Complications of Ramsay Hunt Syndrome
Ramsay Hunt syndrome causes significant neurological complications including permanent facial paralysis, sensorineural hearing loss, vestibular dysfunction, and chronic pain, with worse outcomes than Bell's palsy if not treated early with antivirals and corticosteroids.
Major Neurological Complications
Facial Nerve Paralysis
- Facial paralysis is more severe at onset and less likely to recover completely compared to Bell's palsy, with only approximately 75% achieving recovery even with optimal treatment 1, 2
- Permanent facial muscle weakness can occur if treatment is delayed, representing a critical long-term disability 3
- The severity of initial facial paralysis determines the ultimate prognosis and recovery trajectory 4
Hearing Loss and Auditory Complications
- Sensorineural hearing loss occurs due to the close proximity of the geniculate ganglion to the vestibulocochlear nerve within the bony facial canal 5, 6
- Tinnitus frequently accompanies hearing loss and may persist long-term 5, 6, 1
- Audiometric evaluation should be performed at treatment conclusion and within 6 months to assess recovery 6
- Patients with residual hearing loss require counseling about audiological rehabilitation and supportive measures 6
Vestibular Dysfunction
- Vertigo is a common complication resulting from vestibulocochlear nerve involvement 5, 6, 1
- Nystagmus occurs alongside vertigo due to eighth nerve features 5, 1
- Nausea and vomiting frequently accompany vestibular symptoms 6, 1
Clinical Presentation Pattern
The classical triad consists of:
- Ipsilateral facial paralysis
- Otalgia (ear pain)
- Vesicular rash in the ear or mouth 5
A critical pitfall: 14% of patients develop vesicles AFTER facial weakness onset, making early differentiation from Bell's palsy impossible and necessitating empiric antiviral treatment for all facial palsies 1
Management to Prevent Complications
Immediate Treatment Protocol
- Initiate combination therapy with famciclovir (500 mg three times daily) or acyclovir (800 mg five times daily) PLUS prednisone (60 mg daily for 3-5 days) within 7 days of symptom onset 1
- Early treatment within the first week significantly improves facial nerve recovery outcomes 1, 2
- Treatment duration should be 7-10 days for antivirals 1
Monitoring and Follow-up
- Perform audiometric evaluation at treatment completion and at 6 months 6
- Assess for residual facial weakness and hearing impairment 6
- Provide audiological rehabilitation for persistent hearing loss or tinnitus 6
Prognostic Factors
Poor prognostic indicators include:
- Delayed diagnosis and treatment initiation beyond 7 days 1, 4
- Severe facial paralysis at presentation 1, 4
- Extensive vestibulocochlear nerve involvement 4
- Immunocompromised status (cancer patients, chemotherapy recipients) 2
Key Clinical Pitfall
Zoster sine herpete: Some patients develop facial paralysis without visible rash but have VZV reactivation confirmed by serology or PCR 1. These cases are clinically indistinguishable from Bell's palsy initially, reinforcing the need to treat all acute facial palsies with antivirals and steroids empirically 1.