proportion, initial H-B grades, time before commencement of treatment and the presence of comorbid disease in 2 groups. However, the final H-B grades at 6-month follow-up were significantly better in BP patients than RHS patients. The results of ENoG showed that degeneration index (DI) was significantly higher in the RHS group than the BP group. But no significant difference was found in the value of prolonged latency time (PLT) between the 2 groups. In multivariate analysis, age and ENoG DI were independently associated with functional outcome of recovery in the BP group (OR 0.167, 95% CI 0.038–0.622, P = 0.009 and OR 0.289 95% CI 0.107–0.998, P = 0.050, respectively). However, in the RHS group, only ENoG DI was related to the final H-B grades (OR 0.067, 95% CI 0.005–0.882, P = 0.040). Spearman's rank correlation analysis showed that higher age and ENoG DI were related to poorer prognosis in 2 groups (P < 0.05). PLT was related to functional outcomes only in the BP group (rs = 0.460, P < 0.001). The receiver operating characteristic (ROC) of ENoG DI analysis revealed that the cutoff value was 67.0% for BP prognosis and 64.5% for RHS prognosis. What's more, patients with hypertension or diabetes mellitus had both higher final H-B grade and ENoG DI than those without the same comorbidity.Patients with RHS had poorer prognosis than those with BP. Some factors including age, ENoG DI, and the presence of disease influenced recovery from BP and RHS. The present study demonstrated that BP patients with ENoG DI < 67.0% and RHS patients with ENoG DI < 65.5% had a greater opportunity for recovery within half a year.

Management of Ramsay Hunt syndrome among HIV patients: Our experience in a tertiary care hospital of eastern India

Abstract Introduction Ramsay Hunt syndrome (RHS), also known as herpes zoster oticus as well as shingles of the geniculate ganglion, occurs due to reactivation of varicella zoster virus (VZV) within the geniculate ganglion and associated sensory nerves. Immunocompromised individuals like those with HIV infections are prone to RHS. HIV infections with RHS are at increased risk for disseminated infections, postherpetic neuralgia, neurological complications and recurrence of infections. Rapid diagnosis and treatment of this type of neurodermatologic condition is very crucial to avoid permanent complications. HIV patients with RHS have a poor prognosis if not treated early and adequately. Aim The aim of this study was to manage RHS patients in HIV positive cases in a tertiary care hospital of eastern India. Material and methods In this prospective study, six patients of RHS with HIV infections were reviewed, who presented during the period between 2012 and 2015. Results and discussion Out of six patients, four were male and two were female. All were adult patients whose ages were ranging from 25 to 54 years. All patients underwent thorough clinical examination before coming to diagnosis. All of our cases were recovered by our treatment protocol except case 3, who is still on follow-up with facial exercises. Conclusions Adequate awareness regarding early detection and management of RHS patients particularly among HIV positive cases is paramount among primary physicians.

Ramsay Hunt syndrome

Ramsay Hunt syndrome is defined as herpes zoster oticus associated with an acute peripheral facial nerve paresis and quite often with other cranial nerve lesions. The combination of motor, sensory and autonomic involvement leads to a variety of neurological damage patterns, i. e. facial muscle paresis, hearing and balance disorders, sensory problems and disturbances of taste as well as lacrimal and nasal secretion. Additional variability of the clinical picture of Ramsay Hunt syndrome is produced by varying patterns of skin involvement explained by individual anastomoses between cranial and cervical nerves. Knowledge of these findings and an early diagnosis of Ramsay Hunt syndrome are important as prognosis of cranial nerve damage depends on the time at which acyclovir-corticosteroid therapy is started.

Ramsay Hunt syndrome with multicranial nerve involvement

Conclusions: Ramsay Hunt syndrome (RHS) with multiple involvement of cranial nerves is more severe and intractable than RHS without such involvement. Objectives: Typically, RHS involves VII and VIII nerves and unilaterally, and RHS accompanied by multiple cranial neuropathy is very rare. We describe 11 patients who developed RHS with multicranial nerve involvement and we analyzed their clinical characteristics and compared them with those of patients with RHS not accompanied by multiple cranial neuropathy. Methods: During the period 1995–2009, we treated 339 patients with RHS; of these, 11 patients had concurrent multiple cranial neuropathy. We assessed the clinical characteristics of RHS patients with and without multiple cranial neuropathy. Results: The mean age of the 11 patients with multiple cranial neuropathy (6 men, 5 women) was 49.2 ± 19.4 years, although 7 were aged 50 years or older. Eight patients had right-sided and three had left-sided facial paralysis. The initial degree of facial paralysis was House-Brackmann (HB) grade IV in four patients (36.4%) and HB grade V in seven (63.6%). Six patients showed improvement in symptoms, whereas five (45.6%) showed no improvement. The recovery rates from facial paralysis in patients with and without multiple cranial neuropathy were 54.5% and 82.9%, respectively, and the complete recovery rates were 27.3% and 67.7%, respectively.

