~~~~~~~ ~~~
DISORDERS AFFECTING THE ORAL CAVITY
MELKERSSON-ROSENTHAL
SYNDROME AND OROFACIAL
GRANULOMATOSIS
Melkersson-Rosenthal syndrome is a triad
of recurrent orofacial swelling, relapsing fa-
cial paralysis, and fissured tongue. The classic
triad is not always present at the same time,
and the disease may be seen in incomplete
forms such as cheilitis granulomatosa. The
histologic findings of noncaseating sarcoidal
granulomas support the diagnosis, but these
findings are not invariably present.
In 1928, Melkerss~nl~ described a 35-year-
old woman with facial edema and facial pa-
ralysis and suggested the relationship be-
tween these two findings. In 1931, Ro~enthal’~
described the additional feature of lingua pli-
cata. Since 1949, the triad has been known as
Melkersson-Rosenthal syndrome.”
In 1985, the concept of orofacial granuloma-
tosis was introduced by Wiesenfield and col-
leaguesz4 to include lesions that resemble
Crohn’s disease, clinically and histologically,
but occur in patients who do not exhibit the
gastrointestinal manifestations of Crohn’s. A
variety of conditions fall into this group in-
cluding contact stomatitis, solid facial edema,
sarcoidosis, and tooth-associated infections.
Melkersson-Rosenthal syndrome and its oli-
gosymptomatic and monosymptomatic vari-
ants may be included under the banner of
orofacial granulomatosis. It should be noted
that sarcoidosis6and Crohn’s disease6,l7 are
associated uncommonly with the Melkersson-
Rosenthal syndrome.
From the Department of Dermatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
DERMATOLOGIC CLINICS
VOLUME 14 * NUMBER 2 * APRIL 1996
0733-8635/96 $0.00 + .20
Roy S. Rogers 111, MD
MELKERSSON-ROSENTHAL
SYNDROME
The Melkersson-Rosenthal syndrome con-
sists of the presentation of
Recurrent orofacial edema
Recurrent peripheral facial palsy
Lingua plicata
These symptoms may occur at the same
time or at intervals of months to years. Di-
agnostic confusion is common because the
classic presentation is not seen frequently.
Hornsteins reported complete forms of Melk-
ersson-Rosenthal syndrome in only 6 of 73
patients (8%) and Worsaae et alZ6in 6 of 33
patients (18%). Greene and Rogers6 found
the complete triad in 9 of 36 patients (25%).
The dominant feature is swelling of the orofa-
cia1 region, although oral mucosal involve-
ment is more common than previously
emphasized.26,28
The incomplete expression of Melkersson-
Rosenthal syndrome has been recognized as
monosymptomatic and oligosymptomatic
forms. Localized, episodic noninflammatory
swelling of the lip was reported by MiescherI5
in 1945 as cheilitis granulomatosa. This mono-
symptomatic form was recognized in 18% of
Hornstein’s patientss The oligosymptomatic
forms consist of two of the three parts of the
classic triad. In our study of 36 patients? half
371
372 ROGERS

Table 1. CLINICAL FEATURES IN 36 PATIENTS WITH
THE MELKERSSON-ROSENTHALSYNDROME
Group Features Present
Orofacial edema, facial palsy, and
lingua plicata
Initial symptom
Facial palsy
Orofacial edema
Lingua plicata
Orofacial edema and facial palsy
Initial symptom
Facial palsy
Orofacial edema
Both simultaneously
Orofacial edema and lingua plicata
Initial symptom
Orofacial edema
Lingua plicata
Both simultaneously
Unsure
Orofacial edema only
From Greene RM, Rogers RS 111: Melkersson-Rosenthal syn-
drome: A review of 36 patients. J Am Acad Dermatol
21:1263-1270, 1989; with permission.
of the patients had oligosymptomatic Melk-
ersson-Rosenthal syndrome (Table 1).The ex-
tent of involvement may vary from patient to
patient, and the initial presentation may vary
from the signs present during the course of
the disease (Table 2).
Demographic Information
Most series have been reported from Eu-
rope and North America, although cases have
Table 2. SIGNS IN 36 PATIENTS WITH THE
MELKERSSON-ROSENTHAL SYNDROME
Sign
been reported from all continents. The Melk-
ersson-Rosenthal syndrome is an uncommon
Patients disease with nearly equal gender distribution.
