Ramsay Hunt Syndrome: Immediate Treatment with Acyclovir and Prednisone
The appropriate management is acyclovir and prednisone (Option A). This patient presents with classic Ramsay Hunt syndrome (herpes zoster oticus), characterized by unilateral facial paralysis with vesicular eruption in the ear canal, pharyngeal involvement, and associated otalgia—requiring immediate antiviral and corticosteroid therapy.
Clinical Recognition and Diagnosis
This presentation is NOT Bell's palsy—the presence of ear pain, pharyngeal erythema, and visible vesicular lesions in the external ear distinguishes Ramsay Hunt syndrome from idiopathic facial paralysis. 1
Key diagnostic features that confirm Ramsay Hunt syndrome:
- Unilateral facial weakness with inability to move forehead muscles (lower motor neuron pattern) 1
- Vesicular eruption visible in the external ear canal (shown in the image) 2
- Ipsilateral pharyngeal and palatal erythema indicating varicella-zoster virus involvement 2
- Otalgia and sore throat preceding or accompanying facial weakness 2
Evidence-Based Treatment Protocol
Combination therapy with acyclovir and prednisone must be initiated immediately for optimal outcomes in Ramsay Hunt syndrome. 3, 4
Antiviral Therapy
- Acyclovir 800 mg orally five times daily for 7-21 days is the standard antiviral regimen 5, 3
- Treatment should begin within 72 hours of symptom onset for maximum efficacy 5, 3
- Valacyclovir (1 g three times daily for 7 days) is an acceptable alternative with improved bioavailability 4
Corticosteroid Therapy
- Prednisone 60 mg daily for 7 days, then 30 mg daily for days 8-14, then 15 mg daily for days 15-21 provides optimal anti-inflammatory effect 3
- Alternative tapering: 50 mg daily for 5 days, then reduce by 10 mg daily for 5 days 4
- Combined acyclovir plus prednisone significantly improves recovery rates compared to either agent alone or no treatment 3, 4
Outcomes with Combination Therapy
The evidence strongly supports combination therapy:
- 87.5% complete recovery with valacyclovir plus prednisone versus 68% with no treatment (p < 0.05) 4
- Only 1.8% severe sequelae with combination therapy versus 18% without treatment (p < 0.01) 4
- Accelerated time to cessation of acute neuritis (risk ratio 3.02) and return to normal function (risk ratio 3.22) with acyclovir plus prednisone 3
- Elderly patients (>60 years) show particularly dramatic benefit: 100% complete recovery with treatment versus 42% without treatment (p < 0.01) 4
Why Other Options Are Incorrect
Option B (Gabapentin) is used for neuropathic pain management, not acute viral facial paralysis. While it may have a role in post-herpetic neuralgia prevention, it does not address the underlying viral infection or inflammation. 5
Option C (Topical capsaicin) is used for chronic neuropathic pain conditions and has no role in acute herpes zoster oticus management. 5
Option D (Topical steroid cream) addresses neither the viral infection nor provides adequate systemic anti-inflammatory effect needed for facial nerve inflammation within the temporal bone. 1
Critical Management Considerations
Eye Protection is Mandatory
- Incomplete eyelid closure requires urgent ophthalmology consultation to prevent corneal exposure and ulceration 2
- Artificial tears, lubricating ointment at night, and eye taping may be necessary 1
Monitoring and Follow-up
- Assess response at 48-72 hours; lack of improvement warrants re-evaluation 6
- Seventh nerve palsy developing during the first week of treatment is typically benign and does not mandate treatment change 1
- Incomplete recovery may require facial plastic surgery referral for reconstructive procedures (eyelid weights, facial suspensions) 2
Common Pitfall to Avoid
Do not confuse this with Bell's palsy and treat with steroids alone—the presence of vesicular lesions and pharyngeal involvement mandates antiviral therapy. 1, 2 Failure to provide antiviral treatment significantly increases the risk of permanent facial weakness and post-herpetic neuralgia. 4