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A 24-year-old man with HIV presents to the ED with intensifying left ear pain, swelling, and dizziness. His hearing in his left ear is muffled compared to that in his right ear. There is no history of trauma or allergic reactions, and the patient does not take any medications. The physical examination is notable for an obviously erythematous and edematous left ear, as well as a subtle left facial droop and weakness. What is the diagnosis?
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A 24-year-old man who was recently diagnosed with human immunodeficiency virus (HIV) presents to the emergency department (ED) with a chief complaint of left ear pain that has lasted for the past 24 hours. Yesterday, the patient visited his primary care provider (PCP) and was informed that his ear appeared normal, without any evidence of infection. Today, however, he reports that the pain is significantly more intense and that his ear is now red and swollen. He also states that he has vomited twice today and he feels "dizzy." He describes the dizziness as a feeling that the room is spinning, and it is made worse with any movement of his head. Additionally, he states that his hearing in his left ear is muffled compared to that in his right ear. He denies experiencing any fever, chills, headache, or generalized weakness. He also denies scratching his ear or placing foreign bodies (such as cotton swabs) into his ear. There is no history of trauma. The patient has no chronic medical conditions, and he has no allergies, and does not take any medications.

On physical examination, the patient is noted to be alert and calm. His initial vital signs include a temperature of 97.9°F (36.6°C), a blood pressure of 132/87 mm Hg, a heart rate of 124 bpm, and a respiratory rate of 18 breaths/min. The head and neck examination is remarkable for an obviously erythematous and edematous left ear. The erythema and swelling involve the entire left auricle, with multiple overlying areas of superficial vesicles (see Figure 1). The tympanic membrane is clear, with no erythema, exudates, or bulging. The oropharynx is clear. On examination of his eyes, he is noted to have a left beating nystagmus on rightward gaze, and a subtle left facial droop and weakness are noted as well. There is involvement of the muscles of the forehead, in addition to the muscles around his eye and mouth. Otherwise, the cranial nerve evaluation is within normal limits. There is normal strength in his extremities, with normal proprioception and sensation. The deep tendon reflexes are within normal limits. The remainder of the physical exam, including the cardiac and respiratory systems, is unremarkable.

Hint: Look carefully at the distribution of the rash and the type of lesions present.

the diagnosis is Ramsay Hunt Syndrome