Insect bite and arrows

A 68 year old man was noted by his wife to have an “insect bite” on the pinna of his left ear. The lesion was red and swollen like a blister. The patient described shooting pains “like arrows” originating from his left ear and radiating over the top of his head. On the morning of presentation he was unable to close his left eye, and his wife noticed that the left corner of his mouth was drooping. Examination of the ear showed several crusted lesions and blisters in the left external acoustic meatus and pinna (fig 1).

The patient was asked to close his eyes firmly and attempt to smile. Fig 2 shows that he was unable to close his left eye and the left side of his mouth remained motionless. While forcing his right eyelid shut against resistance, the left eye rolled upwards. When asked to raise his eyebrows,