Ramsay Hunt Syndrome vs. Bell’s Palsy: What’s the Difference?

Ramsay Hunt syndrome and Bell’s palsy both cause facial paralysis, but the conditions are different. Ramsay Hunt syndrome occurs due to infection with herpes zoster. The cause of Bell’s palsy is unknown. Ramsay Hunt syndrome, also known as Ramsay Hunt disease, and Bell’s palsy are both types of facial nerve paresis. Paresis refers to mild to moderate muscle paralysis.

As much as 60–75% of cases of facial nerve paresis may be due to Bell’s palsy.

This article discusses Ramsay Hunt syndrome versus Bell’s palsy, including their differences in symptoms, causes, and treatment. It also explains differences in the outlook of the conditions and their diagnosis.

Key differences between Bell’s palsy and Ramsay Hunt syndrome include differences in their:

• symptoms
• causes
• treatment and outlook

Below is an overview of Bell’s palsy vs. Ramsay Hunt syndrome and their main differences.

Ramsay Hunt syndrome and Bell’s palsy can share some of the same symptoms. Shared symptoms can include:

• facial numbness
• difficulty moving the face, such as the eyelid or lip
• unwanted muscle contractions
• drooping of the face
• facial pain
• dry eye
• other eye irritation, such as watery eyes
• dry mouth
• drooling
• increased sensitivity to sounds
• taste changes

In both conditions, symptoms of paralysis can be ipsilateral, meaning they affect one side of the face.

However, the two conditions can also have distinct symptoms.

Ramsay Hunt syndrome can cause a painful red or discolored rash on the face. It may also cause fluid-filled blisters on the face or in the mouth.

This rash may appear before or after facial paralysis. However, for some people, the rash may not develop at all.

Other symptoms of Ramsay Hunt syndrome can include:

• aching or painful sensations in the ear
• hearing changes or loss
• flu-like symptoms, such as a fever and headache
• vertigo
• nausea or vomiting
• nasal blockage
• swallowing difficulties and hoarseness

Also, Ramsay Hunt syndrome may be more severe than Bell’s palsy.

Bell’s palsy can also cause facial nerve paralysis on one side of the face which may be mild to severe. It may cause partial to total weakness or paralysis.

These symptoms can often develop suddenly and reach peak severity within 72 hours.

Unlike Ramsay Hunt syndrome, Bell’s palsy does not cause a rash to form.

The causes of Bell’s palsy differ from Ramsay Hunt syndrome causes.

Ramsay Hunt syndrome develops from infection with VZV, the same virus that causes chickenpox and shingles. When a person initially gets a VZV infection, they can develop chickenpox. Eventually, the infection and illness can clear, but the virus can stay dormant in the body.

If the VZV reactivates, people may develop shingles or Ramsay Hunt syndrome. Reactivation may happen if you have a weakened immune system.

Learn more about Ramsay Hunt syndrome causes and VZV reactivation.

By contrast, research on Bell’s palsy has yet to confirm a clear cause. However, some clinicians suggest that swelling and inflammation of certain nerves in the brain may be involved.

According to a 2022 research overview, evidence also suggests that some health conditions may link to partial facial paralysis and Bell’s palsy. These conditions include:

• diabetes
• pregnancy
• preeclampsia
• high body mass index (BMI)
• high blood pressure
• infection with:
  • herpes simplex virus
  • VZV
  • Epstein-Barr virus

The 2022 research overview notes that some clinicians may misdiagnose a person with Bell’s palsy when it is actually Ramsay Hunt syndrome or another known cause. This may happen particularly if you develop Ramsay Hunt syndrome without a rash or blisters.

To distinguish Bell’s palsy from Ramsay Hunt syndrome, a doctor will examine your medical history.

Clinicians can also use a laboratory test for VZV infection. This cannot always accurately confirm Ramsay Hunt syndrome itself, but it can test to see whether a VZV infection has occurred, which may possibly cause it. Due to this, your doctor may rely on information from clinical visits rather than laboratory testing for diagnosis.

Additional tests can include electromyography and electroneurography, which check the muscles and nerves. MRI or CT scans may also help rule out other causes.

While VZV infection can resolve independently, early treatment for Ramsay Hunt syndrome can be helpful to reduce the risk of complications and recover facial function.

By contrast, around 71% of people with Bell’s palsy can recover completely without treatment. However, treatment can be given in severe cases or if facial function hasn’t fully returned.

Treatments for Ramsay Hunt syndrome and Bell’s palsy can be similar, and may include:

• antivirals
• corticosteroids
• pain relief medication, such as acetaminophen or ibuprofen
• treatment for dry eyes, such as ointments or eye patches
• physical therapy
• acupuncture
• facial massage
• in severe cases, reconstructive surgery

The complications and outlook of Ramsay Hunt syndrome and Bell’s palsy can differ slightly.

People can experience varying grades of dysfunction after Ramsay Hunt syndrome. However, most people recover within 1 year. The main factor affecting the outlook of Ramsay Hunt syndrome is the degree of facial paralysis you experienced. 

Bell’s palsy may have a more favorable outlook than Ramsay Hunt syndrome, as most people completely recover without treatment.

However, complications can develop with both conditions. Also, outlook can depend on individual factors, such as age or the severity of the condition. Contact your doctor for individualized advice.

Read more about the complications and outlook of Ramsay Hunt syndrome and Bell’s palsy.

Ramsay Hunt syndrome and Bell’s palsy both cause partial facial paralysis and weakness. However, they are distinct conditions and have many differences.

Key differences include their causes. Ramsay Hunt syndrome is caused by VZV infection, while the cause of Bell’s palsy is unknown. Ramsay Hunt syndrome may also cause a facial rash, whereas Bell’s palsy doesn’t.

Other areas of difference include their treatment and outlook. However, both can be resolved with monitoring and effective treatment.

Contact your doctor for diagnosis and personalized advice regarding outlook.