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Ramsay Hunt syndrome vs. stroke

How to differentiate between a stroke and the viral infection Justin Bieber is suffering from


Singer Justin Bieber recently revealed he was diagnosed with Ramsay Hunt syndrome.

Collage/Getty Images/Robb Cohen for Invision via AP

Singer Justin Bieber recently cancelled some of his upcoming shows, revealing that he has been diagnosed with Ramsay Hunt syndrome.

In the video posted online, Bieber’s noticeably can’t move the right side of his face. He shows followers that he is only able to blink one eye and move one nostril, and when he attempts to smile, only the left side of his face moves.

Ramsay Hunt syndrome occurs when a shingles outbreak affects the facial nerve near one of your ears. In addition to the painful shingles rash, Ramsay Hunt syndrome can cause facial paralysis and hearing loss in the affected ear.

“Ramsay Hunt syndrome is a rare neurological condition caused by varicella-zoster infection affecting the facial nerve,” Dr. Murtaza Amir, MD, FAAN; a board-certified neurologist explained.

As Ramsay Hunt syndrome (herpes zoster oticus) mimics the signs and symptoms of a stroke, how can pre-hospital clinicians differentiate between the two?


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Ramsay Hunt syndrome: Signs and symptoms

According to the Mayo Clinic, two of the defining signs and symptoms of Ramsey Hunt syndrome including a painful, red rash with fluid-filled blisters on, in and around one ear, and facial weakness or paralysis on the same side as the affected ear. Usually, the rash and facial paralysis occur at the same time, however it has been reported that one can happen before the other.

Dr. Amir said the most effective way for pre-hospital clinicians to differentiate between a stroke and Ramsay Hunt syndrome is by taking a good clinical history, including symptom onset and last known well time.

“Facial droop can be seen both in strokes and Ramsay Hunt syndrome,” Amir said. “Presence of rash, ear pain typically suggests a viral infection.”

Dr. Amir added that common symptoms of a stroke, including motor and sensory deficits, would not be present in patients with Ramsay Hunt, e.g.,

  • Sudden numbness or weakness in the face, arm or leg, especially on one side of the body
  • Sudden confusion, trouble speaking or difficulty understanding speech
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance or lack of coordination
  • Sudden severe headache with no known cause

Dr. Amir noted other symptoms of Ramsey Hunt syndrome include:

  • Ear pain
  • Hearing loss
  • Ringing in the ears
  • Difficulty closing one eye
  • A sensation of spinning or moving
  • A change in taste precepting or loss of taste
  • Dry mouth and eyes
  • Nausea or vomiting

Ramsay Hunt syndrome: Treatment

Treatment that starts within three days of the start of signs and symptoms may help prevent long-term complications from Ramsay Hunt syndrome. The syndrome can occur in anyone that has had chickenpox, but is more common in older adults, typically affecting people older than 60.

“Treatment involves antiviral medicals along with steroids,” Dr. Amir said. “Usual recovery time is 4 to 6 weeks with almost 70% of the patients having complete resolution of symptoms.”

Ramsey Hunt syndrome isn’t contagious; however, reactivation of the varicella-zoster virus can cause chickenpox in people who haven’t previously had chickenpox or been vaccinated. The infection can be serious for people who have immune problems.

Lasting complications may include permanent hearing loss and facial weakness; eye damage from the inability to close the eyelid; and postherpetic neuralgia (i.e., messages sent by nerve fingers become confused and exaggerated causing pain that may last long after other signs and symptoms).


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Todd Bowman is a nationally registered and flight paramedic with more than 18 years of prehospital experience in Maryland. He attended Hagerstown Community College for his paramedic education and later obtained his bachelor’s degree in journalism from Shepherd University in Shepherdstown, West Virginia. His experience ranges from rural, metro and aviation-based EMS. He is an experienced EMS manager, public information officer and instructor. Follow him on social media at @_toddbowman.