The lesion site of vestibular dysfunction in Ramsay Hunt syndrome: A study by click and galvanic VEMP

Ramsay Hunt syndrome (RHS) is characterized by vestibulocochlear dysfunction in addition to facial paralysis and auricular vesicles. The present study investigated the lesion site of vestibular dysfunction in a group of 10 RHS patients. Caloric testing, vestibular evoked myogenic potentials by click sound (cVEMP) and by galvanic stimulation (gVEMP) were used to assess the function of the lateral semicircular canal, saccule, and their afferents. The results of caloric testing (all 10 cases showed canal paresis) mean the existence of lesion sites in lateral semicircular canal and/or superior vestibular nerve (SVN). Abnormal cVEMPs in 7 patients mean the existence of lesions in saccule and/or inferior vestibular nerve (IVN). Four of the 6 patients with absent cVEMP also underwent gVEMP. The results of gVEMP (2 absent and 2 normal) mean that the former 2 have lesions of the vestibular nerve, and the latter 2 have only saccular lesions concerning the pathway of VEMPs. Thus, our study suggested that lesion sites of vestibular symptoms in RHS could be in the vestibular nerve and/or labyrinth, and in SVN and/or IVN. In other words, in the light of vestibular symptoms, there is the diversity of lesion sites.

Different real-time PCR assays could lead to a different result of detection of varicella-zoster virus in facial palsy

Real-time PCR is a useful tool for rapid detection of viral genomic DNA. However, there are many types of real-time PCR, and this variation may induce different results. The sensitivity of two different real-time PCR assays was evaluated for the detection of the varicella-zoster virus (VZV) genome: LightCycler PCR and TaqMan PCR. Auricular skin cells and saliva were sampled from 201 patients with facial nerve paralysis. A hundred and seventy-one of these patients were diagnosed clinically with Bell's palsy, and the remaining 30 with Ramsay Hunt syndrome. In 30 specimens obtained from Ramsay Hunt syndrome patients, VZV DNA was detected in 26 skin and 3 saliva specimens using the LightCycler PCR, while 28 skin and 9 saliva specimens were positive using the TaqMan PCR. None of the patients with Bell's palsy were positive for VZV by the LightCycler PCR, whereas five of these patients were positive by the TaqMan PCR. The TaqMan PCR assay has a better sensitivity compared to the LightCycler PCR for the detection of VZV genome from patients with facial palsy. Further study is required to develop a more sensitive real-time PCR.

MRI findings of Ramsay Hunt syndrome

目的 探讨Ramsay Hunt 综合征的MRI表现及诊断价值.方法 5例临床确诊的单侧Ramsay Hunt 综合征患者,男3例,女2例,年龄29～54岁,行MR平扫及钆喷替酸葡甲胺(Gd-DTPA) 增强检查,其中3例增强前后对面神经颞骨内各节段分别测量信号强度.5例均进行面神经各节段信号强度的双侧对比及增强前后对比.结果 4例患侧面神经节段性异常强化(双侧信号强度增强差值>20或评分相差1级或以上),1例双侧面神经强化无差别.膝状神经节(4/4)和迷路段(3/4)的异常强化相对多见, 内听道末段、鼓室段和乳突段各有2例异常强化.结论对于单侧患病者来说,只有患侧面神经节段性强化高于健侧相应节段才有诊断意义.Ramsay Hunt综合征较易累及迷路段和膝状神经节.Gd-DTPA增强MRI能够客观地反映面神经的病变节段,有助于临床诊断及鉴别诊断,具有一定的临床实用价值.该项检查结果与临床表现的关系还需进一步研究。

Bell's Palsy and Herpes Zoster Oticus.

