Orofacial manifestations of Melkersson-Rosenthal syndrome. A study of 42 patients and review of 220 cases from the literature

Melkersson-Rosenthal Syndrome and Migraine: A New Phenotype Associated with SCN1A Variants?

Peripheral facial palsy rarely occurs as part of Melkersson-Rosenthal syndrome (MRS), which is characterized by the classical triad of tongue cheilitis, recurrent episodes of orofacial swelling, and palsy. MRS is a disorder with variable expressivity and clinical as well as genetic heterogeneity; however, the causative gene remains to be identified. Migraine is a common neurological disorder, presenting with or without aura, which may be associated with neurological symptoms. The classical example of monogenic migraine is familial hemiplegic migraine (FHM), which has phenotypic variability in carriers of variants in the same gene or even carriers of the same variant. We present a family in which two sisters displayed recurrent migraines, one of which presented recurrent facial palsy and had clinical diagnosis of MRS. We performed WES and Sanger sequencing for segregation analysis in the available family members. We identified a c.3521C>G missense heterozygous variant in SCN1A carried only by the affected sister. Variants in the SCN1A gene can cause a spectrum of early-onset epileptic encephalopathies, in addition to FHM; therefore, our finding reasonably explains the proband phenotype, in which the main symptom was recurrent facial palsy. This report also adds knowledge to the clinical spectrum of SCN1A alterations and suggests a potential overlap between MRS and FHM.

Management of orofacial granulomatosis

Orofacial granulomatosis is a chronic relapsing-remitting inflammatory condition that shares a similar phenotypic presentation to some other granulomatous diseases, particularly Crohn's disease. However, subtle clinical and pathological differences justify it as a separate disease entity. Previous studies have assessed the effectiveness of interventions used in the management of orofacial granulomatosis. This article reviews the management options available. A literature search was conducted to identify studies, in English, which assessed the effect of non-pharmacological and pharmacological interventions in the treatment of orofacial granulomatosis. The interventions were categorised into dietary modification, pharmacological (topical, intralesional and systemic therapy), surgery and psychological. A combination of interventions is often required to effectively manage each patient. There is convincing evidence that diet plays a role in disease severity. In patients where dietary manipulation alone is unsuccessful, topical, intralesional and/or systemic treatment may be considered to manage the condition.

Recurrent Facial Nerve Paralysis: A Case report on Melkersson-Rosenthal Syndrome

This is a case report of a 27-year-old male who presented with recurrent facial swelling and weakness. The clinical evaluation revealed that the patient had Melkersson-Rosenthal syndrome (MRS), a rare neurological disease characterized by the triad of recurrent facial edema, recurrent facial muscle weakness, and a furrowed or fissured tongue. Accurate data regarding the incidence of MRS is challenging to obtain due to the rarity of the disorder, and early recognition and treatment can potentially reduce the probability of permanent disability.

Association between cheilitis granulomatosa and odontogenic infections: A case-control study

The association between cheilitis granulomatosa and dental infections (dental caries and apical periodontitis) is still not well understood. Herein, we aimed to investigate the association in large hospital cases with cohort controls. Cheilitis granulomatosa cases (n = 181) were retrieved from Peking University Hospital of Stomatology and age- and sex-matched to controls (n = 181). The χ² -test, Student's t-test, and Mann-Whitney U-test were used to compare the differences between groups. The χ² -test and odds ratio were used to verify if there was an association and risk relationship. The results showed that both dental caries and apical periodontitis were associated with cheilitis granulomatosa (p < 0.001). Individuals with cheilitis granulomatosa had approximately a twofold increased frequency of dental caries than those without cheilitis granulomatosa (104/181, 57.5% vs. 53/181, 29.3%) (p < 0.001). The odds ratio of dental caries occurring in the case group compared to the control group was 3.211. The frequency of apical periodontitis in patients with cheilitis granulomatosa was significantly greater than in those without cheilitis granulomatosa (109/181, 60.2% vs. 28/181, 15.5%) (p < 0.001). The odds ratio was 8.272. Moreover, apical periodontitis was also locationally related to cheilitis granulomatosa (p < 0.001). Collectively, our study showed that the foci of dental infections are associated with cheilitis granulomatosa, suggesting that proper treatment of focal teeth may be important in the management of cheilitis granulomatosa.

An interesting case of lip swelling!

Melkersson-Rosenthal Syndrome (also termed "Miescher-Melkersson-Rosenthal Syndrome") or (MRS), is a rare neurocutaneous disorder characterized by the clinical triad of recurring facial nerve paralysis, swelling of one or both lips and fissural tongue. We report a patient with Melkersson-Rosenthal Syndrome initially referred to Dermatology Department as angioedema. The diagnosis and treatment procedures were presented with special emphasis to the clinical features of this rare condition.

Orofacial granulomatosis: Clinical and therapeutic features in an Italian cohort and review of the literature

BACKGROUND

Orofacial granulomatosis (OFG) is characterized by granulomatous inflammation of the soft tissues of maxillofacial region. We explored OFG patients from 10 different Italian centers and summarized the most recent literature data.

METHODS

A review of patients with OFG was carried out. An extensive online literature search was performed to identify studies reporting diagnosis and management of OFG.

