Justin Bieber and Ramsay Hunt syndrome: can facial paralysis wait for an appointment?

By Ramon Martins Andrade, attorney (OAB/RJ 188.374)

English translation of an article first published in Portuguese: read the original.

On 10 June 2022, Justin Bieber posted on Instagram a video in which he showed half of his face motionless. “This eye is not blinking. I can’t smile on this side of my face”, he said, in the transcript by Variety. He explained that he had Ramsay Hunt syndrome, caused by a virus that had attacked the nerve of his ear and the nerves of his face, and that he was not physically able to perform the following shows, which were postponed (ABC7). On 4 September, he sang at Rock in Rio; two days later, he said he had given “everything I have to the people in Brazil”, recounted that exhaustion had overtaken him and announced a new pause to prioritize his health, according to the Reuters news agency. The two São Paulo shows, scheduled for 14 and 15 September, were suspended (Uai).

The account is his and ends there: nothing is known, nor asserted here, about his doctors, his treatments or his recovery, and one person’s course does not predict another’s. What the video makes visible is the question of anyone who wakes up with one side of the face drooping: can this wait for the next appointment? The clinical answer is no, and the health-plan law gives that urgency a name. The article follows that question from the science to rehabilitation and to the vaccine, with a look at three other countries.

Before the law, health: a face drooping on one side, difficulty raising both arms or slurred speech call for immediate help through SAMU 192 (the mobile emergency service), because the same appearance may be a stroke.

Ramsay Hunt and Bell: the same face, different prognoses

Ramsay Hunt syndrome is the reactivation of the varicella-zoster virus, the virus of chickenpox and shingles, in the ganglion of the facial nerve next to the ear. MedlinePlus, of the United States National Library of Medicine, describes severe ear pain, blisters in the ear canal or in the mouth, changes in hearing and weakness on one side of the face, with difficulty closing the eye. Sweeney and Gilden (Journal of Neurology, Neurosurgery and Psychiatry, 2001) record that, compared with patients with Bell’s palsy, those with Ramsay Hunt “often have more severe paralysis at onset and are less likely to recover completely”, and that, in the only prospective study then available, 14% developed the blisters only after the facial weakness. In the first hours, the two diseases can be indistinguishable.

Bell’s palsy, with no identified cause, has a more favourable natural history: in the Danish study by Peitersen (Acta Oto-Laryngologica, 2002), with 2,570 peripheral facial palsies followed without treatment, 71% of patients recovered normal facial movement. In the Scottish trial by Sullivan and colleagues (New England Journal of Medicine, 2007), which included only patients recruited within 72 hours of onset, recovery at three months was 83.0% with prednisolone and 63.6% without it; aciclovir brought no benefit. The Cochrane review by Madhok and colleagues (2016), with seven trials and 895 participants, confirmed with moderate- to high-quality evidence less incomplete recovery with corticosteroids: 17% against 28%.

In Ramsay Hunt, the evidence is weaker. The Cochrane review by Uscategui and colleagues (2008) on antivirals found a single trial, with 15 participants and of low quality, with no difference between the groups, and warned that absence of proof of benefit is not proof of ineffectiveness; the sister review, on adjuvant corticosteroids, came up empty. The meta-analysis by Fujiwara and Uraguchi (Auris Nasus Larynx, 2024), with 474 patients, pointed to a benefit from antivirals without statistical significance (odds ratio 0.68; interval 0.37 to 1.27). The data that support the urgency are observational: in 80 patients treated with aciclovir and prednisone in Japan (Murakami and colleagues, Annals of Neurology, 1997), recovery was complete in 75% of those who started treatment by the third day and in 30% of those who started after the seventh. Hence MedlinePlus places the best chance in the first three days, and lists corneal ulcer with loss of vision when the eye does not close.

In Brazil, herpes zoster accounted for 85,888 outpatient visits in the SUS (Brazil’s public health system) between 2008 and 2024, and 30,801 hospital admissions, according to data from the National Immunization Programme compiled by Conitec (the national health-technology assessment committee) in 2025; the same report lists Ramsay Hunt among the neurological complications of the disease.

