What is the recommended treatment for an immunocompetent adult with a history of chickenpox or shingles diagnosed with Ramsey Hunt syndrome, presenting with facial weakness, ear pain, and vesicles in the ear?

Treatment of Ramsay Hunt Syndrome in Immunocompetent Adults

Initiate combination therapy with oral acyclovir 800 mg five times daily (or valacyclovir 1000 mg three times daily) PLUS oral prednisone 60 mg daily within 72 hours of symptom onset for optimal facial nerve recovery. 1

Immediate Pharmacologic Management

Antiviral Therapy

• Acyclovir 800 mg orally every 4 hours (5 times daily) for 7-10 days is the standard antiviral treatment 1, 2
• Alternatively, famciclovir 500 mg three times daily for 7-10 days can be used 2
• Valacyclovir 1000 mg three times daily is another effective option, as it is FDA-approved for herpes zoster treatment in immunocompetent adults 3, 4
• Treatment must be initiated within 72 hours of rash onset for maximum efficacy 1, 3

Corticosteroid Therapy

• Prednisone 60 mg orally daily for 3-5 days should be given concurrently with antivirals 1, 2
• Never use antivirals as monotherapy without corticosteroids, as this approach lacks supporting evidence 1
• The combination of antivirals plus corticosteroids improves outcomes compared to corticosteroids alone, though the evidence base is limited 2, 5

Pain Management

• Provide adequate analgesia for severe otalgia, which is a prominent feature of Ramsay Hunt syndrome 1
• Pain control is essential as ear pain can be severe and debilitating 6

Clinical Recognition and Diagnostic Features

Classic Triad

• Ipsilateral facial paralysis with vesicular rash on the ear (zoster oticus) or in the mouth is the hallmark presentation 1, 2
• Actively search for vesicles in the external ear canal, posterior auricular surface, oral mucosa, and tongue as these may be subtle or develop after facial weakness 1, 7
• 14% of patients develop vesicles AFTER the onset of facial weakness, making early diagnosis challenging 2

Associated Symptoms from Vestibulocochlear Nerve Involvement

• Tinnitus, hearing loss, vertigo, nausea, vomiting, and nystagmus occur due to the geniculate ganglion's proximity to the eighth cranial nerve 1, 8, 2
• These symptoms help distinguish Ramsay Hunt syndrome from Bell's palsy 2

Zoster Sine Herpete

• Some patients present with facial paralysis WITHOUT visible rash but have VZV DNA in auricular skin, blood, middle ear fluid, or saliva 2
• This represents "Ramsay Hunt syndrome zoster sine herpete" and should still be treated as Ramsay Hunt syndrome 2

Isolation and Infection Control

Standard Precautions for Immunocompetent Patients

• Isolate in a single room with self-contained toilet facilities during the contagious period 9
• Complete covering of all lesions is sufficient; no airborne isolation is required if lesions can be completely covered 9
• The contagious period begins 1-2 days before rash onset and continues until all lesions have dried and crusted (typically 4-7 days after rash onset) 9
• Maintain isolation for a minimum of 24 hours after effective antiviral therapy is initiated, though longer periods may be necessary based on lesion status 9

Critical Pitfall to Avoid

• Do not assume antiviral therapy immediately renders the patient non-contagious—viral shedding continues until lesions are fully crusted 9

High-Risk Populations Requiring Protection

• Patients must avoid contact with pregnant women, premature infants, neonates, immunocompromised persons, and anyone without history of chickenpox or varicella vaccination 9

Healthcare Worker Precautions

• Only personnel with documented immunity to varicella (2 doses of vaccine, laboratory evidence of immunity, or confirmed prior disease) should provide care 9
• Use disposable gloves and aprons when in contact with the patient; fluid-repellent surgical masks with eye protection should be used where droplet transmission risk exists 9

Audiologic Assessment and Follow-up

Hearing Evaluation

• Perform audiometric evaluation at treatment conclusion to establish baseline hearing status 1, 8
• Repeat audiometric testing within 6 months to assess hearing recovery 1, 8
• Hearing loss is common due to vestibulocochlear nerve involvement 8, 2

Rehabilitation

• Counsel patients with residual hearing loss and/or tinnitus about audiological rehabilitation and supportive measures 1, 8

Prognosis and Expected Outcomes

Recovery Patterns

• Patients with Ramsay Hunt syndrome have more severe paralysis at onset and are less likely to recover completely compared to Bell's palsy 2
• Early treatment with antivirals and corticosteroids within 7 days of onset improves facial palsy recovery 2
• Complete recovery can be achieved, particularly with prompt treatment, though this may take up to 6 months 4, 6

Special Considerations for Older Adults

• Older adults are at increased risk for VZV reactivation and potential complications including encephalitis 10, 1

Evidence Quality and Limitations

The evidence base for Ramsay Hunt syndrome treatment is limited. A 2008 Cochrane review found only one small randomized controlled trial (15 participants) comparing acyclovir plus corticosteroids to corticosteroids alone, which showed no statistically significant difference but was underpowered 5. Despite this limited evidence, the widespread use of antivirals is justified by their proven efficacy in herpes zoster at other body sites and their known safety profile 2, 5. The current guideline recommendations prioritize early combination therapy based on clinical experience and extrapolation from other VZV infections 1.

Patient Education

• Instruct patients to avoid touching vesicular lesions to prevent inadvertent inoculation 1
• Explain the expected timeline for recovery and the importance of audiologic follow-up 8