Facial palsy is a common cranial nerve disorder that necessitates prompt and accurate assessment to distinguish between central and peripheral etiologies, as this distinction significantly impacts treatment and prognosis. Evaluating the forehead musculature is crucial in this process. The frontalis, corrugator, and orbicularis muscles are innervated centrally; thus, weakness in these muscles typically indicates a peripheral facial nerve issue, while sparing of these muscles suggests a central lesion. Clinicians can identify the problem’s source by assessing the patient’s ability to tightly close their eyes or wrinkle their forehead. Normal movement on the unaffected side further highlights the involvement of the forehead musculature.

Idiopathic causes account for more than half of peripheral facial palsy cases, with other etiologies including viral infections, diabetes, Lyme disease, and sarcoidosis. Among viral causes, Herpes simplex virus is the most common pathogen, followed by Herpes zoster. James Ramsay Hunt, an American neurologist, first described three distinct syndromes, with HZO, also known as type 2 HZO, being the best known. being the most well-known. RHS is relatively uncommon, with less than 1% of zoster cases involving the facial nerve and resulting in RHS. RHS is typically characterized by facial paralysis and a rash affecting the ear, predominantly in Hunt’s Zone, which includes the tympanic membrane, middle ear, and cavum conchae. Additional symptoms frequently reported include ipsilateral altered taste perception and tongue lesions, hearing abnormalities (such as decreased hearing, tinnitus, and hyperacusis), vestibular disturbances (such as vertigo), and lacrimation, though these symptoms do not necessarily coincide [3].

Several grading systems are used to evaluate the severity of facial palsy, including the House-Brackmann, Sydney, Sunnybrook [4]. The House-Brackmann system is often preferred due to its quick and standardized evaluation, whereas others offer more detailed and complex assessments. However, no universally accepted standard grading system exists. The diagnosis of RHS is primarily based on clinical presentation, but in uncertain cases, laboratory tests such as polymerase chain reaction (PCR) testing, direct fluorescent antibody (DFA) testing, and viral culture PCR can confirm the diagnosis using cerebrospinal fluid, blood, and other non-cutaneous specimens.

Treatment for RHS includes symptom control, antiviral agents, and glucocorticoids [5]. Elderly and immunocompromised patients are at increased risk for varicella-zoster virus reactivation and its complications. RHS has a high rate of complete recovery, with up to 70.4% of patients regaining facial nerve function, particularly with early medical treatment. Therefore, early identification and treatment of RHS are essential.