What the guidelines require: rule out stroke and start within 72 hours

The guideline of the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS), published by Baugh and colleagues in 2013, made four strong recommendations for acute-onset facial paralysis on one side: examine the patient to exclude identifiable causes; prescribe oral corticosteroids “within 72 hours of symptom onset” to patients with Bell’s palsy aged 16 and over; not prescribe antivirals alone; and protect the eye that does not close. It also required reassessment or referral to a specialist for anyone with a new neurological sign, an ocular symptom or incomplete recovery at three months, and recorded that there was no basis for recommending physiotherapy.

The English public service translates the rule for the citizen. The NHS page says to call 999 if the face droops on one side, if the person cannot raise both arms or has difficulty speaking, because these “could be signs of a stroke, which is a medical emergency”, and to ask for an urgent appointment or call NHS 111 in the face of symptoms of Bell’s palsy, because treatment “is more effective if started early (within 72 hours)”. A drooping face is same-day care, first to rule out stroke, then so as not to miss the window. An appointment two weeks from now accomplishes neither.

Irreparable injury is also an emergency

Almost every discussion of emergency under a health plan revolves around the risk of death, but Lei 9.656/1998 (the Health Plans Act) says more. Art. 35-C, I, makes coverage mandatory in cases of emergency, “defined as those involving an immediate risk to life or of irreparable injury to the patient, as characterized in a statement by the treating physician”. The conjunction is “or”. A facial paralysis with an eye that does not close does not put life at immediate risk, but it does put the cornea at risk and, according to the studies above, the recovery of the nerve itself. And it is the treating physician who characterizes it, not the audit department. That is why the record of the urgent-care visit must set out the clinical picture, the hypothesis, whether the eye closes and the need for immediate treatment, and the request for coverage must come with a report in the language of the law, saying why the delay exposes the patient to an injury that may not reverse, and not merely with the ICD code.

The vocabulary is confusing: Resolution 1.451/1995 of the CFM (Federal Council of Medicine) calls urgency an unforeseen condition “with or without a potential risk to life” that requires immediate care, but the health-plan law calls urgency only what results from a personal accident or from a complication of pregnancy (art. 35-C, II). Infectious facial paralysis falls under art. 35-C as an emergency, by reason of irreparable injury.

Resolution RN 566/2022 of the ANS (the health-plan regulator), which replaced RN 259/2011, allows up to fourteen working days for a “consultation in the other medical specialties” (art. 3, II), such as otorhinolaryngology and neurology, but “urgency and emergency: immediate” (item XVII), and art. 4, § 3, guarantees urgent care outside the network, if no provider is available, “without the need for prior authorization”. Anyone who calls the operator with a paralysed face and is told there is an ENT appointment in twelve days has received an answer within the wrong deadline; the elective deadlines are in the article on the maximum waiting times for health-plan care (in Portuguese). The waiting period is no excuse either: art. 12, V, “c”, of the Act sets a “maximum period of twenty-four hours for coverage of cases of urgency and emergency”, and Súmula 597 of the STJ (Superior Court of Justice) treats as abusive any clause that goes beyond that, as explained in the article on urgency, emergency and waiting periods (in Portuguese). CONSU Resolution 13/1998 limits the outpatient plan to the “first 12 (twelve) hours of care”, a limit debated in the courts and under re-examination in Theme 1.314 (in Portuguese); in facial paralysis, which rarely requires hospital admission, the decisive point is usually urgent care without prior authorization.

There is a counter-argument: facial paralysis without other signs is usually benign. The law does not require every facial complaint to be treated as an emergency, but neither does it give the operator the final word: if the physician examined the patient and declared the need for immediate treatment, the assessment has already been made by the person the law chose, and the disagreement is not resolved by leaving the patient without care.

After the emergency: the rehabilitation that the health plan and the SUS owe

Once the first day has passed, there come the specialist, the ophthalmologist when the eye does not close and, sometimes, months of rehabilitation. Medication to be taken at home is, as a rule, outside mandatory coverage (Lei 9.656/1998, art. 10, VI); rehabilitation is not. RN ANS 541/2022 revoked the utilization guidelines that limited sessions with physiotherapists, speech therapists, psychologists and occupational therapists (art. 3), and the ANS note of 11 July 2022 described the “end of the limit on the number of consultations and sessions”, valid for “any disease or health condition listed by the World Health Organization”. The requirement is the prescription. The science of this stage is modest: the Cochrane review by Teixeira and colleagues (2011) found no benefit from electrical stimulation and saw improvement with facial exercises in only one small study. Which therapy and for how long is a decision for the care team; what RN 541 prevents is the counting of sessions taking the place of that decision.

