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Description
An otherwise healthy 23-year-old man presented to ear, nose and throat clinic with burning sensation in the mouth since 5 days, followed 4 days later by a vesicular skin eruption on half of the lower lip and extending to the ipsilateral cheek (figure 1).
Cutaneous lesions of mandibular zoster on the cheek, the lower lip and the chin, all limited to the left side.
Oral inspection revealed well circumscribed, fibrin-covered ‘patches’ on the mobile tongue, more marked on its ventral surface (figure 2A) and multiple vesicles on the mucosa of the cheek (figure 2B) and the palatoglossal arch. All lesions were strictly limited on the left side.
(A) Oral lesions of mandibular zoster occupying the tongue, the floor of the mouth and the cheek mucosa. (B) Vesicles of mandibular zoster on the cheek mucosa and lesions on the ventral surface of the mobile tongue.
Varicella-zoster virus (VZV) DNA was detected by PCR on a swab from the cutaneous lesions, confirming the diagnosis of mandibular zoster.
A month after complete regression of all acute lesions, skin hyperpigmentation and recurrent sensation of burning and stinging pain on the skin and the mouth were still persisting.
The pictures illustrate mucosal and cutaneous lesions’ distribution following sensory fibres of the mandibular nerve.
Primary infection with VZV results in varicella. As symptoms resolve, viral particles stay dormant in the sensory ganglia of the peripheral nervous system. Reactivation occurs in 30% of infected individuals1 resulting in herpes zoster with characteristic dermatome distribution.
The branch of the trigeminal nerve which is most often affected is the ophthalmic nerve. Mandibular nerve involvement is much rarer and may be accompanied by gustatory dysfunction in addition to other symptoms of zoster. Complications include postherpetic neuralgia and skin alterations (pigmentation or scarring) while rare cases of dental and mandibular involvement have been described.2 Early prescription of antiviral agents hastens acute symptoms’ resolution and possibly decreases the risk of postherpetic neuralgia.3
Learning points
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The mandibular nerve carries motor and sensory fibres, the latter distributed to part of the face and the mouth (temporal region, part of the pinna, cheek, chin, lower lip, cheek mucosa, floor of the mouth and anterior 2/3 of the tongue). Moreover, the lingual nerve's connection to the corda tympani transfers taste fibres from the mobile tongue and parasympathetic fibres to the submandibular ganglion.
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Zoster limited to the mandibular nerve is relatively rare compared to ophthalmic zoster, but not exceptional in clinical practice.
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Early initiation of antiviral treatment accelerates recovery and may decrease the risk of postherpetic neuralgia.
Footnotes
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Competing interests None.
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Patient consent Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.