RESULTS

Thirty-nine patients were recruited between January 2018 and February 2020. Most of them (97.4%) displayed involvement of the lips, and 28.2% suffered from Melkersson-Rosenthal syndrome. Two patients received diagnosis of CD and one patient of sarcoidosis, suggesting secondary OFG. Oral aphthosis and cervical lymphadenopathy were also described. The mean diagnostic delay was 3.4 years. Histological evaluation was performed in 34/39 patients (87.2%); non-caseating granulomas were found in 73.5% of them. Neurological symptoms (28.2%), gastrointestinal symptoms in absence of overt inflammatory bowel disease (IBD) (20.5%), and atopy (35.9%) were also identified. Therapeutic approaches varied among the centers. Steroids (51.3%) were used with good or partial results. Anti-TNF-α and anti-IgE monoclonal antibodies were used in 6 (15.4%) and 1 (2.6%) patients, respectively, with variable results. Surgery was the choice for 2 patients with good response.

CONCLUSIONS

OFG is a rare and neglected disease showing multiple clinical phenotypes. While early diagnosis is crucial, management is difficult and highly dependent on the expertise of clinicians due to the lack of international guidelines. There is a need to establish registry databases and address challenges of long-term management.

Chronic macrocheilia: a clinico-etiological series of 47 cases

BACKGROUND

Macrocheilia is an inflammatory disfiguring condition responsible for the swelling of the lips. This multi-etiological entity represents a diagnostic and therapeutic challenge. Published data on macrocheilia is scarce, often limited to granulomatous cheilitis.

METHODS

We conducted a retrospective study, including all patients presenting with chronic macrocheilia (CM) for nineteen years. CM was defined as a persistent enlargement of one or both lips for at least eight weeks. Both descriptive and analytical analyses were performed.

RESULTS

Of the 47 patients identified, 20 (43%) had cutaneous leishmaniasis, 10 (21%) had Miescher's cheilitis, five (11%) had Melkersson-Rosenthal syndrome, five (11%) had sarcoidosis, one (2%) had lepromatous leprosy, one (2%) had systemic amyloidosis, and one (2%) had Crohn's disease. In four cases, the CM was unlabeled. Ulcerations were significantly associated with leishmaniasis (P < 0.05). Histological study showed a granulomatous infiltrate in 72% of cases. Medical treatment was adapted to the etiology of CM. Surgery was performed in two cases. Improvement of CM secondary to leishmaniasis was seen in all cases. In patients with idiopathic orofacial granulomatosis, partial improvement was noted in four cases and a total improvement in one case. Recurrences were noted in three cases after complete regression.

CONCLUSIONS

Macrocheilia is a rare and disfiguring condition that requires an etiological investigation, considering that it can reveal a serious underlying systemic disease. We identified several factors that could help recognize the cause of CM, including age, history of intermittent swelling, the extent of lip enlargement, the existence of ulceration, and systemic symptoms.

Clinical Profile of Melkersson-Rosenthal Syndrome/Orofacial Granulomatosis: A Review of 51 Patients

BACKGROUND

Melkersson-Rosenthal syndrome (MRS) is a rare disease characterized by the triad of granulomatous cheilitis, fissured tongue, and facial paralysis. Publications concerning large series are rare in the literature.

OBJECTIVES

To describe the clinical and histopathological characteristics of patients with complete and oligosymptomatic forms of MRS.

METHODS

A retrospective records review was performed for the diagnoses of Melkersson-Rosenthal syndrome, granulomatous cheilitis, and orofacial granulomatosis at oral Diseases Clinic of the Department of Dermatology, University of São Paulo, Brazil (2003, 2017).

RESULTS

A total of 51 patients were included, mean age at presentation 35.69 years. Four patients were younger than 18 years. The complete triad of was observed in 10 patients. The rare findings of granulomatous blepharitis, gingivitis and palatitis are presented. Comorbidities included Crohn's disease (5 patients), migraine headaches (1 patient) and convulsions (2 patients). Granulomatous inflammatory infiltrate was detected in 31 biopsies. Medical therapies included included oral and intralesional steroids, thalidomide, dapsone, azathioprine, tetracycline, methotrexate, and surgery, with variable responses.

CONCLUSIONS

Our report meant to draw attention to the clinical spectrum of this rare disorder, mainly to oligosymptomatic forms and rarer presentations.

The histopathological spectrum of Melkersson-Rosenthal syndrome: Analysis of 47 cases

BACKGROUND

Melkersson-Rosenthal syndrome (MRS) is a rare disease characterized by the triad of recurrent orofacial edema, relapsing facial paralysis and plicated tongue. Histopathological features of MRS have not been extensively analyzed.

METHODS

This study investigated the histopathological aspects of oral lesions from 47 MRS patients.

RESULTS

The most common biopsy site was the upper lip, followed by the lower lip, gingiva and palate. The most important findings were ill-defined and well-formed granulomas. Lymphoplasmacytic inflammatory infiltrate was seen in early and late stages of MRS. Edema, fibrosis, vasodilatation and congestion were the most common finding in the lamina propria. Gingival and palate exams also demonstrated granulomatous infiltrates. Regarding the evolution time of the disease, we demonstrated that, in initial phases, there is a lymphoplasmacytic inflammatory infiltrates, followed by a granulomatous infiltrate and, subsequently, fibrosis.

CONCLUSION

Histopathological examination of oral lesions is helpful for the diagnosis of MRS; the absence of granulomatous inflammation does not exclude the diagnosis of syndrome. Clinical and histopathological analysis of the rare gingival and palate lesions is important, since all histopathological findings of the disease were detected in these sites.

