Medical Mystery of the Week

Because of the COVID19 pandemic, you are practicing telemedicine. You are provided a picture of a 25-year-old man whose complaints include hyperacusis in his left ear (see below). 
      What is your diagnosis, what test(s) do you recommend to confirm your suspicions, and what treatment, if any, do you recommend? Does he have a medical sign ? If he does, what is its name?

DIAGNOSIS: Ramsay Hunt syndrome (RHS). RHS is a lower motor neuron facial nerve palsy due to reactivation of a latent herpes zoster infection of the geniculate ganglion. The clues to the diagnosis in the presented case are the vesicles on the conchae and the history of hyperacusis, the latter due to paresis of the stapedius muscle which normally dampens sound-induced vibrations of the stapes. 
      In addition to lower motor neuron facial palsy and hyperaccusis, patients with the RHS may experience loss of taste on the anterior two-thirds of their tongue and diminished salivation and tear production due to involvement of the chorda tympani. Cranial nerve VIII may also be involved producing vertigo and dysequilibrium.
      The presented case demonstrates Bell's sign (upward rotation of the eyeball during attempts to close the lid).  
      RHS (AKA herpes zoster oticus) patients may have vesicles on the eardrum, external auditory canal and conchae, antihelix, fossa of the antihelix, incisura intertragica, and lobule (Hunt's zone). RHS accounts for 12-18% of Bell's palsies.
      Early treatment with acyclovir or famciclovir  plus prednisone is indicated in patients with the RHS. In one series, 75% of patients treated within the first 3 days had a complete remission compared to 48% of those who were treated between 4 and 7 days of onset and 30% of those who were treated after 7 days of onset.