Lepr Rev (2003) 74, 383±385
CASE REPORT
Bilateral facial palsy in Hansen's disease
ARUN C. INAMADAR & APARNA PALIT
Department of Dermatology, Venereology & Leprology,
BLDEA's SBMP Medical College, Hospital & Research Centre,
Bijapur, Karnataka, India
Accepted for publication 9 August 2003
Introduction
Bilateral lower motor neuron (LMN) facial nerve paralysis is a rare phenomenon. It can be
seen in association with brain stem encephalitis,1 basal meningitis, acute in¯ammatory
polyradiculoneuropathy, Heerfordt's syndrome, leukaemic in®ltration and osteopetrosis.
Leprosy, one of the most important causes of peripheral neuropathy in endemic countries,
can give rise to partial bilateral facial nerve paralysis. When the nerves supplying the
extraocular muscles are involved, it causes bilateral lagophthalmos and the quality of life of
the affected person is greatly impaired. Here, two such cases are described.
Patient 1
A 35-year-old male agricultural worker presented with a painful erythematous shiny plaque
lesion over the central face, and an inability to close both eyes for the previous 2 days. On
questioning, he admitted the presence of hypopigmented patches over his face and right side
of his neck for some time, for which he did not seek medical advice. On examination, there
was a large, erythematous, oedematous shiny plaque lesion of about 12 ´ 10 cm on the
mid-face, involving the upper lip, both cheeks, nose, eyelids and lower part of the forehead. A
similar lesion was seen extending from the front of the right pinna to the retroauricular area
and right side of the neck. There were no other lesions on his body. On attempting gentle
eye closure, the eyelids did not approximate and there was a bilateral Bell's phenomenon
(Figure 1). Both supraorbital and infraorbital nerves, the zygomatic branches of the facial
nerves, and the right greater auricular nerves were enlarged and tender. A skin biopsy from
the edge of the lesion on forehead showed changes suggestive of BT leprosy. A slit skin smear
from both ear lobules and the lesion on the face were positive with a BI of 1‡. The patient
was given MDT along with prednisolone. The skin reaction gradually subsided but the patient
Correspondence to: A. C. Inamadar (Tel: ‡91-8352-262770, Ext 2021; Fax: ‡91-8352-263019; e-mail:
Aparunal@rediffmail.com)
0305-7518/03/064053+03 $1.00 q Lepra
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A. C. Inamadar and A. Palit
Figure 1. Bilateral Bell's phenomenon.
was left with lagophthalmos (Figure 2). The prednisolone was tapered gradually and eye care
and physiotherapy were advised.
Patient 2
A 23-year-old male labourer presented to the ophthalmology outpatient department for
sudden onset of inability to close both eyes and epiphora of 3 days duration. He was a
diagnosed case of BT leprosy, and had been receiving MDT for the past 2 months. On
examination, there were two erythematous, shiny, tender plaque lesions, each of about
Figure 2. Persistent bilateral lagophthalmos with visible Bell's phenomenon.
Bilateral facial palsy
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7 ´ 5´5 cm, involving both cheeks. A similar lesion on the right elbow region, with a right
ulnar claw hand deformity, was recorded. Zygomatic branches of both facial nerves and
right ulnar nerves were thickened and tender. He was unable to close his eyes effectively and
exhibited bilateral Bell's phenomenon. The MDT was continued with the addition of
prednisolone in gradually tapering doses. Subsequently physiotherapy was advised for the
persistent deformities of the eyes and right hand.
Discussion
The zygomatic branch of the facial nerve crosses the zygomatic bone and adjacent part of the
maxilla to supply the lower part of the orbicularis oculi muscle.2 In this location, it is easily
involved if an overlying lesion of leprosy undergoes a type I reaction.3 This gives rise to
eversion of the lower eyelid, epiphora and a visible Bell's phenomenon demonstrable on
gentle closure of eyes.
Unlike other causes of bilateral LMN type of facial paralysis, leprosy involves individual
terminal branches of the facial nerve. These give rise to partial clinical features in the form of
bilateral lagophthalmos but the lines of facial expression are preserved. Though reported
rarely,4 in endemic countries leprosy should be considered as an important cause of bilateral
LMN facial paralysis. The action of the upper part of orbicularis oculi, which is supplied
mostly by temporal branch of facial nerve,2 is preserved in such cases. Thus a forceful
attempt of eye closure conceals the Bell's phenomenon, and a subtle deformity is masked.3
This fact should be kept in mind while evaluating the functional integrity of the facial nerve in
a leprosy patient with lesions on the face.
Lagophthalmos may persist after MDT and corticosteroid treatment and is both stigmatizing and threatening to sight. It is very important that the sufferer is properly taught the
principles of regular self-care, and may be considered for reconstructive surgery.
References
1
2
3
4
Lange DL, Trojaborg W, Rowland LP. Peripheral and cranial nerves. In: Rowland LP (ed) Merritt's textbook of
neurology, 9th edn. Williams & Wilkins, Baltimore, 1995, pp. 461±483.
Sinnatanby CS. Head and neck and spine. In: Last's anatomy, regional and applied, 10th edn. ChurchillLivingstone, Edinburgh, 2001, pp. 321±447.
Jopling WH, Mc Dougall AC. The disease. In: Handbook of leprosy, 5th edn. CBS Publications, New Delhi, 1996,
pp. 10±49.
Inamadar AC, Krishnakumar G. Bilateral facial palsy following type I reaction. Ind Pract, 1991; XLII (1): 63±64.