In the SUS, Lei 8.080/1990 (the Organic Health Law) defines comprehensiveness as the “articulated and continuous set of preventive and curative actions and services” (art. 7, II), and Ordinance GM/MS No. 793/2012, on the Care Network for Persons with Disabilities, covers “temporary or permanent” disability (art. 1), with the Specialized Rehabilitation Centre as the reference in each territory (art. 19). What makes delay verifiable is asking for the referral in writing and keeping the number. The firm dealt with the same crossing in the article on Guillain-Barré syndrome (in Portuguese).

The vaccine that prevents it, and why it is not in the SUS

Ramsay Hunt is a complication of herpes zoster, and herpes zoster has an effective vaccine. In the ZOE-50 trial (Lal and colleagues, New England Journal of Medicine, 2015), with 15,411 adults aged 50 and over, the recombinant adjuvanted vaccine reduced the risk of the disease by 97.2%; in ZOE-70 (Cunningham and colleagues, 2016), with people aged 70 and over, by 89.8%. The trials did not measure Ramsay Hunt as a separate outcome, and the article does not claim that the vaccine prevents it in particular. Anvisa (the Brazilian health regulator) registered the vaccine for adults aged 50 and over and from age 18 for those at increased risk.

The SUS assessed it and declined. In Recommendation Report No. 1.073, for older people aged 80 and over and immunocompromised people aged 18 and over, Conitec recorded that “the evidence of the vaccine’s effectiveness is not denied” and that the decisive factor was cost: 244,051.67 reais per quality-adjusted life year, a proposed price of 403.30 reais per dose against 75.75 reais for it to be cost-effective, and 417.6 million reais over five years for the immunocompromised alone. The public consultation received 8,811 contributions, mostly favourable, and on 10 December 2025 the committee recommended, by majority, against incorporation. Ordinance SCTIE/MS No. 3 of 8 January 2026 made the decision official and allowed a new process “should new facts be presented” (art. 2). The Manual of the Reference Centres for Special Immunobiologicals (6th edition, 2023) includes the varicella vaccine and varicella-zoster immunoglobulin, not the herpes zoster vaccine. Under health plans, as Idec (the Brazilian consumer defence institute) notes, “the immunization system is not part of the list of mandatory procedures”, and the route of art. 10, § 13, of Lei 9.656/1998 depends on the criteria set by the STF (Supreme Federal Court) in ADI 7.265, as the firm explained in the article on revaccination after bone marrow transplantation (in Portuguese). In practice, anyone who wants it, as a rule, pays for it.

Comparative law: the same urgency, different prevention

The three countries below treat sudden facial paralysis as same-day care; what separates them is the vaccine, and who pays.

1. United Kingdom: public triage and vaccine by age

In England, the NHS is free by law (National Health Service Act 2006, section 1), and triage of the drooping face goes through 999 and NHS 111. On prevention, the official NHS page states that, since 1 September 2023, a person becomes eligible for the shingles vaccine on turning 65, that everyone aged 70 to 79 is eligible and that so are those over 18 with a “severely weakened immune system”.

2. United States: the prudent layperson and the vaccine without cost-sharing

The federal hospital emergency law (EMTALA, 42 U.S.C. § 1395dd) defines an emergency by acute symptoms whose lack of immediate attention could result in “serious impairment to bodily functions”: as here, function is protected, not only life. The difference lies in who judges. For insurers, 42 U.S.C. § 300gg-19a requires emergency coverage without prior authorization and measures it through the eyes of “a prudent layperson”, with an average knowledge of health: what counts is the symptom that led to the hospital, not the final diagnosis. On prevention, § 300gg-13 requires plans to cover, without cost-sharing, the immunizations recommended by the federal committee ACIP, which recommended the recombinant vaccine from age 50 in 2017 (Dooling and colleagues, MMWR, 2018) and for immunocompromised people from age 19 in 2021 (Anderson and colleagues, MMWR, 2022).

