RHS

RHS means Ramsay Hunt syndrome. It happens when the virus that causes chickenpox and shingles becomes active in a nerve controlling one side of the face. The medical term for this is herpes zoster oticus with facial palsy.

After chickenpox, the varicella-zoster virus stays inactive inside nerve tissue. Years later, it can reactivate as shingles. In RHS, it affects the facial nerve close to one ear. This nerve controls facial expression and also contributes to taste, tear production, and protection of the eye.

RHS usually causes weakness or paralysis on one side of the face, often with severe ear pain and fluid-filled blisters in or around the ear. It can also affect nearby nerves involved in hearing and balance.

Prompt assessment matters because treatment works best when started early. Facial weakness can also be caused by a stroke or other conditions, so it should not be diagnosed from symptoms alone.

Symptoms usually affect one side of the face and the ear on that side. They may appear together or develop over several days.

Common symptoms include:

• Weakness or paralysis on one side of the face
• Ear pain, which may begin before the rash
• Painful blisters in the ear canal, on the outer ear, or nearby skin
• Difficulty closing one eye
• A drooping mouth or difficulty smiling
• Food or drink leaking from one side of the mouth
• Changes in taste or a dry mouth
• Hearing loss, ringing in the ear, or increased sensitivity to sound
• Dizziness, spinning sensations, or poor balance

Blisters can also appear inside the mouth, including on the tongue or roof of the mouth. The rash may be easy to miss when it is deep inside the ear canal.

Some people develop facial weakness without a visible rash. This is sometimes called zoster sine herpete, meaning shingles without blisters. It can be difficult to distinguish from Bell’s palsy, another cause of sudden facial weakness.

If the eyelid cannot close fully, the surface of the eye may dry out. This can cause irritation, blurred vision, or injury to the clear front surface of the eye, called the cornea.

RHS is caused by reactivation of the varicella-zoster virus. It is not caused by a new shingles infection caught from somebody else.

Anyone who has previously had chickenpox can later develop shingles. The virus may reactivate when immune control of it becomes weaker. This becomes more likely with increasing age, but RHS can occur in younger adults and, less commonly, in children.

Factors associated with shingles include:

• A weakened immune system
• Medicines that suppress immune activity
• Some cancers or cancer treatments
• Increasing age
• Serious illness or major physical stress

Many people who develop RHS have no clear trigger. Emotional stress alone does not prove that stress caused it.

RHS itself is not passed from person to person. However, fluid from active shingles blisters contains the virus. Someone who has never had chickenpox or its vaccine could develop chickenpox after direct contact with that fluid.

RHS is usually diagnosed from the combination of one-sided facial weakness, ear pain, and characteristic blisters. A clinician will examine the face, eye, outer ear, ear canal, mouth, hearing, and balance.

You may be asked to raise your eyebrows, close your eyes tightly, smile, and show your teeth. These movements help assess which parts of the facial nerve are affected.

If the diagnosis is uncertain, fluid from a blister may be tested with polymerase chain reaction, or PCR. This test looks for genetic material from the varicella-zoster virus. A negative result does not always exclude RHS, especially when there are no blisters to sample.

Hearing tests may be arranged if hearing has changed. Balance testing can help when dizziness continues. An eye examination may be needed if the eyelid does not close or the eye is painful.

Imaging such as an MRI scan is not routinely needed for a typical case. It may be used when symptoms are unusual, worsen unexpectedly, or suggest another problem affecting the brain or nerves.

Treatment is usually started as soon as RHS is suspected rather than waiting for every test result. Early treatment, particularly within the first few days, may improve the chance of facial nerve recovery.

Treatment commonly combines an antiviral medicine with a corticosteroid like prednisone or hydrocortisone. Antivirals like acyclovir or oseltamivir reduce replication of the varicella-zoster virus. Corticosteroids reduce inflammation and swelling around the facial nerve. The exact medicines and whether they are suitable depend on factors such as kidney function, other health conditions, pregnancy, and current medicines.

Evidence from randomized trials is limited because RHS is uncommon and difficult to study. However, antiviral and corticosteroid treatment is widely used based on the available evidence and specialist experience.

Protecting the eye is essential when the eyelid cannot close. Management may include lubricating eye drops during the day, ointment at night, or carefully closing the eyelid for sleep. An eye professional may recommend additional protection. Persistent eye pain, redness, light sensitivity, or blurred vision needs urgent assessment.

Pain may be treated with standard pain relievers. Burning or electric-shock-like nerve pain may require medicine designed for nerve pain. Severe nausea or spinning sensations can also be treated.