Think Melkersson-Rosenthal Syndrome: A Fissured Tongue With Facial Paralysis

Melkersson-Rosenthal syndrome (MRS) was first described and named after E. Melkersson in 1928 and C. Rosenthal in 1931. MRS is a rare cause of recurrent facial nerve palsy and can manifest as facial paralysis, orofacial edema, and/or tongue fissuring. Presenting with the complete triad, it was scarcely reported in literature. However, the patient reported here had the complete triad. MRS should be considered when facial paralysis is recurrent or when it presents with orofacial edema, and/or tongue fissuring. 

A severe case of cheilitis granulomatosa: clinical-pathologic findings and management

INTRODUCTION

Cheilitis granulomatosa is an idiopathic granulomatous disorder which is rare and cosmetically disturbing. It presents with a persistent painless labial swelling which obscure etiology. Diagnosis is mainly based on the histopathological features following biopsy. There is no definitive treatment of this disease, reason being its lack of well-defined etiology. It has been proven largely resistant to most of the treatment options.

CASE DESCRIPTION

A 28-year-old man presented with the labial swelling which was confirmed to be cheilitis granulomatosa following histopathologic examination. We have successfully managed this case using intralesional steroids.

CONCLUSION

Intralesional steroids can be used successfully in management of cheilitis granulomatosa.

Systematic review of oral and craniofacial findings in patients with Fabry disease or Pompe disease

Fabry disease and Pompe disease are rare lysosomal storage disorders that belong to a heterogeneous group of more than 200 distinct inborn metabolic diseases. Mutations followed by loss of function of enzymes or transporters that are localised in the acidic environment of the lysosome may result in degradation of many substrates, such as glycosaminoglycans, glycosphingolipids, glycogen, cholesterol, oligosaccharides, glycoproteins, and peptides, or the excretion of the products degraded by the lysosome. Our aim was to identify the oral signs and symptoms of Fabry disease and Pompe disease from a systematic review made using MEDLINE/PubMed, and a hand search for relevant articles, following the PRISMA guidelines. Both diseases show various craniofacial and oral changes, including supernumerary teeth, dental agenesis, angiokeratoma, and telangiectases in Fabry disease; and macroglossia, teeth fusion, and taurodontism in Pompe disease. Common clinical signs of Fabry disease include hyposalivation, hypohidrosis, and xerophthalmia, and a generally reduced physical resilience was apparent in patients with Pompe disease. Oral and craniofacial changes in patients with both diseases extend over their entire lifetime and can be detected even in an infant. Lysosomal storage diseases should be taken into consideration in the differential diagnosis of relevant diverse symptoms, because treatment, when available, is most effective when started early. The main therapeutic concepts are enzymatic replacement for Pompe disease, whereas patients with Fabry disease require additional oral chaperone treatment or enzyme replacement.

Angioedema Masqueraders

Angioedema is a common reason for referral to immunology and allergy specialists. Not all cases are in fact angioedema. There are many conditions that may mimic its appearance, resulting in misdiagnosis. This may happen when a clinician is unfamiliar with conditions resembling angioedema or when there is a low index of clinical suspicion. In this article, we explore a list of differential diagnoses based on body parts, including the lips, the limbs, periorbital tissues, the face, epiglottis and uvula, as well as the genitalia, that may pose as a masquerader even to an experienced eye.

Melkersson⁻Rosenthal Syndrome in Childhood: Report of Three Paediatric Cases and a Review of the Literature

Melkersson–Rosenthal syndrome (MRS) in children is a rare condition, clinically characterised by a triad of synchronous or metachronous symptoms: recurrent peripheral facial palsy, relapsing orofacial oedema, and a fissured tongue; the most recent review published on the topic has reported 30 published patients. The aetiology of this disease is still unclear. However, genetic factors, as well as alterations in immune functions, infections, and allergic reactions have been postulated. We report three children suffering from MRS and perform a literature review of paediatric cases. Taking into account that clinical and laboratoristical criteria for the diagnosis of MRS are lacking, this syndrome is probably underestimated, and we suggest increasing awareness of such a rare syndrome. Close multidisciplinary follow-up of these children with a team composed by paediatricians, neurologists, neuro-ophthalmologists, dermatologists, and otolaryngologists is crucial to guarantee exhaustive management and treatment success, while minimising relapses.

[Recurrent and alternating peripheral facial palsy in a Rehabilitation department]

Peripheral facial palsy is a relatively frequent condition in rehabilitation departments. The most common aetiology is idiopathic, known as Bell's palsy, which usually has a good prognosis and resolves without sequels. The presence of uncommon symptoms with the facial palsy should lead to suspicion of another possible aetiology, as occurred in the case presented here. Melkersson-Rosenthal's syndrome is one of the entities to keep in mind in the diagnosis of atypical facial palsies. This is an underdiagnosed disease due to the variability of its clinical manifestations. Classically, it manifests as a recurrent and alternating facial edema with peripheral facial palsy and fissured tongue.

