Facial Paralysis

For 2 weeks, a 59-year-old woman had experienced weakness on the left side of her face. She described her appearance as "deviated" and complained of dribbling from the corner of her mouth and difficulty in chewing. The patient was unable to close her left eye and said that noises sounded unpleasantly loud and distorted in the left ear. She denied earache, vertigo, fever, headache, and rash. Six years earlier, the patient had undergone a radical mastectomy for lobular invasive carcinoma of the left breast followed by chemotherapy and treatment with tamoxifen(. She was still taking tamoxifen. The patient was conscious and alert. A cranial nerve examination demonstrated weakness of the left upper and lower facial muscles, loss of taste sensation in the anterior two thirds of the tongue, and Bell’s phenomenon. Cranial nerve VII was affected; other cranial nerves were normal. Drs Shanmugam Uthamalingam and Sivakumar Natanasabapathy of New Rochelle, NY, diagnosed lower motor neuron facial palsy. Because of the absence of retroauricular pain, Bell’s palsy was considered unlikely; thus, further diagnostic evaluation to determine the underlying cause of the patient's symptoms was warranted. Noncontrast (A) and contrast (B) MRI scans with bone windows showed a metastatic tumor at the petrous tip of the temporal bone, which invades the mastoid air cells and the facial nerve. Metastases to the temporal bone and consequent facial nerve paralysis most often originate from a breast tumor. Lung, kidney, stomach, and prostate neoplasms also can spread to the temporal bone.¹ Bell’s palsy is a considerably more common cause of unilateral facial paralysis; according to a recent study, between 11.5 and 40.2 cases per 100,000 persons occur annually.^2,3 It is estimated that 5% of all cases of peripheral facial paralysis are caused by tumor involvement of the facial nerve.⁴ The diagnosis of Bell's palsy is one of exclusion. Oral acyclovir and corticosteroids are frequently used to treat the disorder.^5,6 Signs and symptoms inconsistent with a diagnosis of Bell's palsy need to be recognized early so that further workup can be undertaken and appropriate treatment started promptly. This patient was given corticosteroids and underwent cranial irradiation in fractions over 8 weeks; her condition improved slowly and significantly.