NO. Yo No racial or ethnic predilection exists. Symp-
toms usually present in young adults, al-
9 25 though children may be affected, particularly
with cheilitis granulomatosa. Because of the
chronic nature of Melkersson-Rosenthal syn-
7
0
drome, the patients may present to the clini-
2 cian at virtually any age.
8 22
7
Orofacial Swelling
0
1 The orofacial swelling is the most im-
9 25 portant and consistent symptom of the Melk-
ersson-Rosenthal syndrome. It is described as
5 a painless, nonpruritic, firm edema. The
1 swelling is often asymmetrical and may be
1 unilateral. If confined to the lip, the lip may
2
10 28 swell to two to three times normal size. The
edematous lips develop a chapped and fis-
sured appearance with a purple coloration
(Fig. 1). Swelling may affect the chin, lip,
cheeks, and periorbital tissues.
The swelling is characteristically short-
lived, occurring at hectic or irregular inter-
vals. The edema may resolve completely at
first, but with repeated episodes, the resolu-
tion is incomplete, leaving residual swelling
that becomes firm and indurated. The indura-
tion reflects the development of granuloma-
tous inflammation in the orofacial tissues.
Solid facial edema as a manifestation of Melk-
ersson-Rosenthal syndrome has been re-
ported in the French 1iterat~re.l~
Facial swelling was the presenting com-
plaint in 26% of 42 Mayo Clinic patients,
whereas labial swelling was the presenting
complaint in 43Y0.*~ During the course of the
illness, almost all patients will have facial or
Patients labial swelling.
No. YO

Present during course

Orofacial edema 36 100
Facial palsy 17 47
Lingua plicata 18 50
Initial presenting
Orofacial edema 15 42
Facial palsy 14 39
Lingua plicata 3 8
Facial palsy and orofacial edema 1 3
simultaneously
Lingua plicata and orofacial 1 3
edema simultaneously
Patient unsure 2 6

From Greene RM, Rogers RS 111: Melkersson-Rosenthal syn- Figure 1. Orofacial swelling involving upper and lower
drome: A review of 36 patients. J Am Acad Dermatol lips. Note enlargement and scaling of lips (Miescher's
21:1263-1270, 1989; with permission. cheilitis granulomatosa).
 MELKERSSON-ROSENTHAL SYNDROME AND OROFACIAL GRANULOMATOSIS 373

Oral Manifestations Table 3. OROFACIAL MANIFESTATIONS DURING

THE COURSE OF THE MELKERSSON-ROSENTHAL
SYNDROME
The oral manifestations probably have been
underreported in the literature.26,28 These Manifestation No.* YO

manifestations, along with facial and labial Labial swelling 31 74

swelling, constitute the orofacial swelling that Upper 25 60
is the constant feature of Melkersson-Rosen- Lower 15 36
thal syndrome. Of the 42 Mayo Clinic pa- Facial swelling 21 50
Facial palsy 15 36
tients, 5 (12%) presented with mucosal swell- Migraine or headache 7 17
ing or paresthesias.28The gingival, lingual, Gingival swelling 8 19
and buccal mucosae may be involved. Recur- Gingival erythema 5 12
rent polypoid gingival swelling has been em- Gingival pain 4 10
Gingival erosions 2 5
phasized by Worsaae and PindborgZ5(Fig. 2, Buccal mucosal swelling 3 7
see also Color Plate 2 Fig. 10). Buccal mucosal erosion 3 7
During the course of the disease, additional Palatal swelling 4 10
oral mucosal findings may occur as reported Lingua plicata 21 50
in our series of 42 patients (Table 3).28The Lingual swelling 7 17
Lingual paresthesia 8 19
clinician should consider the diagnosis of Alteration of taste 1 2
Melkersson-Rosenthal syndrome when en- Hyposalivation 1 2
countering patients with recurrent oral swell-
ing, erythema, paresthesias, erosions, or ab- 'Mayo Clinic, n = 42 patients.
From Zimmer WM, Rogers R S 111, Reeve CM, et al: Orofacial
normal salivation. manifestations of Melkersson-Rosenthal syndrome. Oral Surg
Oral Med Oral Pathol 74:610-619, 1992; with permission.