Melkersson-Rosenthal Syndrome: A Rare Cause of Recurrent Facial Nerve Palsy and Acute Respiratory Distress Syndrome

Melkersson-Rosenthal Syndrome (MRS) is a rare disease characterized by persistent or recurrent orofacial oedema, relapsing peripheral facial paralysis, and furrowed tongue. Pathologically, granulomatosis is responsible for oedema of face, labia, oral cavity, and facial nerve. We present a patient with MRS admitted to our hospital with acute respiratory distress syndrome (ARDS). 45-year-old woman was admitted to an emergency department with dyspnea and swelling on her hands and face. She was intubated because of ARDS and accepted to intensive care unit (ICU). After weaning from ventilatory support, peripheral facial paralysis was diagnosed and steroid treatment was added to her therapy. On dermatologic examination, oedema on her face, pustular lesions on her skin, and fissure on her tongue were detected. The patient informed us about her recurrent and spontaneous facial paralysis in previous years. According to her history and clinical findings, MRS was diagnosed.

Melkersson-Rosenthal Syndrome: the possible role of comorbidities in the etiopathogenesis

BACKGROUND

Melkersson-Rosenthal Syndrome (MRS) is a rare syndrome. Recently, possible association between MRS and psoriasis was reported. Our objective is to evaluate the presence of comorbidities in MRS with a focus on psoriasis-related morbidities.

METHODS

We conducted a case-control study consisting of a series of 12 patients with MRS and two groups of age- and gender-matched controls: 30 patients with psoriasis vulgaris and 28 patients with acute contact dermatitis. A comparative analysis for the prevalence of comorbidities, with a focus on psoriasis-related morbidities, was done.

RESULTS

Psoriasis-related morbidities including smoking, obesity, dyslipidemia, hypertension, and diabetes mellitus were recorded in 5 (42%) patients with MRS, compared to 15 (50%) patients with psoriasis and 2 (7%) patients with acute contact dermatitis. The prevalence of psoriasis-related morbidities did not differ significantly between the group of patients with MRS and the group of patients with psoriasis. On the other hand, the difference between the group of patients with MRS and the group of patients with contact dermatitis was statistically significant (P=0.01).

CONCLUSIONS

The similar prevalence of psoriasis-related morbidities in MRS and in psoriasis may further support an association between MRS and psoriasis.

Management of orofacial granulomatosis: a case report

Introduction: Orofacial granulomatosis is characterized by recurrent swelling affecting the lips, cheeks, and tongue. The rarity of this pathology and the lack of consensus in therapeutic management make the reporting of this clinical case relevant. Observation: A 48-year-old man consulted for labial and gingival orofacial granulomatosis. The treatment consisted of 40 mg/L injections of triamcinolone acetonide once weekly for 3 weeks. The symptoms improved after 1 week of treatment. Comments: The usual treatment for this condition targets the inflammation caused by the lesion. Corticosteroids (clobetasol, triamcinolone acetonide, prednisolone), monoclonal antibodies (infliximab, adalimumab), or TNF-α inhibitors are commonly used. Symptom recurrenceis frequently observed after treatment with corticosteroids. Biotherapies are often used as a second-line treatment. Conclusion: Orofacial granulomatosis symptoms are rare and difficult to diagnose due to its varying manifestations. Common treatments target one of the steps of the inflammatory response. The detection of specific cellular markers is a way to enable a more precise etiological diagnosis and allows for a more targeted therapy.

Miescher's cheilitis: Surgical management and long term outcome of an extremely severe case

INTRODUCTION

Miescher's cheilitis is clinically characterized by persistent swelling of the lip(s). Its pathogenesis is still unknown. Histopathologically is characterized by sub-epithelial edema, increased number of dilated lymphatic vessels and an inflammatory infiltrate and/or non-caseating/non- necrotic granulomas. Even if the disorder must be controlled by medical therapy, surgery may be required to treat most severe cases.

PRESENTATION OF THE CASE

We report a 30-year-old man who presented a persistent swelling of both lips since 8 years, previously treated with intralesional steroid and immunosuppressive therapy. Clinical examination did not show facial nerve palsy or other associated conditions. On the base of clinical and histopathological findings, a diagnosis of Miescher's syndrome was made. Patient underwent Conway's reduction cheilopasty repaired with local flaps. At one-year follow-up, the patient does not show local recurrence of the deformity; both oral continence and lip sensation are preserved.

DISCUSSION

Because of its extreme rarity and unknown etiopathogenesis, Miescher's cheilitis receives poor attention and may often remain misdiagnosed. Several medical therapies are proposed, in particular steroids and immunosuppression. Even if medical therapy remains the main treatment, surgery may be required.

CONCLUSION

Satisfactory results have been obtained combining medical therapy and surgical approach.

Diagnostic approach to sudden onset of diffuse isolated oedema of the lips

In the light of a case of sudden onset of diffuse, isolated oedema of the lips, the authors describe the key points of the diagnostic approach and the main epidemiological and clinical data.

Melkersson-rosenthal syndrome: a case report

Melkersson-Rosenthal Syndrome (MRS) is a rare disorder consisting of a triad of persistent or recurrent orofacial edema, relapsing facial paralysis and fissured tongue. It is rarely possible to observe all aspects of the classical triad at the same time, since these symptoms may appear in different times of life cycle. The most common symptom is orofacial edema. Although etiology of MRS is unclear, various factors such as infections, genetic predisposition, immune deficiency, food intolerance and stress have been held responsible. MRS is diagnosed based on clinical features. This case report describes a 39 years old male patient with recurrent swelling of the upper lip. Clinical examinations showed classical triad of MRS. The diagnosis and treatment procedures were presented with special emphasis to the clinical features of this rare condition.

