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Neurology India, Vol. 54, No. 3, July-September, 2006, pp. 249 Invited Commentaries Leprosy: Face beyond the cranial nerves Low Wong-Kein Dept. of Otolaryngology, Singapore General Hospital,Singapore - 169 608. Code Number: ni06082 Leprosy is endemic in certain regions of the world, particularly the tropics. The clinical spectrum of leprosy ranges between two principal microscopic types: tuberculoid and lepromatous leprosy.[1] In the tuberculoid type, cell-mediated immunity is good; although the skin exhibits limited clinical features, peripheral nerve involvement may be pronounced. Few, if any, demonstrable bacilli are present in these lesions. On the other hand, the lepromatous type represents poor cell-immunity, resulting in extensive intracellular bacilli in the skin and nerves. Borderline leprosy is an entity with features belonging to these two polar types. Physicians and surgeons who frequently manage problems in the head and neck should be familiar with manifestations of leprosy in these parts of the body. Besides the usual features of possible cranial nerve deficits, unrelated structures in the face may be involved. In the nose, leprosy may result in obstruction, epistaxis, hyposmia, septal perforation and deformities. In the ear, cosmetic deformities of the pinna and external ear canal stenosis may result. In the mouth, there may be palatal destruction. These lesions are a result of lepromatous leprosy and are usually clinically obvious. An uncommon facial manifestation is hemifacial erythematous swelling, which is a result of reversal reaction. Although reversal reactions can occur in tuberculoid and lepromatous types of leprosy, nearly 90% occur in the borderline type.[2] Spontaneous remission is frequent in leprosy, whereas ′reversal′ is lesser known. Reversal reactions are episodes of acute inflammation affecting skin and nerves, occurring when a patient develops increased cell-mediated immunity towards M. leprae and moves towards the tuberculoid end of the leprosy spectrum. The clinical features may be confused with those of facial cellulitis and sinusitis.[3] It is important to accurately diagnose and promptly treat this condition, as the rapid and severe nerve destruction may result in permanent damage. References
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