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ANORL-509; No. of Pages 2

European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2016) xxx–xxx

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Letter to the Editor Bilateral facial palsy in a child An 8-year-old child, in complete remission from acute myeloid leukaemia (AML), presented with a first episode of left peripheral facial palsy (PFP). A favourable course was observed in response to antibiotics, corticosteroids and antiviral agents. One month later, the child presented with contralateral PFP. The right external auditory canal presented a stenotic appearance and a raspberry lesion. The child presented bilateral conductive hearing loss of 55 dB. On CT scan, the mastoid air cells were obliterated by nonspecific tissue thickening. MRI showed bilateral obliteration of air mastoid cells, predominantly on the left, with a mass presenting a low-intensity signal on T1- and T2-weighted sequences and gadolinium enhancement, suggestive of granulocytic sarcoma (GS) or chloroma. Contrast enhancement of the facial and vestibulocochlear nerves was observed in the internal auditory canal together with a poorly demarcated left parotid nodule, suggesting dissemination of the lesion (Fig. 1). Surgical exploration revealed a friable, bluish green mass. Histological examination demonstrated cells resembling blast cells. Immunohistochemistry confirmed the haematopoietic origin of the CD 45+ and Ki67+ cells, and the diagnosis of mastoid GS. The child was treated by another course of chemotherapy according to the ELAM02 protocol. One month later, the PFP had almost completely resolved with

a normal appearance of the external auditory canal and normal hearing. 1. Discussion Most cases of PFP in children correspond to totally benign Bell’s palsy with an excellent prognosis, but Bell’s palsy is a diagnosis of exclusion. Otoscopic examination must be systematically performed due to the high prevalence of congenital or acquired chronic otitis [1], together with examination of the other cranial nerves, lymph nodes and parotid gland. One of the leading causes of bilateral facial palsy with a normal tympanum is Lyme disease transmitted by a tick bite and due to spirochaetal borreliosis [2]. Two other neurological causes must be systematically excluded by MRI: multiple sclerosis (MS) and Guillain-Barré syndrome [1]. In patients with a history of AML, two other rarer aetiologies must be considered: vincristine neurotoxicity [3] and granulocytic sarcoma [4]. When imaging demonstrates a mass in the middle ear, a biopsy must be performed. Histological examination reveals a disorganized architecture with the presence of cells resembling blast cells organized to form a mass. Treatment consists of intravenous and intrathecal chemotherapy. Surgical decompression of the facial nerve is not recommended because it is dangerous and less effective [4,5].

Fig. 1. Brain MRI, gadolinium-enhanced T1-weighted sequence, axial and coronal sections showing obliteration of the mastoid air cells and a left parotid nodule.

http://dx.doi.org/10.1016/j.anorl.2016.01.003 1879-7296/© 2016 Published by Elsevier Masson SAS.

Please cite this article in press as: Abitbol C, et al. Bilateral facial palsy in a child. European Annals of Otorhinolaryngology, Head and Neck diseases (2016), http://dx.doi.org/10.1016/j.anorl.2016.01.003

G Model ANORL-509; No. of Pages 2

ARTICLE IN PRESS Letter to the Editor / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2016) xxx–xxx

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Disclosure of interest The authors declare that they have no competing interest. References [1] Darrouzet V, Houliat T, Lacher Fougere S, Bébéar JP. Paralysie faciale. EMC ORL 2002 [20-260-A-10]. [2] Skogman BH, Glimåker K, Nordwall M, Vrethem M, Ödkvist L, Forsberg P. Long-term clinical outcome after Lyme neuroborreliosis in childhood. Pediatrics 2012;130(2):262–9. [3] Sarkar S, Deb AR, Saha K, Das CS. Simultaneous isolated bilateral facial palsy: a rare vincristine-associated toxicity. Indian J Med Sci 2009;63:355–8. [4] Crovetto M, Marquez JA, Ereno C, Elexpuru J, Crovetto R, Martinez A. Granulocytic sarcoma presenting as atypical mastoiditis with facial paralysis: description of a case. Case Reports Otolaryngol 2011, http://dx.doi.org/10.1155/2011/191852. [5] Gokcan MK, Batikhan H, Caluner M, Tataragasi A. Unilateral hearing loss as a presenting manifestation of granulocytic sarcoma (chloroma). Otol Neurotol 2006;27(1):106–9.

C. Abitbol M. Franc¸ois ∗ S. Quesnel S. Demondion Service d’ORL et de chirurgie cervico-faciale, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France ∗ Corresponding

author. Tel.: +33 1 40 03 22 22; fax: +33 1 40 03 22 02. E-mail address: [email protected] (M. Franc¸ois)

Please cite this article in press as: Abitbol C, et al. Bilateral facial palsy in a child. European Annals of Otorhinolaryngology, Head and Neck diseases (2016), http://dx.doi.org/10.1016/j.anorl.2016.01.003