Treatment for Ramsay Hunt Syndrome
Treat Ramsay Hunt syndrome immediately with combination therapy of corticosteroids plus antivirals—never use antivirals as monotherapy. 1
Acute Pharmacologic Management
Combination Therapy (Standard Approach)
- Administer oral corticosteroids (prednisone 60 mg daily for 3-5 days) combined with antiviral therapy (famciclovir 500 mg three times daily OR acyclovir 800 mg five times daily for 7-10 days) within 7 days of symptom onset. 2
- The combination of acyclovir and steroids significantly improves facial nerve recovery rates compared to steroids alone (90% complete recovery versus 64% with steroids alone). 3
- Avoid using antivirals as monotherapy without corticosteroids, as this approach lacks evidence support. 1
High-Dose Corticosteroid Protocol (Severe Cases)
- For House-Brackmann grade VI (complete facial paralysis), consider high-dose corticosteroids (prednisolone 200 mg/day) combined with antivirals, which achieves 71.1% recovery compared to 60% with standard-dose corticosteroids. 4
- High-dose intravenous methylprednisolone should be considered even as late salvage therapy in patients with poor prognostic factors (advanced age, complete paralysis, absent blink reflex responses) who fail to respond to standard oral therapy. 5
Timing Considerations
- Initiate treatment within 7 days of facial palsy onset for optimal outcomes—early treatment initiation is a significant predictor of recovery. 4, 3
- Patients whose vesicular rash appears before facial palsy have better recovery rates than those with simultaneous or delayed rash presentation. 4
Audiologic Assessment and Management
Initial and Follow-up Evaluation
- Perform audiometric evaluation at the conclusion of acute treatment to establish baseline hearing status. 6
- Repeat audiometric testing within 6 months to assess hearing recovery, as vestibulocochlear nerve involvement commonly causes sensorineural hearing loss, tinnitus, vertigo, and nystagmus due to anatomic proximity of the geniculate ganglion to the eighth cranial nerve. 1
Rehabilitation
- Counsel patients with residual hearing loss and/or tinnitus about audiological rehabilitation and other supportive measures. 6, 1
Clinical Pitfalls to Avoid
- Do not dismiss early Bell's palsy as unrelated to varicella-zoster virus—14% of Ramsay Hunt syndrome patients develop vesicles after facial weakness onset, making initial presentation indistinguishable from Bell's palsy. 2
- Some patients develop "zoster sine herpete" (facial paralysis without visible rash) but have serologic or molecular evidence of VZV reactivation, justifying empiric antiviral treatment for all acute facial palsies. 2
- Recognize that Ramsay Hunt syndrome has inherently worse prognosis than Bell's palsy, with more severe paralysis at onset and lower complete recovery rates, necessitating aggressive early treatment. 2