What is the recommended acute management of Ramsay Hunt syndrome (herpes zoster oticus with facial nerve palsy)?

Ramsay Hunt Syndrome Management

Initiate combination therapy with oral corticosteroids (prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days with 5-day taper) PLUS high-dose antiviral therapy (acyclovir 800 mg five times daily OR famciclovir 500 mg three times daily for 7-10 days) within 72 hours of symptom onset, along with aggressive eye protection measures. 1, 2

Immediate Treatment Algorithm (Within 72 Hours)

Pharmacologic Management

• Start oral corticosteroids immediately using prednisolone 50 mg once daily for 10 days (no taper) OR prednisone 60 mg once daily for 5 days followed by 10 mg reduction each day for 5 days. 3, 1

• Add high-dose antiviral therapy concurrently with acyclovir 800 mg five times daily for 7-10 days OR famciclovir 500 mg three times daily for 7-10 days—this is critical because varicella zoster virus is less sensitive to acyclovir than herpes simplex virus and requires higher dosing than Bell's palsy. 1, 4

• Never use antiviral monotherapy—combination therapy with steroids achieves 90% complete recovery versus only 64% with steroids alone in Ramsay Hunt syndrome, a significantly larger benefit than the modest 6.8% improvement seen in Bell's palsy. 2

Eye Protection Protocol (Mandatory for All Patients)

• Apply lubricating ophthalmic drops every 1-2 hours while awake to prevent corneal exposure. 3

• Use ophthalmic ointment at bedtime for sustained overnight moisture retention. 3

• Implement eye taping or patching at night with careful instruction on proper technique to avoid corneal abrasion. 3

• Prescribe sunglasses for outdoor use to protect against wind, debris, and foreign particles. 3

• Refer urgently to ophthalmology if complete inability to close the eye, signs of corneal exposure, or any ocular symptoms develop. 3

Critical Diagnostic Distinctions

Ramsay Hunt Syndrome vs. Bell's Palsy

• Look for erythematous vesicular rash on the ear (zoster oticus) or in the mouth—this confirms Ramsay Hunt syndrome, but 14% of patients develop vesicles AFTER facial weakness onset, making early distinction from Bell's palsy impossible. 1

• Assess for eighth nerve symptoms: tinnitus, hearing loss, vertigo, nausea, vomiting, and nystagmus strongly suggest Ramsay Hunt syndrome due to geniculate ganglion proximity to the vestibulocochlear nerve. 1

• Recognize "zoster sine herpete"—some patients have facial paralysis from varicella zoster virus without any rash, presenting identically to Bell's palsy but requiring the higher antiviral dosing used for Ramsay Hunt syndrome. 1

What NOT to Order

• Do not obtain routine laboratory tests or imaging for typical presentations—this delays treatment beyond the critical 72-hour window without improving outcomes. 3

• Reserve MRI with and without contrast for atypical features: recurrent paralysis on the same side, isolated branch paralysis, other cranial nerve involvement, bilateral weakness, progressive weakness beyond 3 weeks, or no recovery after 3 months. 3

Prognostic Factors and Escalation

Poor Prognosis Indicators

• Ramsay Hunt syndrome has worse outcomes than Bell's palsy—patients often have more severe paralysis at onset and are less likely to recover completely even with optimal treatment. 1

• Complete facial paralysis at presentation carries up to 50% risk of incomplete recovery. 3

• Age, high-grade weakness, absent blink reflex responses (R1 and R2), and greater superficial petrosal nerve involvement all predict poor recovery. 5

Rescue Therapy for Non-Responders

• Consider intravenous high-dose methylprednisolone for patients with poor prognostic factors who fail to show recovery after standard oral antiviral and steroid therapy—case series demonstrate almost complete recovery even when administered late in patients with all recognized negative prognostic factors. 5

• Surgical decompression is rarely indicated and should only be considered in specialized centers for persistent paralysis without clinical signs of recovery after 6 weeks to 2 months, comparing it with maximal medical therapy. 3, 6

Mandatory Follow-Up and Referral Triggers

• Reassess at 3 months—refer to facial nerve specialist if recovery is incomplete, as 30% of Ramsay Hunt patients may experience permanent facial weakness with muscle contractures. 3

• Refer immediately for new or worsening neurologic findings at any point, development of ocular symptoms, or progressive weakness beyond 3 weeks. 3

• Electrodiagnostic testing may be offered to patients with complete facial paralysis, ideally performed 3-14 days post-onset, but is NOT recommended for incomplete paralysis. 3

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates the proven benefit of both corticosteroids and antivirals. 3, 1

• Using Bell's palsy antiviral dosing (acyclovir 400 mg five times daily) instead of the higher Ramsay Hunt dosing (800 mg five times daily) may result in treatment failure because varicella zoster virus requires higher drug concentrations. 1, 4

• Waiting for vesicles to appear before starting antivirals—14% of Ramsay Hunt patients develop rash after facial weakness, and some never develop visible lesions (zoster sine herpete). 1

• Inadequate eye protection can lead to permanent corneal damage, particularly in Ramsay Hunt syndrome where recovery is slower and less complete than Bell's palsy. 3

• Using standard methylprednisolone dose packs delivers only 105 mg prednisone-equivalent versus the required 540 mg over 10-14 days, representing significant underdosing. 3