Facial Palsy
The recurrent peripheral facial paralysis is
characteristically sudden in onset and is in-
distinguishable from Bell's palsy.23This mani-
festation of Melkersson-Rosenthal syndrome
occurred in half of the patients in the 1989
Mayo series.6 The palsy is usually unilateral
(Fig. 3) and clears spontaneously, only to re-
cur in 10% of patients. Some patients may
have both sides of the face affected, but it is
unusual to have both affected at the same
time. The paralysis typically occurs at the site
of facial swelling (see Fig. 3).
Defects in taste along the anterior two
thirds of the tongue can accompany the facial
palsy in a minority of the patients. The facial
paralysis may occur months to years after the
presenting symptom of orofacial swelling. In

Figure 2. Gingival involvement with orofacial swelling. Note edema

and erythema of maxillary and mandibular attached gingiva. (From
Zimmer WM, Rogers RS 111, Reeve CM, et al: Orofacial manifestations
of Melkersson-Rosenthal syndrome. Oral Surg Oral Med Oral Pathol
74:610-619,1992;with permission).
374 ROGERS

but tend to radiate from the main trunk,

which runs anteroposteriorly. The tongue
may be enlarged as well as fissured. The
swelling may be secondary to the chronic
inflammation from bacterial and mycotic de-
bris deep in the grooves, or as a manifestation
of the orofacial swelling. The tongue also may
be the site of paresthesias or diminished taste
sensations.

Associated Disorders

Many clinical findings have been reported

in association with the Melkersson-Rosenthal
syndrome. Some are coincidental, but others
may be related to the Melkersson-Rosenthal
syndrome in a fundamental manner.
Ophthalmologic findings in patients with
Melkersson-Rosenthal syndrome include lag-
ophthalmos, exposure keratitis, retrobulbar
Figure 3. Facial palsy typical of Bell’s palsy involving left
face. Note also orofacial edema involving left cheek and
lip. (From Zimmer WM, Rogers RS Ill, Reeve CM, et al:
Orofacial manifestations of Melkersson-Rosenthal syn-
drome. Oral Surg Oral Med Oral Pathol 74:610-619,
1992; with permission).

other patients, the Melkersson-Rosenthal syn-

drome can present with the facial palsy and
develop other parts of the triad later, as was
the situation in 39% of patients in the 1989
Mayo series.6

Lingua Plicata

The lingua plicata or fissured tongue com-

ponent of the Melkersson-Rosenthal syn-
drome seems to be the least important and
least common of the classic triad of the syn-
drome. Hornstein*noted it in one third of his
patients, and we6noted it in 50% of the Mayo
series of 36 patients (see Tables 1 and 2) (Fig.
4, see also Color Plate 2 Fig. 11).
Lingua plicata is thought to be a genetic
trait with dominant inheritance and incom-
plete penetrance. Halperin and colleagues7
found lingua plicata in 5% of 2478 dental
patients. The prevalence is greater in older
patients (17% older than 70 years) than with Figure 4. Fissured tongue (lingua plicata) with furrows
younger patients (0.37% younger than 10 radiating from central raphe. Note also erythema and
year^).^ edema causing macroglossia, another type of orofacial
edema. (From Zimmer WM, Rogers RS Ill, Reeve CM,
C1inicallyr the PIicated Or fissured tongue et al: Orofacial manifestations of Melkersson-Rosenthal
shows deep grooves in the dorsal swface. syndrome. Oral Surg Oral Med Oral Pathol 74:610-619,
These grooves may extend in any direction 1992; with permission).
 MELKERSSON-ROSENTHAL SYNDROME AND OROFACIAL GRANULOMATOSIS 375

neuritis, diplopia, and paralysis of the medial
rectus muscle?, 6,
Neurologic manifestations include hyper-
hidrosis, hypogeusia, glossodynia, acropares-
thesia, hyperacusis, and epiphoria.8,2o Mi-
graine was found in l l % of 117 patients
reported by Vistnes and Kernahan.22 We
found 7 of 36 patients in the 1989 series with
migraine or cluster headaches.6
Stosiek and emphasized the re-
lapsing craniofacial, neurovegetative symp-
toms associated with Melkersson-Rosenthal
syndrome. These include relapsing disorders
of lacrimation, sweating, migraine-like head-
aches, hyperacusis, blepharospasm, unilateral
rhinorrhea, hypersalivation, hyposalivation,
dysgeusia, and dysesthesias of the face. These
minor symptoms can be characteristic hints
to the diagnosis of oligosymptomatic Mel-
kersson-Rosenthal syndrome.
