Case Report Journal of Neurology, Neurosurgery and Spine Published: 24 Jan, 2017 Painful Trigeminal Neuropathy as a Rare but Important Presenting Complication of Metastasis of Head and Neck Cancer: A Case Report and Review Aucoin JA, Muscat P and Lu-Emerson C* Department of Neurology, Maine Medical Center/Maine Medical Partner Neurology, USA Abstract Neoplastic perineural involvement of cranial nerves represents an uncommon but important feature of metastatic involvement of squamous cell carcinoma of the head and neck. Tumor cells invade all nerve compartments, possibly causing ischemia and subsequent degradation of the nerve. Invasion is guided by targeted proliferation in the context of secreted neurotropins and growth factors. Patients often present insidiously with symptoms of isolated cranial neuropathies and atypical facial pain. The most frequently affected nerve is cranial nerve V (CN V), followed by cranial nerve VII (CN VII), due to the widespread anatomic connections between the skin and subcranial structures. The following case reports highlight the different presentations and the associated diagnostic challenges of perineural involvement by squamous cell carcinoma of the head and neck. We will review the proposed biology underlying perineural tumor metastasis, the anatomical basis for cranial nerve involvement, and current treatment options. Prognosis is poor in cases of extensive disease highlighting the importance of early recognition and detection. Keywords: Cranial nerve; Trigeminal neuralgia; Paresthesia Introduction Painful trigeminal neuropathy arising from dysfunction of CN V is a relatively uncommon OPEN ACCESS but potentially debilitating presentation in the outpatient neurological practice. In the neurology *Correspondence: practice, facial pain is typically caused by classic idiopathic trigeminal neuralgia or atypical painful Christine Lu-Emerson, Department of trigeminal neuropathy. Classic trigeminal neuralgia (TN) is characterized by sudden, recurrent, Neurology, Maine Medical Center/Maine brief stabbing pain, involving the distribution of one or more branches of the trigeminal nerve Medical Partner Neurology, 49 Spring [1,2]. Patients report a lancinating shock like quality, often provoked by mild stimulus. Classic TN Street, Scarborough, ME 04074, USA, encompasses all cases without an established etiology, including idiopathic and those secondary to Tel: 2078831414; Fax: 2078831010; vascular compression of CN V; importantly, there is no clinical evidence of neurological deficit. E-mail: [email protected] Atypical painful trigeminal neuropathy implicates secondary structural causes, such as demyelinating Received Date: 10 Nov 2016 plaques, trauma, infection, and skull base lesions, affecting the fifth cranial nerve. Accepted Date: 23 Jan 2017 Besides space occupying lesions, insidious infiltration of CN V by different disease processes Published Date: 24 Jan 2017 can cause facial pain and dysfunction. Inflammatory diseases, including neurosarcoid and collagen Citation: vascular disease, and neoplastic infiltration of cranial nerves can result in pain, sensory and motor Aucoin JA, Muscat P, Lu-Emerson dysfunction of CN V [3,4]. Perineural spread of tumor involves extension of the tumor along the C. Painful Trigeminal Neuropathy nerves and is more difficult to detect due to the lack of an obvious mass lesion. Clearly, this results as a Rare but Important Presenting in a neurological diagnostic challenge with diagnostic delays potentially limiting effective treatment. Complication of Metastasis of Head We report 2 patients who initially presented with a typical facial pain and CN V dysfunction and and Neck Cancer: A Case Report and then subsequently developed other cranial neuropathies due to perineural metastasis of squamous Review. J Neurol Neurosurg Spine. cell carcinoma of head and neck. Neoplastic involvement of cranial nerves should be an important 2017; 2(1): 1007. consideration in presentation of atypical facial pain. Copyright © 2017 Lu-Emerson C. This Case Presentation is an open access article distributed under the Creative Commons Attribution Case 1 License, which permits unrestricted An 83 year old female with a remote history of basal and squamous cell facial cancer presents use, distribution, and reproduction in with a 2 year history of difficulty chewing followed by right upper lip paresthesia, radiating to the any medium, provided the original work cheek and nose with occasional sharp “shock-like” pains from the cheek to lower eye. A few months is properly cited. later, she developed numbness to the roof of the mouth, upper gums and teeth, decreased taste Remedy Publications LLC. 1 2017 | Volume 2 | Issue 1 | Article 1007 Lu-Emerson C, et al., Journal of Neurology, Neurosurgery