Synopsis
Recognise VZV-associated facial palsy, arrange early specialist treatment with safe antiviral selection, and protect hearing, balance and the ocular surface during recovery.
- Look for painful vesicles in the ear canal, pinna and palate.
- VZV can cause facial palsy with hearing loss, tinnitus or vertigo.
- The rash may follow weakness, so early absence does not exclude the diagnosis.
Key red flags
Facial palsy with red eye, visual change or incomplete closure needs urgent assessment of corneal and ocular risk.
Investigation priorities
Establish the syndrome, its extent and the urgency of specialist involvement.
Management branches
Facial palsy with otalgia and vesicles raises suspicion of Ramsay Hunt syndrome.
- Discuss the patient with ENT the same day, recording onset, eye closure, hearing, neurological findings and immune status.
- Begin the agreed antiviral plan promptly and consider combined oral corticosteroid treatment after the relevant contraindications and risks have been assessed.
Key medicines
Aciclovir 800 mg oral tablets, product 4336When the specialist selects oral treatment, give 800 mg five times daily, about four hours apart while awake, for seven days. For zoster, reduce to 800 mg every eight hours at creatinine clearance 10–25 mL/min, or every twelve hours below 10 mL/min.
Valaciclovir oral alternative, product 101527If an oral alternative is specifically agreed, the immunocompetent zoster regimen is 1 g three times daily for seven days. At creatinine clearance 30–49 mL/min use 1 g twice daily; at 10–29 use 1 g daily; below 10 use 500 mg daily.