Histopathology
The characteristic finding in Melkersson-
Rosenthal syndrome is a noncaseating sarcoi-
dal granuloma. Most biopsies are obtained
from the lip. Biopsies of gingiva and other
oral mucosae, however, also show the charac-
teristic features.25,26, 28 This granulomatous in-
flammation is helpful, supportive evidence
for the diagnosis of Melkersson-Rosenthal
syndrome.
Histologically, there may be mild epithelial
hyperplasia overlying the inflamed dermis or
lamina propria. Dilated lymphatics, perivas-
cular aggregates of histiocytes, lymphocytes,
and plasma cells in the milieu of nonspecific
edema are seen in early lesions (Fig. 5). As
the lesions become more established, espe-
cially after weeks of persistent swelling, the
classical histopathologic features begin to
emerge. Many small noncaseating granulo-
mas with Langhans’ giant cells are found
scattered throughout the dermis or lamina
propria (Fig. 6). Irregular fibrosis may be
seen. Sometimes, serial sections are required
to identify the granulomas.26,28
The granulomas are not always present,
and their absence does not exclude Melkers-
son-Rosenthal syndrome. Negative histologic
findings in the presence of the typical clinica1
picture do not refute the diagnosis because
individual granulomas may form and vanish
within days to weeks and do not strictly coin-
cide with the clinical course of the swelling8
Differential Diagnosis
The diagnosis of Melkersson-Rosenthal
syndrome is always difficult to establish be-
cause the classical features are not always

Figure 5. Histopathology of Melkersson-Rosenthal syndrome showing early changes

with dilated lymphatics, perivascular inflammation, and edema. As this inflammatory
reaction organizes, the sarcoidal granulomas begin to form (hematoxylin-eosin, original
magnification x 40).
376 ROGERS

Figure 6. Histopathology of Melkersson-Rosenthal syndrome showing granuloma

organization. Note the tight, noncaseating granulomas with Langhans’ giant cells
characteristic of this condition (hematoxylin-eosin, original magnification x 160).

present at the same time and because nonca-
seating granulomas may not always be pres-
ent. There is no pathognomonic laboratory
test for Melkersson-Rosenthal syndrome; it
remains a diagnosis based on clinicopatho-
logic correlation.
Unilateral, firm labial swelling may occur
in a variety of clinical settings (Table 4). Like-
wise, firm swelling of the oral mucosa may
be seen in several conditions (Table 5).
Histologic confirmation of the nature of the
swelling is important. Working through the
differential diagnosis by histology, physical
findings, and appropriate laboratory tests or
imaging techniques is critical to establish
the diagnosis of Melkersson-Rosenthal syn-
drome, which may be based on exclusion of
other causes of orofacial granulomatosis.
Prognosis
Melkersson-Rosenthal syndrome may pur-
sue an acute, recurrent, or chronic course. The

Table 4. DIFFERENTIAL DIAGNOSIS OF THE MELKERSSON-ROSENTHAL SYNDROME AND OTHER DISEASES

WITH LABIAL SWELLING
Disease Characteristics of Labial Swelling Other Features
Melkersson-Rosenthal syndrome Often unilateral, firm, intermittent, or lntraoral or face swelling, palsy, lingua
persistent plicata
Crohn’s disease Rare, diffuse, edematous, or firm Granulomatous inflammation of
intestines, aphthous ulcers
Angioneurotic edema Rapidly occurring, transient, pale Swelling of oral mucosa, tongue, larynx,
joints
Insect bite Soft, edematous, diffuse History of insect bite
Trauma Signs of hemorrhage, injured epithelium History of trauma
Mucocele Soft, pale, small, round, localized History of fluctuation in size
Submucosal neoplasms Firm, movable, localized Salivary gland or connective tissue
origin
Ascher syndrome Mostly upper lip Swelling of eyelid, nontoxic goiter
Erysipelas Edematous, erythematous, warm Sharply delineated edematous
erythema of face, fever, chills,
vomiting, permanent facial edema
after relapse

from Zirnrner WM, Rogers RS Ill, Reeve CM, et al: Orofacial manifestations of Melkersson-Rosenthal syndrome. Oral Surg Oral Med
Oral Pathol 74:610-619, 1992; with permission.
