What is the treatment for Ramsey Hunt syndrome?

Treatment for Ramsay Hunt Syndrome

Treat Ramsay Hunt syndrome 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, initiated as early as possible and ideally within 7 days of symptom onset. 1

Primary Treatment Approach

Combination Antiviral and Corticosteroid Therapy

• Do NOT use antivirals as monotherapy—the American Academy of Otolaryngology-Head and Neck Surgery explicitly advises against routine use of antivirals without corticosteroids, as this approach lacks supporting evidence 2

• The standard regimen consists of:

  • Acyclovir 800 mg orally five times daily OR famciclovir 500 mg orally three times daily 1
  • PLUS prednisone 60 mg daily for 3-5 days 1
  • Total treatment duration: 7-10 days 1

• Combination therapy (acyclovir plus steroids) achieves 90% complete recovery compared to only 64% with steroids alone, with statistically significant improvement in facial nerve function 3

• Early initiation is critical—treatment should begin within 7 days of facial palsy onset for optimal outcomes 1, 3

Rationale for Combination Therapy

• Varicella-zoster virus reactivation in the geniculate ganglion causes inflammation and edema of the facial nerve 1

• Antivirals target viral replication while corticosteroids reduce nerve inflammation and edema 3

• Patients with Ramsay Hunt syndrome have more severe paralysis at onset and lower complete recovery rates compared to Bell's palsy, making aggressive early treatment essential 1

Treatment for Non-Responders

Escalation to High-Dose IV Corticosteroids

• For patients with poor prognostic factors (advanced age, high-grade facial weakness, absent blink reflex responses) who fail to improve with standard oral therapy, consider intravenous high-dose methylprednisolone even as a late treatment option 4

• This approach has shown almost complete recovery in patients with multiple negative prognostic factors who did not respond to standard oral antiviral and steroid therapy 4

Supportive Care and Monitoring

Eye Protection

• Patients with lagophthalmos require eye lubrication and protective measures to prevent corneal damage 5

Audiometric Assessment

• Perform audiometric evaluation at treatment conclusion 6, 2

• Repeat audiometric testing within 6 months to assess hearing recovery 6, 2

• Counsel patients with residual hearing loss and/or tinnitus about audiological rehabilitation and supportive measures 6, 2

Clinical Recognition Pearls

Diagnostic Challenges

• 14% of patients develop vesicles AFTER facial weakness onset, meaning Ramsay Hunt syndrome may initially be indistinguishable from Bell's palsy 1

• Some patients have "zoster sine herpete"—facial paralysis without rash but with serologic or molecular evidence of VZV reactivation 1

• Given the difficulty distinguishing early Ramsay Hunt from Bell's palsy and the safety of antiviral therapy, consider treating all acute facial palsies with combination therapy 1

Expected Clinical Features

• The classical triad includes ipsilateral facial paralysis, otalgia, and vesicular rash in the ear or mouth 7

• Vestibulocochlear nerve involvement commonly causes hearing loss (sensorineural), tinnitus, vertigo, and nystagmus due to anatomic proximity of the geniculate ganglion to the eighth cranial nerve 7, 2

Common Pitfalls to Avoid

• Do not delay treatment waiting for vesicles to appear—they may develop after facial weakness or never appear at all 1

• Do not use antivirals alone without corticosteroids—this is explicitly not recommended 2

• Do not assume complete recovery is guaranteed—Ramsay Hunt syndrome has inherently poorer prognosis than Bell's palsy, with less likelihood of complete recovery even with optimal treatment 1

• Do not forget audiometric follow-up—hearing complications require specific assessment and rehabilitation 6, 2