A Diagnostic Challenge of Facial Nerve Palsy and Hearing Loss With Bilateral Otomastoiditis in an Elderly Patient

Facial nerve palsy in older adults is commonly idiopathic or viral in origin, but secondary otologic and neurological causes must be carefully excluded, particularly when associated with hearing loss. We report a diagnostically challenging case of a 79-year-old woman who presented with acute right lower motor neuron facial palsy and new-onset hearing impairment, without otalgia, rash, or otorrhoea. Examination confirmed severe right-sided facial weakness, and initial imaging with computed tomography (CT) of the head and temporal bones demonstrated bilateral mastoid and middle ear opacification without bony erosion or intracranial extension. Despite these findings, the clinical presentation was not consistent with otogenic facial palsy. Given the combination of complete unilateral facial paralysis, hearing impairment, and absence of vesicular eruption, Ramsay Hunt syndrome presenting as zoster sine herpete was suspected. The patient was transferred to a tertiary otolaryngology centre and commenced on antiviral therapy and systemic corticosteroids. Subsequent specialist follow-up identified bilateral mixed hearing loss with a left-sided conductive component due to middle ear effusion, which did not anatomically or temporally correlate with the acute right-sided facial palsy. The patient experienced gradual clinical improvement. This case highlights the diagnostic complexity that arises when imaging findings mimic otologic infection but the clinical picture supports viral neuritis. It underscores the importance of cautious interpretation of radiologic findings and early recognition of Ramsay Hunt syndrome even in the absence of vesicular rash, as timely initiation of antiviral and corticosteroid therapy may improve neurological outcomes.