 MELKERSSON-ROSENTHAL SYNDROME AND OROFACIAL GRANULOMATOSIS 377

Table 5. DIFFERENTIAL DIAGNOSIS OF THE MELKERSSON-ROSENTHAL SYNDROME AND OTHER DISEASE

WITH SWELLING OF GINGIVA, BUCCAL, OR PALATAL MUCOSA
Disease Characteristics of Labial Swellina Other Features

Melkersson-Rosenthal syndrome Gingival swelling located anteriorly,
well-demarcated, bluish red,
cobblestone pattern, swelling of
posterior and lateral palate
Crohn’s disease Edematous, diffuse swelling,
cobblestone pattern of buccal
mucosa
Sarcoidosis Solid nodules
Acute leukemia Gingival swelling, easy bleeding
Drug-induced gingival Localized or generalized, firm, confined
hyperplasia to gingiva
Hormone-induced gingival Soft, localized “pregnancy tumor” or
hyperplasia more generalized at puberty
Fibromatosis gingivae Firm, diffuse swelling
Palsy, extraoral swelling, fissured
tongue
Granulomatous inflammation of
intestines, aphthous ulcers
Epithelioid-cell granulomas of any
organ
Abnormal peripheral blood smear, bone
marrow examination
History of phenytoin, nifedipine, or
cyclosporine administration
Pregnancy, puberty, oral contraceptives
Familial

From Zimmer WM, Rogers RS 111, Reeve CM, et al: Orofacial manifestations of Melkersson-Rosenthal syndrome. Oral Surg Oral Med
Oral Pathol 74:61&619, 1992; with permission.

probability of a complete remission is low,
although spontaneous remission may occur.
The prognosis for good general health is ex-
cellent, but the likelihood for episodic and
intermittent disease activity is high.
Treatment
The cause(s) of Melkersson-Rosenthal syn-
drome remains obscure. No consistent factor
has been elucidated. Hypotheses regarding
hereditary factors, infectious agents, allergies,
and vasomotor disturbances have not been
confirmed. The association with sarcoidosis
or Crohn’s disease is tenuous, at best, because
few patients have manifested both diseases
simultaneously.6,l7
The clinician should search for provocative
causes, which are uncommon but worth the
effort. Tooth-associated infections should be
identified and eliminated.26The elimination
of odontogenic infectious foci was followed
by regression or disappearance of the orofa-
cia1 swelling in 11 of 16 patients,’suggesting
a pathogenic mechanism.26Allergic factors
should be assessed by patch testing, particu-
larly for cinnamic aldehyde and alcohol and
for metals such as cobalt. Food allergies to
cocoa, carvone, monosodium glutamate, and
cinnamon may be sought by testing or elimi-
nation diets.21,26
Treatment of Melkersson-Rosenthal syn-
drome is largely symptomatic. Cold com-
presses and protective lip emollients may be
used for acute swelling. Decompression of
the facial nerve may be indicated for persis-
tent facial palsy. This procedure was reported
to be effective in 11 of 13 patients reviewed
by Kettle.9
Corticosteroids are the single most effective
drug in the treatment of Melkersson-Rosen-
thal syndrome. Systemic corticosteroids are
effective in reducing swelling and preventing
persistent tissue edema. Treatment of a single
episode, however, apparently does not
change the natural history of the disease. In-
tralesional corticosteroids also have been ben-
eficial but multiple injections for months or
years may be necessary.6,10The placement of
an anesthetic lip block before the intralesional
injection of corticosteroids increases the
patient’s acceptance of this form of therapy.
Occasional short courses of systemic corti-
costeroids such as prednisone in a dose of 1.0
to 1.5 mg/kg/d, tapering over 3 to 6 weeks
depending on the severity of the episode,
may be effective. In those circumstances in
which the disease has become chronic with
persistent cosmetically disfiguring edema,
nonsteroidal anti-inflammatory agents are
used to reduce or eliminate the side effects of
long-term, systemic corticosteroid therapy.
Several nonsteroidal anti-inflammatory
agents have been reported to be effective in
the treatment of Melkersson-Rosenthal syn-
drome. These include clofazimine,16, hY-
droxychloroquine,l.l7 dapsone and sulfapyri-
dine: danazo1,12 and broad-spectrum antibi-
otics such as tetracycline, metronidazole, and
trimethoprim-sulfamethoxazide.These drugs
have a better side-effect profile for long-term
378 ROGERS
suppressive therapy than systemic corticoste-
roids.
