Case Presentation: A 84 year old Caucasian male with history of type 2 diabetes mellitus presented to the emergency room with left facial droop. He reported 1 week of left ear pain which progressed to hearing loss, yellow discharge from the canal, and swelling along his ear, cheek, and neck. On the day of presentation, he noted left sided facial droop and sought medical care. He was admitted and given IV fluids and broad spectrum antibiotics. Imaging of the left face revealed acute left malignant otitis externa with extension into the middle ear cavity and dehiscence of the wall of the facial nerve at the level of the tympanic segment of the facial nerve canal. ENT was consulted and debridement was performed in the OR and found the left conchal bowl with ulcerative vesicles consistent with Ramsay-Hunt syndrome. He was treated with oral valacyclovir and ciprofloxacin and discharged home.
Discussion: There are few case reports in the literature regarding otitis externa and Ramsay-Hunt syndrome. Ramsay-Hunt alone is the second most common cause of atraumatic peripheral facial paralysis. There is a higher incidence in children, but can also be seen more commonly in immunocompromised adult and elderly patients rather than immunocompetent adults. There are case reports in the literature regarding Ramsay-Hunt presenting as simple otitis externa, however, none could be found regarding malignant otitis externa superimposed on Ramsay-Hunt syndrome. Though this patient’s diabetes was well controlled, there still posed the risk and he developed malignant otitis externa. Many of these patients seek initial care with their primary care physicians or local emergency rooms eventually admitted to an internal medicine team. Recognition of the disease process early on and starting antivirals is essential to recovery in facial nerve function.
Conclusions: While malignant otitis externa and Ramsay-Hunt syndrome were once thought to be solely in the realm of our colleagues in the subspecialties, more and more “subspecialty” cases find their way to hospitalists and primary care physicians. Thus, seeing more of these cases in the realm of hospital medicine will allow for familiarity and early recognition.