Diagnosis of Lingual Atrophic Conditions: Associations with Local and Systemic Factors. A Descriptive Review

Atrophic glossitis is a condition characterised by absence of filiform or fungiform papillae on the dorsal surface of the tongue. Consequently, the ordinary texture and appearance of the dorsal tongue, determined by papillary protrusion, turns into a soft and smooth aspect.

Throughout the years, many factors, both local and systemic, have been associated with atrophic glossitis as the tongue is currently considered to be a mirror of general health. Moreover, various tongue conditions were wrongly diagnosed as atrophic glossitis. Oral involvement can conceal underlying systemic conditions and, in this perspective, the role of clinicians is fundamental.

Early recognition of oral signs and symptoms, through a careful examination of oral anatomical structures, plays a crucial role in providing patients with a better prognosis.

A rare case of primary orofacial granulomatosis of gingiva during pregnancy

Orofacial granulomatosis (OFG) comprises a group of diseases characterized by noncaseating granulomatous inflammation affecting the soft tissues of the oral and maxillofacial region. It is important to establish the diagnosis accurately because this condition is sometimes a manifestation of many systemic conditions like Crohn's disease or sarcoidosis. The clinical outcome of OFG patients continues to be unpredictable. Current therapies remain unsatisfactory. This article reports a rare case of isolated OFG with langhans type giant cells and inflammatory infiltrate without any systemic involvement, in which the condition was a manifestation of pregnancy. The diagnostic approach to and the treatment of OFG are reviewed.

Obsessive-compulsive disorder concurrent with Melkersson-Rosenthal Syndrome: a case report

OBJECTIVE

To describe a case of obsessive-compulsive disorder (OCD) comorbid with Melkersson-Rosenthal Syndrome (MRS).

METHODS

We present a case study of comorbid OCD and MRS in a 13-year-old girl.

RESULTS

She admitted to doubt obsessions and a control compulsion. The patient history included frequent facial palsy attacks, and she took prednisolone during each attack. She had her first such attack at 5 years of age, and she had suffered five attacks since then, the last one occurring 2 months before her presentation. Her obsessions began 1 week after the last attack. She was diagnosed MRS and concurrent OCD based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnostic criteria. She was started on 20 mg/day fluoxetine. The control compulsion subsided during the second month of therapy, and the doubt obsessions improved significantly.

CONCLUSION

Considering that the etiologies of MRS and childhood-onset OCD have been attributed to infectious agents and autoimmune events, we conclude that both causes may play an important role in the etiology of these conditions.

Clinicopathological significance of Melkersson-Rosenthal syndrome

Melkersson-Rosenthal syndrome (MRS) classically shows a triad of orofacial swelling, fissured tongue and facial palsy, more commonly the oligosymptomatic form. The orofacial swelling is characterised by swollen reddish-brown non-pruritic lips and facial oedema. In one-third to one half of patients, fissured tongue is seen, which also aids in diagnosis. The histological finding of MRS includes non-caseating, sarcoidal granulomas, but their absence does not exclude the diagnosis. All these findings together form a basis for a cautious search for confrontational reasons for the symptom complex of MRS.

Review article: non-malignant oral manifestations in inflammatory bowel diseases

BACKGROUND

Patients with inflammatory bowel diseases (IBD) may present with lesions in their oral cavity. Lesions may be associated with the disease itself representing an extraintestinal manifestation, with nutritional deficiencies or with complications from therapy.

AIM

To review and describe the spectrum of oral nonmalignant manifestations in patients with inflammatory bowel diseases [ulcerative colitis (UC), Crohn's disease (CD)] and to critically review all relevant data.

METHODS

A literature search using the terms and variants of all nonmalignant oral manifestations of inflammatory bowel diseases (UC, CD) was performed in November 2014 within Pubmed, Embase and Scopus and restricted to human studies.

RESULTS

Oral lesions in IBD can be divided into three categories: (i) lesions highly specific for IBD, (ii) lesions highly suspicious of IBD and (iii) nonspecific lesions. Oral lesions are more common in CD compared to UC, and more prevalent in children. In adult CD patients, the prevalence rate of oral lesions is higher in CD patients with proximal gastrointestinal tract and/or perianal involvement, and estimated to range between 20% and 50%. Oral lesions can also occur in UC, with aphthous ulcers being the most frequent type. Oral manifestations in paediatric UC may be present in up to one-third of patients and are usually nonspecific.

CONCLUSIONS

Oral manifestations in IBD can be a diagnostic challenge. Treatment generally involves managing the underlying intestinal disease. In cases presenting with local disabling symptoms and impaired quality of life, local and systemic medical therapy must be considered and/or oral surgery may be required.

Orofacial Granulomatosis

Orofacial granulomatosis (OFG) is an uncommon chronic inflammatory disorder of the orofacial region. It is characterized by subepithelial noncaseating granulomas and has a spectrum of possible clinical manifestations ranging from subtle oral mucosal swelling to permanent disfiguring fibrous swelling of the lips and face. Etiopathogenesis is unknown. A range of systemic granulomatous disorders, including Crohn disease and sarcoidosis, may cause orofacial manifestations that cannot be distinguished from those of OFG. Treatment of OFG has proven difficult and unsatisfactory, with no single therapeutic model showing consistent efficacy in reducing orofacial swelling and mucosal inflammation.

Recurrent facial palsy in Melkersson Rosenthal syndrome: total facial nerve decompression is effective to prevent further recurrence

OBJECTIVE

To study the role of total facial nerve decompression in preventing further recurrence of facial palsy in Melkersson Rosenthal syndrome (MRS).