Surgical approaches have been recom-
mended to improve the cosmetically disfig-
uring swelling from which some of these pa-
tients ~ u f f e rReduction
.~ cheiloplasty has been
proposed to address this problem.2,lo,27 Some
have recommended intralesional corticoste-
roid injections postoperatively in an attempt
to prevent a recurrence.’O The inflammatory
disease process should be under medical con-
trol before a surgical procedure is under-
taken.
OROFACIAL GRANULOMATOSIS
Some patients with Crohn’s disease have
symptomless intestinal disease for months to
years before the bowel symptoms lead to a
diagnosis. Many of these patients have oral
lesions such as aphthous stomatitis or chronic
hyperplastic buccal or gingival lesions pro-
ducing a cobblestone appearance, pyostoma-
titis vegetans, and fissuring of the lips and
oral mucosa. In addition, similar lesions may
occur in the perianal tissues.
Wiesenfield and c011eagues~~ introduced
the concept of orofacial granulomatosis to in-
clude those patients whose clinicopathologic
features resemble Crohn’s disease but who
did not have the characteristic gastrointesti-
nal findings of the inflammatory bowel dis-
ease. The unifying precept was the presence
of noncaseating granulomas in orofacial bi-
opsy specimens.
Orofacial granulomatosis as a unifying con-
cept? includes some patients with Crohn’s
disease whose diagnosis will not be apparent
for months to years, patients with oral
Crohn’s disease, patients with sarcoidosis,
and patients with the Melkersson-Rosenthal
syndrome or its oligosymptomatic or mono-
symptomatic variants such as cheilitis granu-
lomatosa of Miescher. In addition, a host of
patients with ill-defined and heterogeneous
conditions such as food or contact allergies,
tooth-associated and solid facial
edema13must be considered.
The vast majority of patients with the Mel-
kersson-Rosenthal syndrome do not develop
Crohn’s disease or sarcoidosis. The cause(s)
for the Melkersson-Rosenthal syndrome re-
mains obscure, and the Melkersson-Rosenthal
syndrome is best considered a reactive pro-
cess with a characteristic clinical pattern. The
value of the clinicopathologic concept of oro-
facial granulomatosis is to provide a stimulus
to undertake a careful clinical evaluation for
factors that may be associated with the Melk-
ersson-Rosenthal syndrome. These factors,
when identified, may permit a more specific
approach to therapy.
SUMMARY
The Melkersson-Rosenthal syndrome is a
rare disorder of unknown etiology character-
ized by a triad of recurrent orofacial swelling,
relapsing facial paralysis, and fissured
tongue. Exacerbations and recurrences are
common. The orofacial swelling is character-
ized by fissured, reddish-brown, swollen,
nonpruritic lips or firm edema of the face.
The facial palsy is indistinguishable from
Bell’s palsy. The fissured tongue is seen in
one third to one half of patients and, although
the least common manifestation, its presence
assists in diagnosis.
The classic triad is not seen frequently in
its complete form; therefore, diagnosis is dif-
ficult. This is particularly true because mono-
symptomatic and oligosymptomatic variants
are seen more commonly. Cheilitis granulo-
matosa of Miescher is an example of a mono-
symptomatic variant of the Melkersson-
Rosenthal syndrome.
The histologic findings of noncaseating,
sarcoidal granulomas support the diagnosis.
These granulomas are not invariably present,
and their absence does not exclude the diag-
nosis of the Melkersson-Rosenthal syndrome.
Thus, the Melkersson-Rosenthal syndrome is
a disease with elements of orofacial granulo-
matosis.
Orofacial granulomatosis is a clinicopatho-
logic entity describing oral lesions with non-
caseating granulomas. The spectrum of this
entity includes patients with oral Crohn’s dis-
ease, patients with oral lesions who will de-
velop typical bowel symptoms of Crohn’s dis-
ease in the ensuing months to years, patients
with tooth-associated infections, patients with
sarcoidosis, and patients with food or contact
allergies. The value of the clinicopathologic
construct of orofacial granulomatosis is to
provoke the careful search for provocative
causes for the reactive symptom complex of
the Melkersson-Rosenthal syndrome.
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Mayo Clinic
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