Treatment of Ramsay Hunt Syndrome
Treat Ramsay Hunt syndrome immediately with combination therapy of oral antivirals (acyclovir 800 mg five times daily or famciclovir 500 mg three times daily) plus oral corticosteroids (prednisone 60 mg daily) for 7-10 days, starting within 72 hours of symptom onset for optimal facial nerve and hearing recovery. 1, 2
Acute Treatment Protocol
First-Line Combination Therapy
- Never use antivirals as monotherapy—always combine with corticosteroids, as antiviral monotherapy is not supported by evidence 3
- Start oral acyclovir 800 mg five times daily OR famciclovir 500 mg three times daily for 7-10 days 1
- Add oral prednisone 60 mg daily for 3-5 days 1
- Timing is critical: Treatment initiated within 3 days of facial paralysis onset achieves complete recovery in 75% of patients, compared to only 30% when treatment begins after 7 days 2
Route of Administration
- Oral administration is equally effective as intravenous acyclovir for standard cases 2
- Consider IV high-dose methylprednisolone for patients who fail to respond to standard oral therapy or who present with poor prognostic factors (severe facial weakness, absent blink reflex, older age) 4
Clinical Assessment Requirements
Initial Evaluation
- Confirm the classical triad: ipsilateral facial paralysis, otalgia, and vesicular rash in the ear or mouth 5
- Important caveat: 14% of patients develop vesicles AFTER facial weakness onset, making early differentiation from Bell's palsy impossible 1
- Assess for vestibulocochlear nerve involvement: hearing loss, tinnitus, vertigo, and nystagmus occur due to anatomic proximity of the geniculate ganglion to the eighth cranial nerve 3
Audiometric Monitoring
- Perform baseline audiometric evaluation 6
- Repeat audiometry at treatment conclusion 6
- Conduct follow-up audiometric testing within 6 months to assess hearing recovery 6, 3
- Counsel patients with residual hearing loss and/or tinnitus about audiological rehabilitation and supportive measures 6, 3
Prognostic Considerations
Poor Prognostic Indicators
- Age over 60 years 4
- High-grade facial weakness at presentation 4
- Absent R1 and R2 responses on blink reflex testing 4
- Involvement of greater superficial petrosal nerve 4
- Ramsay Hunt syndrome has inherently worse prognosis than Bell's palsy, with more severe paralysis at onset and lower complete recovery rates 1
Treatment Response Monitoring
- Early acyclovir-prednisone administration reduces nerve degeneration as demonstrated by nerve excitability testing 2
- Hearing recovery also improves with early treatment 2
Critical Clinical Pitfalls
- Do not delay treatment waiting for vesicles to appear—some patients never develop visible rash (zoster sine herpete) but have serologic or PCR evidence of VZV reactivation 1
- Do not withhold treatment in older patients—even an 87-year-old patient showed significant improvement with prompt antiviral and corticosteroid therapy 7
- Do not abandon treatment in non-responders—late administration of IV high-dose methylprednisolone can achieve near-complete recovery even in patients with multiple poor prognostic factors 4