If symptoms continue, care may involve:

• Hearing assessment and hearing support
• Vestibular rehabilitation for ongoing balance problems
• Specialist facial therapy for weakness or unwanted movements
• Pain-clinic support for persistent nerve pain
• Eye care if eyelid closure remains incomplete

Forceful facial exercises or electrical stimulation should not be started without advice from a clinician experienced in facial nerve problems.

Some people recover without lasting problems. Others have ongoing effects because the facial or hearing nerves have been injured.

Possible complications include persistent facial weakness, hearing loss, ringing in the ear, dizziness, or balance difficulty. Nerve pain can continue after the rash has healed; this is called postherpetic neuralgia.

During nerve recovery, facial movements may reconnect in an altered way. This is called synkinesis. For example, the eye may partly close when you smile, or the mouth may move when you blink.

Incomplete eyelid closure can lead to corneal drying, scratches, infection, or scarring. Eye protection lowers this risk.

Rarely, the infection or inflammation affects additional nerves or the tissues around the brain. New confusion, severe headache, fainting, seizures, or widespread weakness require emergency assessment.

RHS cannot always be prevented because the virus may remain inactive in the nerves for many years without causing symptoms.

Shingles vaccination lowers the risk of shingles and its complications, although it cannot remove the risk completely. Eligibility is based on age, immune health, and the vaccination program where you live. Having had shingles or RHS does not necessarily provide lifelong protection against another episode.

Chickenpox vaccination helps prevent the original varicella infection. It is mainly given according to childhood or catch-up vaccination schedules.

While blisters are present, keeping them clean, dry, and covered helps reduce spread. Avoid direct blister contact with people who have never had chickenpox or its vaccine, especially pregnant people, newborn babies, and people with weakened immune systems. The risk of transmission falls once all blisters have dried and crusted.

The rash generally heals before the facial nerve fully recovers. Blisters often crust over within days, while weakness may take weeks or months to improve.

Recovery is different for each person. Some regain normal or nearly normal facial movement. Others are left with weakness, tightness, involuntary movements, hearing changes, or balance symptoms. Improvement can continue gradually for many months, but complete recovery cannot be promised.

Severe or complete facial paralysis, major hearing or balance involvement, and a delay before treatment may be linked with a less complete recovery. Follow-up allows facial movement, hearing, balance, and eye safety to be checked over time.

Eating may be awkward at first. Smaller bites, drinking slowly, and chewing on the stronger side may help. Take care with hot drinks if facial sensation or control is reduced.

Changes in facial movement can affect speech, eating, social confidence, and emotional wellbeing. These effects are real even when they are not obvious to others. Facial therapy, hearing support, counselling, or peer support may be useful when symptoms continue.

Arrange urgent, same-day medical assessment for new one-sided facial weakness, especially with ear pain or blisters. Treatment may be most useful when started early, and other causes must be considered.

Seek urgent eye care if you cannot close the eye fully or develop eye pain, increasing redness, light sensitivity, or blurred vision.

Call emergency services for facial drooping accompanied by signs that could indicate a stroke, including:

• Arm or leg weakness or numbness
• Slurred, confused, or lost speech
• Sudden severe headache
• New loss of coordination, collapse, or confusion

Emergency assessment is also appropriate for seizures, marked drowsiness, widespread weakness, or a rapidly spreading blistering rash in someone with a severely weakened immune system.

Routine follow-up is important if facial movement is not improving, pain continues after the rash heals, or hearing and balance problems interfere with daily life. These symptoms are not usually emergencies, but they may need specialist support.

Is RHS the same as Bell’s palsy?

No. Both can cause sudden weakness on one side of the face. RHS is caused by reactivation of the chickenpox virus and commonly includes ear pain, blisters, hearing changes, or dizziness. Bell’s palsy has no visible shingles rash and has a different typical outlook. RHS without a rash can be difficult to distinguish from Bell’s palsy.

Will my face return to normal?

Many people improve, but recovery cannot be predicted with certainty. Some have lasting weakness, facial tightness, or linked movements such as the eye closing while smiling. Recovery may continue for months, and specialist facial therapy can help manage persistent problems.

Can I catch RHS from someone with shingles?

You cannot catch RHS itself. Direct contact with fluid from shingles blisters can pass the varicella-zoster virus to someone who is not immune. That person would develop chickenpox, not RHS.

Can RHS happen without an ear rash?

Yes. Facial weakness and pain may appear before the blisters, and some people never develop a visible rash. Because several conditions can cause facial weakness, an examination is needed.

Can RHS come back?

It can recur, although a repeat episode is not the usual course. Shingles vaccination may reduce the risk of future shingles, depending on your eligibility and local vaccination guidance.

How long does RHS last?

The rash and acute pain often settle before the nerve symptoms. Facial weakness, altered hearing, or dizziness may improve over weeks to months. Some effects can continue longer or become permanent.