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This is a case of an 85-year-old woman whom was admitted with otalgia and an abducens nerve palsy alongside a Pseudomonas otitis externa; she was presumed to have malignant otitis externa. However, despite optimum treatment and resolution of her otitis externa, she went on to develop an ipsilateral facial nerve palsy and sensorineural hearing loss. After further investigation, it was discovered that varicella-zoster meningitis was causing her polyneuropathy. She eventually responded to antivirals and steroids and, at follow-up, her sixth and seventh cranial nerve palsies had completely resolved, though a hearing deficit remained. This case highlights the importance of keeping a diagnosis under review, with the help of the multidisciplinary team, when the clinical course is not progressing as expected., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

A 67-year-old woman presented with a 1-week history of left otalgia and a 1-day history of odynophagia, pain extending into the face and neck, and a productive cough. Flexible nasendoscopy showed features of supraglottitis, with swollen arytenoids and pooling of saliva in the piriform fossae. Laboratory investigations revealed a mildly raised C reactive protein. A CT scan of the neck supported the diagnosis of supraglottitis and pharyngitis, with thickening of the mucosa of the left piriform fossae and left oropharynx. Standard supraglottitis treatment was instigated, but on day 4 of the admission, a vesicular rash and features of cranial nerve involvement (V, VII, VIII, X) developed. A revised diagnosis of Ramsay Hunt syndrome with cranial polyneuropathy was made and later confirmed by varicella zoster virus PCR. After 4 weeks, facial nerve function normalised, but features of other cranial nerve palsies were persistent., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Ramsay Hunt syndrome (herpes zoster oticus) is a rare complication of latent Varicella Zoster virus infection. It can be complicated by permanent hearing loss, loss of taste and postherpetic neuralgia. Although Ramsay Hunt syndrome most prominently involves the facial nerve, a number of other cranial nerves can be involved such as the vestibulocochlear, glossopharyngeal and the vagus nerve. We report on a case of Ramsay Hunt syndrome with cranial polyneuritis complicated by atrial fibrillation. Vagal involvement as evidenced by physical examination and MRI findings was present in our patient. We hypothesise that viral vagal neuritis likely contributed to the development of atrial fibrillation in our patient through involvement of the autonomic components of the vagus nerve., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

An elderly man presented with severe right ear pain and discharge, hoarseness and dysphagia causing significant involuntary weight loss. Extensive investigations by varied specialties only highlighted right vocal cord palsy and right parotid lymphadenitis. Reassessment on transfer to a rehabilitation ward noted clinically subtle right Ramsay Hunt syndrome with multiple lower cranial nerve involvement. We illustrate a case of varicella zoster virus cranial polyneuritis with bulbar symptoms mimicking bulbar stroke, requiring percutaneous endoscopic gastrostomy feeds, with significant clinical and radiological recovery over 1 year., (2016 BMJ Publishing Group Ltd.)

Ramsay Hunt syndrome is defined by herpes zoster oticus and peripheral facial nerve palsy which is often associated with otalgia. The syndrome is, in rare cases, associated with other cranial nerve paralyses including the vagal nerve causing unilateral vocal cord paralysis. Vocal cord paralysis is more often seen as a symptom of various other diseases, that is, malignant tumours, neurodegenerative illness, cerebrovascular assaults, inflammatory processes or as a result of intubation or surgical procedures. The symptoms of unilateral vocal cord paralysis are mainly hoarseness, dyspnoea and dysphagia. We present a case of Ramsay Hunt syndrome combined with unilateral hearing loss and left vocal cord paralysis. The patient underwent MRI, CT and a lumbar puncture causing anxiety in the patient and delaying the initiation of antiviral and anti-inflammatory treatment, which is only efficient when initiated within 72 h. We hope to raise the awareness of this disease.