Normal facial movement is required for chewing, swallowing, speaking, and protecting the eye. Bell's palsy causes most cases of acute, unilateral facial palsy; infection with herpes simplex virus (HSV) type 1 may be its major cause. Varicella zoster virus (VZV) reactivation (Ramsay Hunt syndrome) is less common, but may appear without skin lesions in a form indistinguishable from Bell's palsy. Symptoms improve in nearly all patients with Bell's palsy, and most patients with Ramsay Hunt syndrome, but many are left with functional and cosmetic deficits. Steroids are frequently used to optimize outcomes in Bell's palsy, but proof of their effectiveness is marginal. Oral prednisone has been studied extensively, although some reports have suggested a higher recovery rate with intravenous steroids. Given the existing data, we support the use of oral prednisone in those patients with complete facial palsy, and no contraindications to their use (Fig. 1). In this author's opinion, the greatly increased cost and inconvenience of intravenous steroids cannot be justified by the data available. Antiviral agents may also be effective in treatment of Bell's palsy; HSV is susceptible to acyclovir and related agents. There have been few investigations of acyclovir treatment in Bell's palsy, but one controlled study showed added benefit when the drug was used with prednisone. The risk and cost of acyclovir is low enough that we support its use, with oral steroids, in those patients with complete facial paralysis. Several small studies have implied that oral acyclovir improves the outcome of facial palsy for patients with Ramsay Hunt syndrome. Although these studies do not prove efficacy, evidence for the benefits of antiviral agents in other forms of zoster is strong enough to recommend their use when the facial nerve is involved. VZV is less sensitive to acyclovir than HSV, so higher doses are recommended to treat Ramsay Hunt syndrome. Because some Ramsay Hunt syndrome patients with partial facial palsy do not fully recover, we recommend oral antiviral agents in all patients suspected of having zoster. There is weak evidence to suggest additional benefit of oral steroids in facial zoster, and their use can be supported in immunocompetent individuals. Facial nerve decompression surgery for Bell's palsy and herpes zoster oticus has experienced varying levels of enthusiasm over the years. Recent work implies that early, extensive decompression of the nerve through a middle fossa craniotomy may benefit patients at high risk for persistent deficits. However, until this procedure is subjected to a rigorous, controlled trial comparing it with maximal medical therapy, it is difficult to justify the very high costs and risk.

Detection of varicella-zoster virus DNA in tear fluid and saliva of patients with Ramsay Hunt syndrome

Ramsay Hunt syndrome develops when the varicella-zoster virus (VZV) is reactivated. In the present study, we examined the secretion kinetics of VZV DNA in the tear fluid, submandibular gland saliva and parotid gland saliva of 15 patients with Ramsay Hunt syndrome. The presence of VZV DNA was detected using PCR and a microplate hybridization method. Hybridization signals were measured using the fluorescence density of an enzymatic reaction product using fluoroscan and a system involving streptavidin-conjugated beta-galactosidase. The results were converted into numerical values and used to estimate the number of virus DNA copies. VZV DNA was detected in the tear fluid, submandibular gland saliva and parotid gland saliva of the Ramsay Hunt syndrome patients. The rate of VZV DNA detection in the submandibular gland saliva was 72%, and the detection rate in the parotid gland saliva was 57%. The detection rate in the tear fluid was 27%, which is significantly lower than other two detection rates. Regarding the submandibular gland saliva and the parotid gland saliva, the VZV DNA was detected in samples collected at a comparatively early stage of onset. In the tear fluid, the detection rate increased significantly in samples collected 2 weeks after onset or later. Thus, differences in the detection rate were observed depending on the type of secretory gland and the timing of the sample collection. The VZV DNA in the tear fluid is thought to derive from the ganglion trigeminale. The increase and decrease in the number of VZV DNA copies detected in samples collected at different times is considered to substantiate VZV reactivation in Ramsay Hunt syndrome.

Detection of varicella-zoster virus DNA in peripheral mononuclear cells from patients with Ramsay Hunt syndrome or zoster sine herpete

On the basis of alterations in varicella-zoster virus (VZV) antibody titers, it appears that Bell's palsy in some patients could be associated with VZV reactivation, that is, zoster sine herpete. To obtain stronger evidence of this association, polymerase chain reaction (PCR) was used to detect VZV DNA in auricular lesions or peripheral blood mononuclear cells (PBMCs) from Bell's palsy or Ramsay Hunt syndrome patients. VZV DNA was detected in the auricular lesions of Ramsay Hunt syndrome, in PBMCs from 2 Ramsay Hunt syndrome patients, and in 4 of 17 samples from 16 Bell's palsy patients. Three of these four positive patients were thought to have zoster sine herpete because of hearing difficulty, vertigo, and pain. VZV IgM antibodies were positive in 1 of the 2 patients with Ramsay Hunt syndrome, and in 2 of the 17 samples from the Bell's palsy patients. VZV IgG antibody titers during the acute phase were significantly higher in the patients positive for the PCR or VZV IgM antibody than in those negative for them. These findings provide evidence that Bell's palsy in some patients could be associated with VZV reactivation.