Ramsay Hunt

Patient TN, a 49 year old teacher presented with facial tightness and residual paralysis resulting from Ramsay Hunt two years prior. 

Prior to the facial palsy, patient TN had been feeling very run down, developed a dull ache deep in the left ear, and had been experiencing a twitching eye.  The pain in the ear steadily increased to a searing face pain.  A doctors appointment was made.  As patient TN brushed her teeth before attending her GP, she couldn’t hold the water in the left side of her mouth.  When she looked closely in the mirror the left side of the lips were drooped.  TN was advised to attend hospital instead to rule out serious pathology.  She was prescribed steroids and strong pain medication.  It was a further two days before small blisters were sighted in the left ear canal.  Over the next three days the facial palsy continued to develop until patient TN had a completely flaccid left face.  TN was given an information sheet on shingles and then informed that there was nothing she could do but wait for the face to recover.

Patient TN believes it was approximately two months before any return of tone was noted in the face, which grades the facial nerve injury as moderate to severe.  TN was debilitated by the facial pain and general fatigue in the first 2 months after the Ramsay Hunt, and emotionally traumatised by her facial asymmetry.  She had three months off work, and avoided going out.  Her Social isolation was made more comfortable for her by the beginning of the pandemic.  Returning to teaching online was very confronting, with her video image appearing to her as very stark in its disfigurement.  TN described the emotional impact and frustration in talking from the right side of the mouth, and the fatigue in trying to minimise speech slurring.  Wearing a face mask due to the pandemic was one of the few ways patient TN could face being in public.

On her initial presentation to this clinic, the most severe issue with TN’s facial movement was severe shortening of the left sided facial muscles, and moderate levels of synkinesis – abhorrent nerve regrowth that causes mass movement patterns that disfigures facial movement quality and symmetry.  The tightness in the left face was so extreme that the left upper lip was elevated in a partial snarl – revealing slightly the left eye tooth.  Patient TN chewed her food exclusively on the right – owing to the constant biting of her left lip and cheek in the early stages of her palsy.  The left upper lip and chin twitched with eye blink.  Smiling and pout expressions caused the left eye to squint to the point of almost closing.  Occasionally, there would be small facial spasms in the cheek when fatigued or particularly stressed.  Eye closure was still only 80% complete on voluntary purposefully closure, and less than 50% on spontaneous blink.

Patient TN was evaluated as having a 49% facial recovery using a standardised scale of facial grading.  TN was assessed as being in the Movement Flexibility stage of recovery, having unfortunately bypassed the earlier Movement Initiation and Movement Facilitation stages.  Patient TN was given an intense facial stretching program, and received deep tissue mobilisations and dry needling to the face to accelerate the break down of the tightness.  Dry needling of the neck and shoulder was also useful in eliminating the hemi-facial spasms.  It took four months before TN could commence activities in the Motor Control phase of rehabilitation.  The asymmetric resting snarl was reduced to a near level resting position with the right lip corner.  This required taping the lip into a downward position overnight for three months.  TN was able to get additional smile excursion while gaining reasonable control over the squinting, but a single round of botox was needed to assist this.  TN continues to work on the pout expression, which had the heaviest pull into the left eye, but symmetry of most speech sounds improved well enough to reduced TN’s self consciousness over talking.