A 52-year-old man with a 2-week history of progressive left facial weakness, left ear pain, and vesicular rash in the left external auditory canal presents to the clinic. Examination confirms left facial paralysis with intact eye closure (mild weakness). He has normal hearing and no neurologic deficits. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis **Key Point:** The presence of **vesicular rash in the external auditory canal** with facial paralysis and otalgia is diagnostic of **Ramsay Hunt syndrome (herpes zoster oticus)** — reactivation of varicella-zoster virus (VZV) affecting the facial nerve. ## Distinguishing Bell's Palsy from Ramsay Hunt Syndrome | Feature | Bell's Palsy | Ramsay Hunt Syndrome | |---|---|---| | **Cause** | Idiopathic (presumed HSV-1) | VZV reactivation | | **Vesicles** | Absent | Present in ear canal, auricle, palate | | **Otalgia** | Absent or mild | Prominent, often precedes paralysis | | **Paralysis severity** | Variable | Often more severe | | **Associated symptoms** | Hyperacusis, taste loss | Hearing loss, vertigo (CN VIII involvement) | | **First-line treatment** | Corticosteroids | **Antivirals + corticosteroids** | | **Prognosis** | 70–85% complete recovery | 50–70% complete recovery (worse prognosis) | **High-Yield:** Ramsay Hunt syndrome requires **combination therapy**: antivirals (acyclovir or valacyclovir) PLUS corticosteroids. Antivirals alone are insufficient. ## Management Algorithm ```mermaid flowchart TD A[Facial paralysis + otalgia]:::outcome --> B{Vesicles present?}:::decision B -->|Yes| C[Ramsay Hunt syndrome]:::outcome B -->|No| D[Bell's palsy or other cause]:::outcome C --> E[IV acyclovir 10 mg/kg 8-hourly]:::action E --> F[Add oral prednisolone 1 mg/kg/day]:::action F --> G[Admit for monitoring]:::action D --> H[Oral corticosteroids only]:::action G --> I[Reassess at 48-72 hours]:::outcome ``` ## Evidence-Based Dosing **Antivirals:** - **Acyclovir IV:** 10 mg/kg 8-hourly (preferred if hospitalized; better CNS penetration) - **Valacyclovir PO:** 1 g 3 times daily × 7 days (alternative if outpatient) **Corticosteroids:** - **Prednisolone:** 1 mg/kg/day (max 80 mg) × 7 days, then taper × 7 days - Start concurrently with antivirals **Clinical Pearl:** Ramsay Hunt syndrome carries a worse prognosis than Bell's palsy (50–70% vs. 70–85% complete recovery) and has higher rates of long-term sequelae (synkinesis, contracture). Early combination therapy within 72 hours of onset is critical. **Warning:** Do NOT treat Ramsay Hunt with corticosteroids alone — this is a common error. VZV requires antiviral coverage to prevent dissemination and reduce nerve damage.