Peripheral facial nerve palsy is a common disease encountered by otolaryngologists, but rarely occurs in both sides at the same time. Causative diseases include Bell’s palsy, Guillain-Barre syndrome, trauma, otitis media, Ramsay Hunt syndrome, sarcoidosis, etc. During the past 10 years, a total of 528 patients with facial nerve palsy visited our department, and only 2 (0.4%) had simultaneous bilateral palsy.
The first patient was a 70-year-old man who presented with a 1-day history of drooling and difficulty in articulating bilabials. The following day, he developed impaired closure of his eyes. He showed bilateral severe facial nerve palsy without other neurological disorders. Brain CT/MRI, cerebrospinal fluid examination, and 67Ga-scintigram showed no abnormalities. Serology for IgM antibody against herpes simplex/varicella-zoster viruses was negative. Under a diagnosis of bilateral Bell’s palsy, the patient received antiviral drug and high-dose steroid, and completely recovered by the 61st day from onset.
The second patient was a 73-year-old woman with a past history of malignant melanoma of the rectum. She presented with an 11-day history of left-sided severe facial palsy. She was initiated on treatment with an antiviral drug and high-dose steroid on the 13th day from onset, but the following day, she manifested facial palsy of the contralateral side. She subsequently developed hemifacial hypesthesia, diplopia, and hoarseness. Brain MRI revealed multiple mass lesions in the cerebrospinal space, including the bilateral cerebellopontine angles and internal acoustic meatus. The patient was diagnosed as having leptomeningeal dissemination of metastatic malignant melanoma and treated with nivolumab and ipilimumab; however, she died of the cancer progression on the 64th day from the onset of the first facial palsy.
It is important to be aware of the difficulties in evaluating the severity of palsy and the importance of thorough systemic examinations to search for latent causes in patients with bilateral simultaneous facial nerve palsy.
