Ramsay Hunt Syndrome and Oral Vesicles
Yes, Ramsay Hunt syndrome can cause vesicles in the mouth. This is part of the classic clinical presentation of the disease, which results from varicella-zoster virus (VZV) reactivation in the geniculate ganglion.
Classic Clinical Presentation
The American Academy of Otolaryngology-Head and Neck Surgery defines Ramsay Hunt syndrome by its classical triad 1:
- Ipsilateral facial paralysis
- Otalgia (ear pain)
- Vesicular rash - which can appear on the ear OR in the mouth
The strict definition specifically includes "peripheral facial nerve palsy accompanied by an erythematous vesicular rash on the ear (zoster oticus) or in the mouth" 2. This means oral vesicles are a recognized diagnostic feature, not merely an associated finding.
Distribution of Vesicular Lesions
Vesicles can appear in multiple locations 2, 3, 4:
- External ear (pinna) and ear canal - most common
- Oral cavity/mouth
- Lips
- Combination of these sites
One documented case specifically described "vesicular lesions on the right pinna and lips" 4, while another reported "vesicles in the ear or mouth" as part of the diagnostic criteria 3.
Important Clinical Pitfall
Vesicles may appear AFTER facial paralysis begins. In a prospective study, 14% of patients developed vesicles after the onset of facial weakness 2. This means:
- Early Ramsay Hunt syndrome may be initially indistinguishable from Bell's palsy
- Absence of vesicles at initial presentation does not rule out the diagnosis
- Clinicians should maintain high suspicion and consider early antiviral treatment even before vesicles appear
Associated Features Beyond Vesicles
The vesicular rash is accompanied by additional symptoms due to proximity of the geniculate ganglion to the vestibulocochlear nerve 1, 5, 2:
- Hearing loss (sensorineural)
- Tinnitus
- Vertigo and nystagmus
- Nausea and vomiting
Treatment Implications
Because oral and auricular vesicles confirm VZV reactivation, early antiviral therapy is critical 2:
- Acyclovir 800 mg five times daily for 7-10 days, OR
- Famciclovir 500 mg three times daily for 7-10 days
- PLUS oral prednisone 60 mg daily for 3-5 days
Early treatment (within 7 days of onset) significantly improves facial palsy recovery outcomes 2.