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Bell's palsy
G Model ANORL-573; No. of Pages 2
ARTICLE IN PRESS European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2016) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
What is your diagnosis?
Bell’s palsy A. Villeneuve ∗ , C. Aussedat , D. Bakhos Service d’ORL-CCF, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
1. Case report A 79-year-old woman presented with sudden onset of left peripheral facial nerve (Bell’s) palsy. Clinical ENT examination demonstrated features of House-Brackmann grade III left Bell’s palsy. The rest of the clinical examination, particularly the neurological examination, was normal. The audiogram showed presbyacusis and absence of the left stapedial reflex. Clinical
interview revealed a history of hormone therapy (letrozole) for bilateral breast cancer initially treated by surgery followed by radiotherapy 15 years previously, as well as antihypertensive treatment. Signs of Bell’s palsy had completely resolved at the follow-up visit. Six months later, she returned with recurrence of left Bell’s palsy. Computed tomography (Fig. 1a, coronal section) and magnetic resonance imaging (Fig. 1b, axial section) of petrous temporal bones were then performed.
Fig. 1. a: CT scan, coronal section of the left petrous temporal bone showing an irregular low-density image (arrow), eroding the cochlea and tegmen tympani, with no calcifications, in contact with the meatal segment of the facial nerve; b: MRI, axial section, gadolinium-enhanced T1-weighted sequence showing an irregular lesion of the petrous temporal bone (arrow) with intense, homogeneous gadolinium enhancement, extending into the facial canal and middle cranial fossa.
What is your diagnosis?
∗ Corresponding author. Tel.: +33 2 47 47 47 35; fax: +33 2 47 47 36 00. E-mail address: [email protected] (A. Villeneuve). http://dx.doi.org/10.1016/j.anorl.2016.06.002 1879-7296/© 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Villeneuve A, et al. Bell’s palsy. European Annals of Otorhinolaryngology, Head and Neck diseases (2016), http://dx.doi.org/10.1016/j.anorl.2016.06.002
G Model ANORL-573; No. of Pages 2
ARTICLE IN PRESS A. Villeneuve et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2016) xxx–xxx
2
2. Answer This patient presented a breast cancer metastasis in the petrous temporal bone. CT scan demonstrated an osteolytic lesion over the left geniculate ganglion. MRI demonstrated contrast enhancement over the geniculate ganglion. Breast cancers, like lung, prostate, renal and thyroid cancers, commonly give rise to bone metastases [1]. Petrous temporal bone metastases can present in the form of various head and neck manifestations, often with a benign appearance, such as Bell’s palsy, hearing loss, vertigo, tinnitus, serous otitis media [2]. The diagnosis is based on CT and/or MRI imaging and PET-CT scan looking for other metastatic lesions [3]. The American Academy of Otolaryngology–Head and Neck Surgery Foundation published guidelines, including the imaging assessment of Bell’s palsy in 2013 [4]. Imaging is not recommended as first-line investigation in a patient with Bell’s palsy. The high-intensity signal commonly observed over the geniculate ganglion can be misleading, suggesting a neoplastic lesion, resulting in unnecessary complementary investigations. However, in a patient with a history of trauma, tumour, a second ipsilateral episode, paralysis of only one branch of the facial nerve, other associated cranial nerve deficits, absence of recovery after 3 months and progressive deterioration, contrast-enhanced CT scan of the petrous temporal bone or preferably MRI should be performed to examine the entire course of the facial nerve. The diagnosis of malignancy can be suggested radiologically by the presence of irregular bone erosions and osteolysis, invasion of adjacent anatomical structures, the presence of cervical lymph nodes or distant metastases [5], while a benign tumour, such as schwannoma, does not present any of these characteristics, is clearly demarcated, with a more or less cystic appearance,
isodense on CT with possible enlargement of the facial canal or internal auditory canal, and an isointense T1 signal, hyperintense T2 signal and gadolinium enhancement on MRI. Metastases of the petrous temporal bone must also be distinguished from facial nerve haemangioma characterized by enlargement of the facial canal with poorly defined margins associated with small calcifications, in contrast with schwannoma, which presents heterogeneous gadolinium enhancement on T1-weighted MRI [6]. The prognosis of metastases from primary solid tumours, regardless of the histological type, is very poor and patients often die within a few months [7]. Disclosure of interest The authors declare that they have no competing interest. References [1] Bakhos D, Chenebaux M, Lescanne E, et al. Two cases of temporal bone metastasis as presenting sign of lung cancer. Eur Ann Otorhinolaryngol Head Neck Dis 2012;129(1):54–7. [2] Lan MY, Shiao AS, Li WY. Facial palsy caused by metastasis of breast carcinoma to the temporal bone. J Chin Med Assoc 2004;67(11):579–82. [3] Gilden DH. Bell’s Palsy. N Enlg J Med 2004;351:1323–31. [4] Baugh, et al. Clinical practice guidelines: Bell’s palsy. Otolaryngol Head Neck Surg 2013;149:S1–27. [5] Recommandations pour la pratique clinique – G2 – Tumeurs malignes primitives de l’oreille – Réseau d’expertise franc¸ais sur les cancers ORL rares (REFCOR).; 2013 www.refcor.org/1260-tumeurs-malignes-primitives-de-l-oreille. [6] Veillon F, et al. Imagerie de l’oreille et de l’os temporal – Tumeurs, nerf facial. Lavoisier; 2014. p. 1022–38. [7] Chen LY, Ni YB, Lacambra MD, et al. Skull bone metastasis with adjacent leptomeningeal involvement from pleomorphic lobular carcinoma of the breast. Histopathology 2015;66(7):1051–3.
