The effect of acyclovir-prednisone treatment in 80 patients with Ramsay Hunt syndrome was analyzed retrospectively at the Department of Otolaryngology, Ehime University School of Medicine, Ehime, Japan. Ages ranged from 15 to 75 years. All presented with facial paralysis and herpetic eruption on the pinna or oral mucosa, and 22 had associated hearing loss. Treatment with acyclovir, 250 mg tid by intravenous drip or 800 mg 5x daily orally, and prednisone, 1 mg/kg day iv or orally, was started 1 to 10 days after onset of facial paralysis. Recovery from paralysis was complete in 21 (75%) of 28 patients treated within 3 days of onset, and in only 7 (30%) of 23 whose treatment was delayed more than 7 days. Nerve excitability testing showed that nerve degeneration was reduced by early administration of acyclovir-prednisone therapy. Recovery of hearing was better in patients treated early. In facial nerve recovery and outcome, intravenous administration of acyclovir was not superior to oral treatment. 
COMMENT. Ramsay Hunt syndrome manifested by facial pain and nerve paralysis, herpetic eruption on the pinna, and frequent vestibulocochlear involvement, is caused by varicella-zoster virus infection. Early administration of acyclovir and prednisone, within the first 3 days of onset, results in 75% rate of facial nerve recovery and less likelihood of residual nerve deafness. Absence of herpetic eruption in 8 to 25% of cases leads to misdiagnosis as Bell’s palsy and poorer prognosis because acyclovir treatment is withheld. A test for early recognition of varicella-zoster virus infection could improve prognosis.