METHODS

Total facial nerve decompression was performed on nine patients with recurrent facial palsy in MRS, and prednisolone treatment was given to 6 cases who declined surgery. They were incorporated into surgery group and control group, respectively. Patients in surgery group and control group were followed up for 5.4 ± 1.4 years (range, 4 to 8 years) and 6.0 ± 1.4 years (range, 4 to 8 years), respectively.

RESULTS

Further episodes of facial palsy affected none of 9 cases (0.0%) in surgery group, while they affected 3 of 6 cases (50.0%) in control group, with significant difference (p<0.05).

CONCLUSIONS

Total facial nerve decompression was effective to prevent further episodes of facial palsy in MRS.

Melkersson-Rosenthal syndrome

Melkersson-Rosenthal syndrome (MRS) is a rare, non-caseating granulomatous disorder of unknown etiology and undefined diagnostic criteria. The classical triad of recurrent orofacial edema, relapsing facial paralysis, and fissured tongue, is not frequently seen in its complete form, and many patients remain misdiagnosed or undiagnosed for years. The purpose of this study is to review the findings in the literature describing the Melkersson-Rosenthal syndrome with aim to identify its clinical and histopathological characteristics and correlate them with definitive diagnostic criteria and effective treatment modalities. A systematic review and analysis of more than 100 publications met eligibility criteria performed by the authors. Orofacial edema of unknown etiology is the most typical clinical feature of the Melkersson-Rosenthal syndrome. Its coexistence with of facial nerve palsy or fissured tongue could be characterized as an oligosymptomatic MRS. Many investigators suggest cheilitis granulomatosa as a monosymptomatic form of MRS, while patients with facial palsy and fissured tongue, without orofacial edema, should not be considered having MRS. Histological evidence is not necessary. Corticosteroids are generally accepted as the mainstay treatment.

Orofacial granulomatosis: clinical signs of different pathologies

Orofacial granulomatosis (OFG) is an uncommon disease characterized by persistent or recurrent soft tissue enlargement, oral ulceration and a variety of other orofacial features. It could be an oral manifestation of a systemic disease. For a correct differential diagnosis, local and systemic conditions characterized by granulomatous inflammation should be excluded using appropriate clinical and laboratory investigations. In fact, the diagnosis of OFG may be confirmed only by histopathological identification of noncaseating granulomas. The literature from 1943 to 2014 was reviewed with emphasis on the etiology of OFG and on clinical manifestations of systemic pathologies associated with OFG. The precise cause of OFG is still unknown, although several theories have been suggested, such as infection, hereditary factors and allergy. OFG is a disease that has a wide spectrum of presentation, which may include the oral manifestation of a systemic condition such as Crohn's disease, sarcoidosis, granulomatosis with polyangiitis and Melkersson-Rosenthal syndrome.

Idiopathic orofacial granulomatosis - a diagnostic and treatment challenge

Orofacial granulomatosis is an uncommon disease, usually presenting as recurrent or persistent swelling of the soft tissues, predominantly lips - termed as Cheilitis Granulomatosa. Though various aetiological factors like foreign body reactions, infections, Crohn's disease and Sarcoidosis have been implicated in the disease process. Delayed Hypersensitivity reaction with a predominant Th1-mediated immune response provide further evidence to the etiopathogenesis in Orofacial granulomatosis. The term Idiopathic Orofacial Granulomatosis is used in cases with unknown aetiology. This case report describes Idiopathic Orofacial granulomatosis in a 25-year-old male patient with persistent upper lip swelling and gingival enlargement. Management with intralesional triamcinolone acetonide 40mg, twice a week for three weeks, resulted in significant remission without recurrence after a eight month follow up.

Melkersson-Rosenthal syndrome: a retrospective study of 44 patients

CONCLUSION

When patients with recurrent facial paralysis are encountered, otolaryngologists should check for fissured tongue, and question those patients about orofacial edema, minor symptoms, and family history. Histologic evidence is not necessary for the diagnosis of Melkersson-Rosenthal syndrome (MRS), while coronary high-resolution CT (HRCT) reconstruction of temporal bone and food allergen detection may be beneficial. Prophylactic decompression of the facial nerve for patients with appropriate electrophysiological indication may prevent further facial palsy attacks.

OBJECTIVES

The objective of this study was to analyze the clinical features of a group of patients with MRS with major complaints of facial palsy treated at the Department of Otorhinolaryngology, and to comment on MRS from the perspective of otolaryngologists.

METHODS

A retrospective review of patient database for the last 6 years in the Department of Otorhinolaryngology in Beijing Shijitan Hospital was performed to find patients diagnosed with MRS.

RESULTS

A total of 44 MRS patients were included in this study. The mean age at onset was 14.1 years. A total of 13 (29.5%) patients had family history, 17 (38.6%) revealed broadened fallopian canal on coronary HRCT reconstruction of temporal bone, and 20/23 (87.0%) patients showed positive results in food allergen detection. Thirty-one patients accepted subtotal facial nerve decompression and only one patient had facial palsy recurrence on the same side as the operation.

