Ramsay Hunt Syndrome: Shingles in the ear

If you had chickenpox in childhood, the virus that caused it is still alive in your body and can reactivate later in life. It lives on in a dormant state in the neurons (nerve cells) that cluster in nerve enlargements called ganglia. If it suddenly awakens as you age, it can migrate down the nerves because these connect the ganglia to skin and other tissues. An eruption on the skin from this reactivating virus is called shingles. Ramsay Hunt syndrome, or Herpes Zoster Oticus, is a type of shingles that affects the skin in or near the ear, and causes weakness of the face, vertigo, and hearing loss.

Read more: Ramsay Hunt Syndrome: Shingles in the ear

It usually begins with deep pain in the ear as the virus begins to migrate down the nerves toward the skin. Once it reaches the skin, red bumps that are exceptionally sore to the touch appear, and eventually these form clusters of small but painful blisters. These are found on the ear or inside the ear canal and can even spread over the side of the face near the ear.

At the same time the virus attacks the skin, it can also migrate down other nearby nerves and cause damage. In Ramsay Hunt syndrome the virus attacks a nerve on one side of the face that affects the muscles controlling facial movement. This will be on the same side as the ear pain and rash. The face on that side will droop and the eyelid may not close properly. If the zoster virus also migrates to the inner ear, you can develop vertigo to the point of seeing the room spin, and you may notice ringing in the ear or loss of hearing.

You should be seen urgently if this happens, because medications can help control the virus and reduce the swelling in the nerves that cause some of the damage to the ear and face. You need to be seen within the first few days to have the best chance of full recovery. The facial paralysis can improve over time, but there may be some residual weakness. The hearing can improve with treatment also. If there is permanent damage to the balance part of the inner ear, symptoms of dizziness and imbalance tend to improve over the first few weeks but may take months to completely resolve. Our series on recovery begins with this post.

The vaccine to prevent shingles (Shingrex) also helps prevent Ramsay Hunt syndrome. You become more likely to have virus reactivation after age 50. Reactivation is very common, up to half of people by the time they reach 80 years of age, so it’s worth considering the vaccine any time after you reach 50.

Ask The Doctor: Nausea and Vertigo

Thank you, thank you Dr Foster, for making this video!! I had terrible vertigo for days and it was so intense one morning that I vomited.  I tried the Epley maneuver and it was only marginally effective. I had to do the half somersault a few times to completely resolve the vertigo, but it did work after the third time.

And another comment: I did the half somersault, got nauseous, and puked and dry heaved for a full minute or two right after. Is this normal? Hours later, I do feel a bit better. Does it take hours to work sometimes? Now I am trying to get my nerve up to do it again. This my first time experiencing BPPV and it’s pretty horrendous! I thought I was having a stroke (I’m not).

Read more: Ask The Doctor: Nausea and Vertigo

As if vertigo isn’t bad enough, it also frequently causes nausea and vomiting. Your brainstem contains many centers (concentrations of neurons) that control certain automatic responses, like vomiting and balancing.   The connection between vertigo and vomiting is due to accidental crosstalk in the brain between these centers.  Setting off the nausea by accidentally stimulating the vomit center in your brain does not cause any permanent change.  Nausea will always slowly disappear once the vertigo ends.  It may continue for minutes to an hour or more after a bout of severe vertigo. 

There is quite a bit of variability in how susceptible a person can be to nausea. Some people don’t get nauseated when they have vertigo, and others can’t tolerate vertigo for even a few seconds before they vomit.  There are some strategies you can use when you want to calm your nausea.

First, stop moving your head to allow the vertigo to settle.  While doing this, breathe slowly and deeply while concentrating on your breathing.  This can override some of the gagging. You can place a wet washcloth over the back of your neck and concentrate on the cool sensation this provides. 

If you vomit or retch, you will need to wait until this subsides because any further maneuvers or brisk head movements will just set it off again.  While waiting, take a dose of over-the-counter meclizine (Non-drowsy Dramamine) or Benadryl. These medications help calm the connections between the vomit center and the balance centers in your brainstem. If you’re afraid of nausea, taking one of these medications before you start vertigo maneuvers can head it off. There are more potent medications that your physician can prescribe if you have vertigo and need to do maneuvers frequently. 

All maneuvers for BPPV cause some vertigo.  The half somersault maneuver is designed to cause less severe vertigo than the Epley maneuver, so it can be helpful if you are prone to nausea.  You may need to repeat maneuvers to be relieved of the vertigo, on average about three times.  Waiting 15 minutes between maneuvers allows your stomach to settle before the next attempt, and also allows the displaced crystals time to move away from the canal you are treating so they won’t fall right back in during a maneuver.