Bifacial palsy is a rare neurological presentation, comprising only 0.3–2% of facial paralysis cases¹. Unlike unilateral palsy, bilateral cases often have identifiable and treatable causes. This series presents three distinct cases of facial diplegia highlighting varied etiologies and outcomes.

1. Molinari G, Lucidi D, Fernandez IJ, et al. Acquired bilateral facial palsy: A systematic review on aetiologies and management. J Neurol. 2023;270(11):5303–5312. https://link.springer.com/article/10.1007/s00415-023-11897-7. doi: 10.1007/s00415-023-11897-7.

Case 1:
A 19-year-old male presented with diplopia and left facial palsy, following resolved right facial palsy one month prior. Exam revealed bilateral abducens palsy and hyperreflexia. Magnetic resonance imaging (MRI) of the brain showed leptomeningeal enhancement. Cerebrospinal fluid (CSF) examination demonstrated elevated opening pressure and positive Lyme immunoglobulins. He was treated with IV ceftriaxone, and had symptom resolution in one week.

Case 2:
A 45-year-old male developed progressive numbness of his hands, tongue, and face, with bilateral facial palsy, dysphagia, and dysarthria. CSF showed albuminocytologic dissociation. Electrodiagnostic testing demonstrated a demyelinating sensorimotor polyneuropathy. Serum GQ1b antibody testing was negative, but clinical features supported a diagnosis of seronegative Miller Fisher Syndrome. Treatment with intravenous immune globulin led to near-complete recovery in one month.

Case 3:
A 64-year-old female initially presented with right lower facial droop, later developing concurrent complete left facial palsy. Stroke and CSF work-up were negative. MRI with and without contrast was unrevealing. She improved with corticosteroids, and ultimately had full resolution at three months. This idiopathic, asymmetric, bilateral presentation was termed “three-quarter syndrome.”