Facial Palsy in Melkersson-Rosenthal Syndrome and Bell’s Palsy

Objective:

The aim of this study was to compare genetic predilection and recurrence tendency between facial palsy in Melkersson-Rosenthal syndrome (MRS) and Bell’s palsy

Methods:

We carried out an investigation on patients with facial palsy in MRS and those with Bell’s palsy who visited the outpatient department in our hospital between February 2009 and February 2013. They were asked about familial history and whether it was the first episode, with the results recorded and compared.

Results:

There were 16 patients with facial palsy in MRS and 860 patients with Bell’s palsy involved in the study. Familial history was positive in 5 of 16 patients (31.3%) with facial palsy in MRS and 56 of 860 patients (6.5%) with Bell’s palsy ( P < .01). Twelve of 16 cases (75%) with facial palsy in MRS and 88 of 860 cases (10.2%) with Bell’s palsy had a history of facial palsy in the past ( P < .01).

Conclusion:

Compared to Bell’s palsy, facial palsy in MRS has an obvious genetic predilection and recurrence tendency.

Melkersson-Rosenthal syndrome: a facial nerve center perspective

OBJECTIVES

Melkersson-Rosenthal syndrome (MRS) is a rare neuro-mucocutaneous granulomatous disorder of unknown etiology, characterized by the triad of facial palsy, lingua plicata (fissured tongue), and orofacial edema. Few articles in the literature report series with more than 20 patients or focus on the facial nerve dominant presentation of MRS.

METHODS

We performed a retrospective review of the patients diagnosed with MRS at a university-based Facial Nerve Center.

RESULTS

Twenty-one patients were identified from 1971 to 2010. The age of presentation ranged from 22 to 67 years (mean 44.1). Seven (33.3%) were male and 14 (66.7%) were female. All (100%) patients had facial paralysis. Fourteen (66.7%) patients who initially presented with unilateral paralysis subsequently developed metachronous contralateral paralysis (alternating unilateral facial paralysis). One (4.7%) patient had simultaneous bilateral facial paralysis. The number of episodes per patient ranged from 1 to 8 (mean 3.1). Laterality was relatively equal: 35 episodes occurred on the right side and 31 on the left. The patient with most episodes of facial paralysis had four on the left and four on the right (metachronous). This was followed by three patients with six episodes each. The age of first incidence of facial paralysis ranged from 2 to 60 years (mean 34.4, median of 39). The mean interval between episodes was 4.7 years (range 0-30, median 3). Six (28.5%) of the patients reported a family history of MRS.

CONCLUSIONS

MRS is a rare disease of unknown pathogenesis in which oligosymptomatic forms predominate. Patients with this disease may present to different specialties complaining of different symptoms, and frequently, not all the classic features of the triad will be present. In our series of facial paralysis patients diagnosed with MRS, a higher proportion had the full triad of symptoms than has been previously reported in the literature.

Subtotal facial nerve decompression for recurrent facial palsy in Melkersson Rosenthal syndrome

CONCLUSIONS

Subtotal facial nerve decompression seems effective to prevent further episodes of facial palsy and promote facial nerve recovery for recurrent facial palsy in Melkersson Rosenthal syndrome (MRS). The main inflammatory sites of recurrent facial palsy in MRS may be the mastoid segment, tympanic segment, geniculate ganglion, and labyrinthine segment.

OBJECTIVE

To present our surgical experience in preventing further episodes of facial palsy and improving facial nerve recovery of patients with recurrent facial palsy in MRS.

METHODS

We performed transmastoid subtotal facial nerve decompression on eight patients with recurrent facial palsy in MRS. They were followed up for 3.3 years on average (range 2-5 years).

RESULTS

There were no further attacks of facial palsy in any of the cases. Seven cases (87.5%) recovered to grade I or grade II, and three of eight cases (37.5%) recovered completely. We found obvious edema of the facial nerve at the mastoid segment in all cases, at the tympanic segment and geniculate ganglion in five cases (62.5%), and at the labyrinthine segment in only one case (12.5%).

Clinical evidence for allergy in orofacial granulomatosis and inflammatory bowel disease

Background

Orofacial granulomatosis (OFG) causes chronic, disfiguring, granulomatous inflammation of the lips and oral mucosa. A proportion of cases have co-existing intestinal Crohn’s disease (CD). The pathogenesis is unknown but has recently been linked to dietary sensitivity. Although allergy has been suggested as an aetiological factor in OFG there are few published data to support this link. In this study, we sought clinical evidence of allergy in a series of patients with OFG and compared this to a series of patients with inflammatory bowel disease (IBD) without oral involvement and to population control estimates.

Methods

Prevalence rates of allergy and oral allergy syndrome (OAS) were determined in 88 patients with OFG using questionnaires, skin prick tests, total and specific serum IgE levels. Allergy was also determined in 117 patients with IBD without evidence of oral involvement (79 with CD and 38 with ulcerative colitis (UC)).

Results

Prevalence rates of allergy in patients with OFG were significantly greater than general population estimates (82% versus 22% respectively p = <0.0005). Rates of allergy were also greater in those with CD (39%) and, interestingly, highest in those with OFG and concurrent CD (87%). Conversely, whist OAS was common in allergic OFG patients (35%) rates of OAS were significantly less in patients with concomitant CD (10% vs 44% with and without CD respectively p = 0.006). Amongst CD patients, allergy was associated with perianal disease (p = 0.042) but not with ileal, ileocolonic or colonic disease location. Allergy in UC (18%) was comparable to population estimates.

