✅ Model Answer:
• Diagnosis: Ramsay Hunt syndrome (herpes zoster oticus) — VZV reactivation in the geniculate ganglion causing sudden severe SNHL, ear pain, vesicles on pinna and ear canal, facial nerve palsy (lower motor neuron), and MRI enhancement of facial/vestibulocochlear nerves. Positive VZV PCR confirms diagnosis.
• Any other test: VZV IgM/IgG serology , audiometry (already done), facial nerve EMG/ENoG (to assess nerve degeneration), vestibular testing (if dizziness), comprehensive neurologic exam.
• What to do next: Start IV acyclovir (10-15 mg/kg TID) + oral prednisone (1 mg/kg/day, taper over 2 weeks). Urgent ENT/neurology consultation. Pain management (analgesics). Eye care (artificial tears, eye patch if corneal exposure).
• Follow-up plan: Serial audiometry (hearing may partially recover). Facial nerve recovery assessment (EMG if poor). Consider vestibular rehabilitation if vertigo. Monitor for postherpetic neuralgia. Ophthalmology consult if eye involvement.

✅ Model Answer:
• Ramsay Hunt syndrome (herpes zoster oticus) is a reactivation of the varicella-zoster virus (VZV) in the geniculate ganglion (cranial nerve VII ganglion).
• Also known as: Herpes zoster oticus.
• Predisposing factors: Immunosuppression, stress, older age (but can occur in children).
• Classic triad:
- Vesicles: On the pinna, external auditory canal, and/or tympanic membrane
- Facial paralysis: Lower motor neuron (peripheral) facial palsy (ipsilateral)
- Hearing loss: Sensorineural hearing loss (SNHL) on the same side
• Other cranial nerves: Can also affect CN VIII (vestibular), CN IX, CN X.

✅ Model Answer:
• Bell's palsy:
- Cause: Idiopathic (often viral, HSV-1 reactivation in the facial nerve)
- Vesicles: Absent (no vesicles)
- Hearing loss: Usually absent (no SNHL)
- Ear pain: May have post-auricular pain, but no vesicles
- Treatment: Corticosteroids (prednisone) alone
- Prognosis: Good (85% recover fully)
• Ramsay Hunt syndrome:
- Cause: VZV reactivation in the geniculate ganglion
- Vesicles: Present (pinna, canal, TM)
- Hearing loss: SNHL (common, may be severe)
- Ear pain: Severe, often with vesicles
- Treatment: Antivirals + corticosteroids
- Prognosis: Worse than Bell's (hearing may not recover fully)

✅ Model Answer:
• Pathophysiology: VZV reactivation in the geniculate ganglion → inflammation and viral spread to the adjacent vestibulocochlear nerve (CN VIII) and facial nerve (CN VII).
• Mechanism of SNHL:
- Viral invasion of the cochlea (inner ear) or the vestibulocochlear nerve
- Inflammatory response → edema, ischemia, and damage to hair cells or the auditory nerve
- MRI findings: Enhancement of the facial and vestibulocochlear nerves (indicating inflammation)
• Why sudden? Viral reactivation is acute and causes rapid damage to the inner ear structures.
• Prognosis: Hearing may partially recover with early treatment, but often permanent if severe.

✅ Model Answer:
• Antiviral therapy:
- Acyclovir: IV 10-15 mg/kg TID (or 800 mg PO 5 times daily) for 7-10 days
- Valacyclovir: 1 g PO TID (alternative)
- Start early: Within 72 hours of symptom onset for best outcomes
• Corticosteroids:
- Prednisone: 1 mg/kg/day (max 60-80 mg) for 5-7 days, then taper over 2 weeks
- Evidence: Combination of antiviral + corticosteroid improves facial nerve and hearing outcomes
• Supportive care:
- Pain management: Analgesics (NSAIDs, opioids if severe)
- Eye care: Artificial tears, eye lubrication, eye patch (if corneal exposure due to incomplete eye closure)
- Vestibular rehabilitation: If dizziness or balance issues
- ENT/Neurology consultation: Urgent for severe cases
- Facial nerve monitoring: EMG/ENoG to assess severity

✅ Model Answer:
• Hearing loss: Can be permanent (severe or profound) — especially if treatment is delayed
• Facial paralysis: May be incomplete recovery (synkinesis, contracture, facial weakness)
• Postherpetic neuralgia: Persistent pain in the affected area after vesicles heal (more common in older adults)
• Corneal exposure/keratitis: Due to incomplete eye closure (facial palsy) → can lead to corneal ulceration
• Vestibular dysfunction: Dizziness, vertigo, imbalance (due to CN VIII involvement)
• Tinnitus: Ringing in the affected ear
• Other cranial nerve involvement: CN IX (glossopharyngeal), CN X (vagus) — palatal weakness, voice changes
• Secondary infection: Bacterial superinfection of vesicles
• Psychological: Anxiety, depression, social isolation (facial disfigurement, hearing loss)

✅ Model Answer:
• MRI with contrast (gadolinium) of the IAC (internal auditory canal):
- Findings: Enhancement of the facial nerve (CN VII) and/or vestibulocochlear nerve (CN VIII) in the internal auditory canal or labyrinthine segment
- Why? Indicates inflammation due to VZV reactivation
- Rule out: Other causes of sudden SNHL + facial palsy (e.g., vestibular schwannoma, other neoplasms)
• Timing: Usually performed if atypical presentation, no vesicles, or no improvement with treatment
• Prognostic value: Enhancement extent may correlate with severity of nerve damage and clinical outcomes
• Limitations: Normal MRI does NOT rule out Ramsay Hunt

✅ Model Answer:
• Prognosis:
- Facial nerve recovery: 70% recover well if treated early with antivirals + steroids; 30% have residual weakness/synkinesis
- Hearing recovery: 50-60% improve, but many have permanent SNHL (especially if severe initially)
- Tinnitus: May persist
- Vestibular: Variable; may improve with vestibular rehabilitation
- Children: Generally better prognosis than adults (better healing capacity)
• Long-term management:
- Hearing aids: If permanent SNHL
- Facial reanimation surgery: If significant residual facial weakness (rare in children)
- Vestibular rehabilitation: If balance issues persist
- Pain management: If postherpetic neuralgia
- Ophthalmology: Annual eye exams (corneal protection)
- Psychological support: Coping with facial paralysis, hearing loss
- Follow-up: ENT, audiology, neurology