Multiple cranial nerve palsies as a result of perineural invasion by squamous cell carcinoma

Abstract

A 70-year-old man presented with a 1-month history of right-sided proptosis, ptosis and intermittent dull ache of the right temple. Three years before, a squamous cell carcinoma had been removed from his right temple at another hospital; excision had been initially incomplete, requiring three further operations over 8 months. Two days after the last operation, he developed a right facial palsy, initially thought to be Bell's palsy and managed with prednisone with no effect. His right forehead, cheek and upper lip had also felt numb since around this time. Five months later, he lost hearing in his right ear and reported some loss of balance but no vertigo. Six months later, he lost sight in his right eye secondary to exposure keratopathy; an upper lid gold weight was inserted and right-sided temporalis transfer performed. Examination revealed a complete right ptosis and 4 mm of proptosis with restricted extraocular movements in all directions. There was a right lower motor neurone facial palsy, reduced sensation in the distribution of the 1st and 2nd division of the trigeminal nerve and sensorineural hearing loss in the right ear. His right cornea was completely vascularized with a visual acuity of counting fingers. There was no relative afferent pupillary defect. No lymphadenopathy was detected. His imaging and histology results are shown in Figures 1 and 2. As a result of these findings, palliative radiotherapy was administered.