3. Germany: the vaccine as a right of the insured

In German statutory health insurance, the insured person “is entitled to vaccination benefits” (SGB V, § 20i, author’s translation), with the details set by the Federal Joint Committee (G-BA) on the basis of the recommendations of the Standing Committee on Vaccination (STIKO). In 2019, the G-BA made the inactivated herpes zoster vaccine a “mandatory benefit of all statutory health insurance funds” from age 60, and from age 50 for those at increased risk. When the technical committee recommends, the fund pays.

On urgency, Brazil does not lag behind: irreparable injury protects function as EMTALA does, and the 24-hour waiting period brings the health plan close to American insurance. The weak point, in the face of the prudent layperson, is depending on the examination documented on the day. On prevention, the distance is greater: the three countries made the vaccine a right by age or by risk, and Brazil, after recognizing its efficacy, decided on price.

Liability: what can be demanded, and what cannot

The Código de Defesa do Consumidor (the Consumer Protection Code) (art. 14) makes the operator, the hospital and the clinic strictly liable for defects in the services they themselves provide: refusal of urgent care on grounds of a waiting period or lack of authorization, lack of a network, the cutting of sessions by counting. When the defect lies in the physician’s act, proof of the physician’s fault is required (art. 14, § 4). The Code of Medical Ethics forbids the physician to fail to use the scientifically recognized means of diagnosis and treatment within reach (art. 32) and to fail to record the care in the medical record (art. 87), and Lei 15.378/2026 (the Patients’ Rights Statute) guarantees a second opinion “at any stage of treatment” (art. 18) and the medical record without having to give reasons (art. 19). It is with this material that the timeline is reconstructed.

There are situations in which the law offers no remedy. If the person waited a week before seeking care, the time lost is not the operator’s. If the physician examined the patient, considered the condition stable and advised an outpatient return visit, there is no declared emergency to claim; if the course of the illness contradicts that assessment, what is discussed is the conduct, not the coverage. And incomplete recovery proves no one’s error. When the delay is avoidable and takes from the patient a serious and real chance of a better outcome, the STJ allows compensation for the loss of a chance; the reference precedent, REsp 1.254.141/PR (Third Panel, Justice Nancy Andrighi reporting, decided on 4 December 2012), is a case of inadequate treatment of breast cancer, and its headnote sets the limit that applies to all: “The chance, however, can never reach the value of the lost good”. In facial paralysis, proof that the missed window changed the outcome is a matter for expert evidence. The general picture is in the guide on what to do when the health plan denies coverage (in Portuguese), and the logic of the first visit to the emergency room appears in the article on the first seizure and the health plan (in Portuguese).

Before deciding

In my view, sudden facial paralysis tests three parts of the system, and Brazil fares best in the first. On urgency, the law is good: the irreparable injury of art. 35-C, the “immediate” of RN 566 and the 24-hour waiting period rule out the appointment in fourteen days, provided the condition is examined and recorded on the day; the fact that the three-day window rests mostly on observational evidence reinforces the reason why the law handed the decision to whoever examines the patient. On rehabilitation, the rule exists and has no ceiling on sessions, but it depends on the prescription. On prevention, the gap is one of public policy, with the door to reassessment left open by the ordinance itself. In practice: note the time, go to urgent care, leave with a copy of the record and, if there is a refusal, ask for it in writing. If urgent care characterized the emergency and the operator told you to wait for the specialist’s schedule, refused care on grounds of a waiting period or cut rehabilitation by counting sessions, get in touch with the firm: the analysis starts from the medical report and the operator’s response, read together, and does not replace medical assessment.

About the author

Ramon Martins Andrade (OAB/RJ 188.374) is a lawyer who graduated from UFRJ in 2011, with master’s degrees from Université Sorbonne Nouvelle and from the Naval War College (EGN, Brazilian Navy). He is currently a researcher in Human Rights and Health at ENSP/Fiocruz.

This content is for information and education only. It does not constitute legal advice, advertising of results or any guarantee of outcome, under Rule 205/2021 of the Brazilian Bar Association (OAB).