and Spine Figure 1: A) MRI coronal T2 sequence showing the obliteration of Meckel’s Figure 2: A) MRI axial T2 demonstrates obliteration of Meckel’s cave cave (white arrow) by tumor. B) MRI axial T2 sequence highlighting infiltration (white arrow) by tumor. B) MRI axial T2 depicts the replacement normal of foramen rotundum (white arrow) by tumor. C) MRI coronal gadolinium pterygoid muscles by fat (white arrow) secondary to denervation of muscle sequence highlight enhancement of CN V (white arrow) as it exits the pons. by perineural involvement of CN V3. There has been atrophy of the masseter D) MRI axial gadolinium sequence depicting the small nodular mass (white muscle (dashed arrow) when compared to the contralateral side. C) MRI arrow) arising from CN VII. axial T2 sequence highlights the infiltration of foramen ovale (white arrow) by perineural involvement of CN V2. D) MRI axial T2 sequence inferior to that shown in C shows the infiltration of foramen rotundum by tumor involvement in the right tongue, and tearing of the right eye. Exam was notable (white arrow) of CN V3. for decreased sensation to the right V2-3 distributions. Initial non- contrast brain MRI reported nonspecific ischemic T2 changes in the laboratories (ESR, CRP, Lyme titers, RPR, ANA, RF, Sjogren’s subcortical white matter of the cerebral hemispheres. Labs, including antibodies, ACE) were negative. CSF was negative for leukocytes are, TSH, B12, SPEP and HgA1c, were all normal. Lyme titers were HSV PCR, gram stain and culture, oligoclonal bands, and malignant positive, and she was treated with antibiotics. cells. 2.5 months later, her symptoms progressed to constant Over the next 2 years, the patient’s facial pain worsened, and he paresthesia of the entire right face, right facial edema, buccal mucosa started to note intermittent swelling and facial spasm over the right burning, and further difficulties with jaw opening. Exam was notable cheek. Exam showed new right ptosis. A repeat MRI with contrast for right facial swelling, enlargement of the palpebral fissure on the at this time revealed abnormal enhancement along the course of the right, and numbness in the right face. Repeat brain MRI with contrast right trigeminal nerve with enlargement of the gasserian ganglion revealed an enhancing right intracanicular nodule with enhancement of the preganglionic segments of the facial nerve and geniculate and enhancement in the foramen ovale and rotundum (Figure ganglion (Figure 1). There was also a fusiform process within the 2).CSF signal within Meckel’s cave was obliterated. Malignancy right cavernous sinus, extending into the foramina rotundum was suspected. The patient underwent a CT guided biopsy of the and ovale with involvement of the sphenopalatine foramen and trigeminal nerve which confirmed the diagnosis of squamous cell masticator space. Cerebrospinal fluid (CSF) analysis was negative carcinoma. The patient was treated with cetuximab and radiotherapy for leukocytosis, malignant cells, or inflammatory disease. CSF Lyme with improvement of his facial pain. titers were inconclusive. Discussion Over the next 6 weeks, the patient continued to develop worsening The two cases presented above reveal the diagnostic difficulties symptoms suggestive of additional cranial nerve involvement with when facing progressive isolated painful trigeminal neuropathy with or refractory facial pain. Repeat contrast MRI revealed an enlarging without other cranial neuropathies. The 1st patient presented initially soft tissue density with enhancement of the right cavernous sinus, with symptoms (difficulties opening and closing jaw) attributable right Meckel’s cave and right foramen ovale. The patient eventually to the motor division of CN V3. After a few years, she developed underwent a tissue biopsy, which revealed invasive squamous cell neuralgic pain and facial numbness (implicating the sensory fibers carcinoma. Ultimately, the patient refused oncologic treatment and of CN V), taste alteration (involvement of lingual nerve from CN V went home on hospice. and chorda tympani from CN VII), and lacrimation (occurring via Case 2 the parasympathetic nerves that travel with CN VII). Familiarity with neuroanatomy would localize symptoms predominantly to CN V A 72 year old man presented with five months of diplopia, and possibly CN VII. Despite progression over years, initial MRI was intermittent dysphagia, paresthesia and lancinating pain in the not revealing and positive Lyme titers were suggestive of peripheral right V2 distribution. Exam was notable for inability to depress the cranial nerve involvement by the B. burgdorferi. The follow up MRI right eye, decreased sensation in the right V1-V3 distribution, and demonstrated enhancement that could be consistent