This patient presented with the typical clinical features of a left-sided Ramsay Hunt syndrome. She had an acute onset of severe vertigo, central nausea, vomiting, headache, with paresthesia of her tongue, hard palate and left external ear. On examination she had a typical left Bell's palsy clinically with facial asymmetry, she was unable to close her left eye, and a vesicular rash was identified on her hard palate, left tongue, left external auditory canal and left external ear/ pinna.

Ramsay Hunt syndrome is also known as herpes zoster oticus or shingles of the facial nerve, and due to varicella-zoster reactivation in the geniculate ganglion.

MRI brain confirmed focal canalicular enhancement at the apex of the left internal auditory canal, likely representing a combined enhancement of the facial-vestibulocochlear nerve complex(known as the fundal tuft sign). There is also asymmetric and prominent enhancement of the left geniculate ganglion, especially in comparison to the asymptomatic right. These features would fit with a left Bell's palsy.

There is an avid noticeable enhancement of the left external auditory canal and external ear/ pinna, an unusual MRI finding and comment, however attributable to the clinical presentation of the varicella-zoster vesicular rash of the external auditory canal and pinna.

There is an incidental finding of type III anterior inferior cerebellar arterial loop extending significantly into the left internal auditory canal. There was no prior history of vertigo, tinnitus or any hemifacial spasm. Clinically the acute presentation was fully suspected due to the varicella-zoster reactivation and suggested likely involvement of the left vestibulocochlear nerves too.