What is the treatment for Ramsey Hunt syndrome?

Treatment for Ramsay Hunt Syndrome

Treat Ramsay Hunt syndrome with combination therapy of oral corticosteroids (prednisone 60 mg daily for 3-5 days) plus antiviral medication (acyclovir 800 mg five times daily or famciclovir 500 mg three times daily) for 7-10 days, initiated as early as possible—ideally within 7 days of symptom onset. 1

Primary Treatment Approach

Standard Combination Therapy

• Corticosteroids plus antivirals should be used together—avoid antiviral monotherapy without corticosteroids, as this approach lacks supporting evidence 2
• The standard regimen consists of:
  • Prednisone 60 mg daily for 3-5 days 1
  • Acyclovir 800 mg five times daily for 7-10 days OR famciclovir 500 mg three times daily for 7-10 days 1
• Early initiation of treatment is a significant factor for better outcomes 3

High-Dose Corticosteroid Therapy for Severe Cases

• For House-Brackmann Grade VI (complete facial paralysis), consider high-dose corticosteroids (prednisolone 200 mg/day) combined with antivirals, which achieved 71.1% recovery rates compared to 60% with standard-dose corticosteroids 3
• High-dose intravenous methylprednisolone may be considered even as a late treatment option in patients not recovering after standard therapy, particularly those with poor prognostic factors 4
• Poor prognostic indicators include: older age, complete facial weakness, absent blink reflex responses, and involvement of the greater superficial petrosal nerve 4

Clinical Recognition and Timing

Key Diagnostic Features

• The classic triad consists of: ipsilateral facial paralysis, otalgia (ear pain), and vesicular rash 5
• Additional symptoms include hearing loss, tinnitus, vertigo, and nystagmus due to vestibulocochlear nerve involvement 6, 5
• Critical caveat: 14% of patients develop vesicles AFTER facial weakness onset, making early differentiation from Bell's palsy impossible 1
• Some patients present with "zoster sine herpete" (facial paralysis without visible rash but with VZV DNA or antibody evidence), representing a subset of apparent "Bell's palsy" cases 1

Prognostic Considerations

• Ramsay Hunt syndrome has worse prognosis than Bell's palsy, with more severe paralysis at onset and lower complete recovery rates 1
• Better recovery occurs when herpetic vesicles appear before facial palsy rather than after 3
• Early treatment within 7 days significantly improves facial palsy recovery outcomes 1

Audiologic Management and Follow-Up

Hearing Assessment

• Perform audiometric evaluation at treatment conclusion 6, 2
• Repeat audiometric testing within 6 months to assess hearing recovery 6, 2
• Hearing loss in Ramsay Hunt syndrome is sensorineural, caused by anatomic proximity of the geniculate ganglion to the eighth cranial nerve 2

Rehabilitation

• Counsel patients with residual hearing loss and/or tinnitus about audiological rehabilitation and supportive measures 6, 2
• Provide information about potential benefits of hearing aids and tinnitus management strategies 6

Common Pitfalls to Avoid

• Do not use antivirals alone without corticosteroids—combination therapy is essential 2
• Do not delay treatment waiting for vesicles to appear—treat suspected cases early since vesicles may develop after facial weakness 1
• Do not assume Bell's palsy without considering Ramsay Hunt syndrome—some cases lack visible rash (zoster sine herpete) 1
• Do not use standard-dose corticosteroids for severe Grade VI paralysis—consider high-dose therapy for these patients 3