Conclusion

We provide compelling clinical evidence for the association of allergy with OFG whether occurring alone or in association with CD. The presence of gut CD increases this association but, conversely, reduces the expression of OAS in those with atopy. Interestingly, there is no evidence of increased allergy in UC.

An update on granulomatous diseases of the oral tissues

With new insights into the pathogenesis of specific granulomatous diseases, and with the advent of high-throughput genetic screening and availability of next-generation biological therapies, clinicians have several options at their disposal to help ensure accurate diagnosis and effective treatment. This article highlights some of the current knowledge about the more common granulomatous systemic diseases that may be encountered in clinical practice.

Clinical behaviour and long-term therapeutic response in orofacial granulomatosis patients treated with intralesional triamcinolone acetonide injections alone or in combination with topical pimecrolimus 1%

BACKGROUND

Orofacial granulomatosis (OFG) is a relapsing inflammatory disorder of unknown aetiology and non-standardized treatment protocols. The aim of this study was to assess the clinical behaviour and long-term therapeutic response in OFG patients treated with intralesional triamcinolone acetonide (TA) injections alone or in combination with topical pimecrolimus 1%, as adjuvant, in those patients partially responders to TA.

METHODS

We analysed data from 19 OFG patients followed-up for 7 years. Demographic characteristics, clinical behaviour and long-term therapeutic response were investigated.

RESULTS

Eleven (57.9%) OFG patients treated with intralesional TA injections therapy reached first complete clinical remission in a mean time of 10 ± 2.2 (95% CI, 8.5-11.5) weeks, while eight (42.1%) patients, partially responders to intralesional TA injections, were treated with TA injections plus topical pimecrolimus 1%, as adjuvant, achieving complete clinical remission in a mean time of 29.8 ± 7.8 (95% CI, 23.2-36.3) weeks. Relapses occurred in four TA responder patients with a disease-free time of 35.8 ± 8.7 (95% CI, 21.9-46.4) weeks and in five patients treated with TA and topical pimecrolimus 1% with a disease-free time of 55.8 ± 18.5 (95% CI, 32.8-78.8) weeks. Patients were followed-up for a mean time of 56.3 ± 18.2 (95% CI, 47.6-65.1) months. At last control, all 19 patients were in complete clinical remission.

CONCLUSION

These preliminary data suggest that intralesional TA injections still represent a mainstay in the treatment of OFG. It is unclear the role of topical pimecrolimus, as adjuvant, in leading OFG patients, partly responders to intralesional TA injections, to a complete clinical remission.

Cheilitis granulomatosa: a case report with review of literature

Cheilitis granulomatosa (CG) is a chronic swelling of the lip due to granulomatous inflammation. It is a rare inflammatory disorder first described by Miescher in 1945. It is a monosymptomatic form or an incomplete variant of Melkersson-Rosenthal syndrome; a triad of recurrent orofacial edema, recurrent facial nerve palsy and fissuring of the tongue. As the etiology remains unknown, treatment of CG is challenging. We present a case of CG in a 43-year-old female patient secondary to allergy to certain food items. The present case highlights the importance of thorough investigations in the diagnosis of this lesion as the findings mimic many other granulomatous conditions.

Melkersson-Rosenthal syndrome: a review of seven patients

Melkersson-Rosenthal syndrome (MRS) is a rare disorder consisting of a triad of persistent or recurrent orofacial edema, relapsing facial paralysis and fissured tongue. It is difficult to diagnose and treat. A retrospective review of our MRS patients was performed. The medical files, and treatment, radiologic and histopathologic records of these patients were reviewed. The study group consisted of seven male MRS patients. In four patients, the three classical manifestations were present simultaneously. Neuroimaging examinations found facial soft-tissue thickening and swelling in two patients. The indicators of the disease in our patients were as follows: two had family histories, two had elevated levels of protein in the cerebrospinal fluid, one had an increased immunoglobulin G level in the blood and one had reactive arthritis. All patients responded to systemic corticosteroid treatment. We discuss the genetic, infectious and immunologic factors in the etiology of MRS. Neuroimaging examinations were useful in determining the diagnosis and in determining whether the initial treatment of MRS should be with systemic corticosteroids.

Orofacial granulomatosis: A case report with review of literature

Orofacial granulomatosis (OFG) encompasses conditions characterized by non-necrotizing granulomatous inflammation of the oral and maxillofacial region that present clinically as labial enlargement, perioral and/or mucosal swelling, oral ulcerations, and gingivitis. The unifying term “OFG” has been introduced to integrate the spectrum of various disorders, including Melkersson-Rosenthal syndrome and granulomatous cheilitis (which is sometimes considered to be a monosymptomatic form of Melkersson-Rosenthal syndrome), and has been shown to be associated with Crohn's disease, sarcoidosis, and infectious diseases such as tuberculosis. Although various etiological agents such as food substances, food additives, dental materials, and various microbiological agents have been implicated in the disease process, its precise pathogenesis is yet to be elucidated. Delayed type of hypersensitivity reaction appears to play a significant role, although the exact antigen inducing the immunological reaction varies in individual patients. However, evidence for the role of genetic predisposition to the disease is sparse. The underlying immunological mechanism appears to show some similarities between OFG and Crohn's disease, emphasizing the need for more comparative studies of the two entities. The aim of this article is to report a case of OFG, along with a detailed literature review of the facts and variations associated with its nomenclature, clinical presentation, and etiology. It also projects the challenges that a professional has to face in the diagnosis and treatment planning of such cases.