6th Edition of Neurology World Conference 2026

Abstract

Introduction: 

Mastoiditis occurs when there is inflammation within the mastoid air cells of the middle ear. Symptoms of fever, erythema and posterior ear pain may indicate clinically significant suppurative mastoiditis. In adults, it may present severely with several complications. We present a case of a patient with a sudden loss of hearing in his right ear associated with pain, vertigo, and nausea. He subsequently developed facial paralysis with an eventual diagnosis of Ramsay-Hunt Syndrome (RHS).

Case Presentation: 

We present a 63-year-old male with a history of recurrent acute sinusitis and substance abuse who presented complaining of six days of right ear pain with drainage and difficulty hearing. He was first seen at another facility and prescribed amoxicillin 875 mg b.i.d. However, he continued to report progressively worsening throbbing right ear pain and purulent drainage, edema, and erythema of the right ear and face. On physical examination, significant erythema and edema of the right ear were noted, as well as thick, purulent drainage. The urine drug screen was positive for amphetamines, opiates, and cannabis. A CT of the internal auditory canal (CT IAC) with contrast showed right mastoiditis within the right external auditory canal and middle ear. Throughout his stay, the patient began reporting facial weakness and spiked a fever of 102.03 F. On physical exam, a right-sided facial droop and vesicular eruptions spreading to the right frontal scalp and auricle were observed. Cultures detected coagulase-negative staphylococcus species. Clinical suspicion of mastoiditis was now low due to a lack of bony erosions and subperiosteal abscesses. An MRI IAC with contrast revealed abnormal enhancement within the right IAC without focal nodules or masses along the seventh and eighth cranial nerve complexes. At this time, the patient’s facial weakness, pain, vesicular rash, and MRI findings garnered a high suspicion of RHS. The patient’s paralysis was categorized as House Brackmann grade 5 paralysis of the right face. Our patient was discharged on valacyclovir 500 mg bid, levofloxacin 750 mg bid, and Ciprodex eye drops and scheduled for outpatient follow-up.

Discussion:

As described in our patient, complicated mastoiditis was at the top of the initial differential due to his clinical presentation of ear drainage, postauricular erythema, and pain. His additional complaints of hearing loss, facial paralysis and vertigo were suspected to be complications of an escalating infection. The diagnosis of mastoiditis was further supported by CT IAC imaging. However, our patient did not improve with antibiotics. The appearance of herpetic-like vesicles raised a clinical suspicion of RHS. Although the primary nerve affected in RHS is the geniculate ganglion of the facial nerve (CN7), the most appropriate presentation of our patient was herpes zoster cephalicus, with additional involvement of CN V and CN VIII. An ability to quickly rule out alternative causes and appropriately treat RHS improves the prognostic outcome of facial palsy. Unfortunately, as seen in our patient, although it only took three days to reach the diagnosis and begin appropriate treatment, his condition continued to deteriorate, and he may now have permanent hearing loss. The mainstay treatment for RHS includes a combination of antiviral and corticosteroids, as well as supportive measures. The recovery prognosis is heavily dependent on the time to treatment. This report emphasizes the importance of thorough neurological exams amongst high-risk patients and the necessity for practitioners to maintain a high suspicion for more severe conditions such as RHS.