Please cite this article in press as: Villeneuve A, et al. Bell’s palsy. European Annals of Otorhinolaryngology, Head and Neck diseases (2016), http://dx.doi.org/10.1016/j.anorl.2016.06.002
ARTICLE IN PRESS European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2016) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
What is your diagnosis?
Bell’s palsy A. Villeneuve ∗ , C. Aussedat , D. Bakhos Service d’ORL-CCF, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
1. Case report A 79-year-old woman presented with sudden onset of left peripheral facial nerve (Bell’s) palsy. Clinical ENT examination demonstrated features of House-Brackmann grade III left Bell’s palsy. The rest of the clinical examination, particularly the neurological examination, was normal. The audiogram showed presbyacusis and absence of the left stapedial reflex. Clinical
interview revealed a history of hormone therapy (letrozole) for bilateral breast cancer initially treated by surgery followed by radiotherapy 15 years previously, as well as antihypertensive treatment. Signs of Bell’s palsy had completely resolved at the follow-up visit. Six months later, she returned with recurrence of left Bell’s palsy. Computed tomography (Fig. 1a, coronal section) and magnetic resonance imaging (Fig. 1b, axial section) of petrous temporal bones were then performed.
Fig. 1. a: CT scan, coronal section of the left petrous temporal bone showing an irregular low-density image (arrow), eroding the cochlea and tegmen tympani, with no calcifications, in contact with the meatal segment of the facial nerve; b: MRI, axial section, gadolinium-enhanced T1-weighted sequence showing an irregular lesion of the petrous temporal bone (arrow) with intense, homogeneous gadolinium enhancement, extending into the facial canal and middle cranial fossa.
What is your diagnosis?
∗ Corresponding author. Tel.: +33 2 47 47 47 35; fax: +33 2 47 47 36 00. E-mail address: [email protected] (A. Villeneuve). http://dx.doi.org/10.1016/j.anorl.2016.06.002 1879-7296/© 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Villeneuve A, et al. Bell’s palsy. European Annals of Otorhinolaryngology, Head and Neck diseases (2016), http://dx.doi.org/10.1016/j.anorl.2016.06.002
G Model ANORL-573; No. of Pages 2
ARTICLE IN PRESS A. Villeneuve et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2016) xxx–xxx
2
2. Answer This patient presented a breast cancer metastasis in the petrous temporal bone. CT scan demonstrated an osteolytic lesion over the left geniculate ganglion. MRI demonstrated contrast enhancement over the geniculate ganglion. Breast cancers, like lung, prostate, renal and thyroid cancers, commonly give rise to bone metastases [1]. Petrous temporal bone metastases can present in the form of various head and neck manifestations, often with a benign appearance, such as Bell’s palsy, hearing loss, vertigo, tinnitus, serous otitis media [2]. The diagnosis is based on CT and/or MRI imaging and PET-CT scan looking for other metastatic lesions [3]. The American Academy of Otolaryngology–Head and Neck Surgery Foundation published guidelines, including the imaging assessment of Bell’s palsy in 2013 [4]. Imaging is not recommended as first-line investigation in a patient with Bell’s palsy. The high-intensity signal commonly observed over the geniculate ganglion can be misleading, suggesting a neoplastic lesion, resulting in unnecessary complementary investigations. However, in a patient with a history of trauma, tumour, a second ipsilateral episode, paralysis of only one branch of the facial nerve, other associated cranial nerve deficits, absence of recovery after 3 months and progressive deterioration, contrast-enhanced CT scan of the petrous temporal bone or preferably MRI should be performed to examine the entire course of the facial nerve. The diagnosis of malignancy can be suggested radiologically by the presence of irregular bone erosions and osteolysis, invasion of adjacent anatomical structures, the presence of cervical lymph nodes or distant metastases [5], while a benign tumour, such as schwannoma, does not present any of these characteristics, is clearly demarcated, with a more or less cystic appearance,
isodense on CT with possible enlargement of the facial canal or internal auditory canal, and an isointense T1 signal, hyperintense T2 signal and gadolinium enhancement on MRI. Metastases of the petrous temporal bone must also be distinguished from facial nerve haemangioma characterized by enlargement of the facial canal with poorly defined margins associated with small calcifications, in contrast with schwannoma, which presents heterogeneous gadolinium enhancement on T1-weighted MRI [6]. The prognosis of metastases from primary solid tumours, regardless of the histological type, is very poor and patients often die within a few months [7]. Disclosure of interest The authors declare that they have no competing interest. References [1] Bakhos D, Chenebaux M, Lescanne E, et al. Two cases of temporal bone metastasis as presenting sign of lung cancer. Eur Ann Otorhinolaryngol Head Neck Dis 2012;129(1):54–7. [2] Lan MY, Shiao AS, Li WY. Facial palsy caused by metastasis of breast carcinoma to the temporal bone. J Chin Med Assoc 2004;67(11):579–82. [3] Gilden DH. Bell’s Palsy. N Enlg J Med 2004;351:1323–31. [4] Baugh, et al. Clinical practice guidelines: Bell’s palsy. Otolaryngol Head Neck Surg 2013;149:S1–27. [5] Recommandations pour la pratique clinique – G2 – Tumeurs malignes primitives de l’oreille – Réseau d’expertise franc¸ais sur les cancers ORL rares (REFCOR).; 2013 www.refcor.org/1260-tumeurs-malignes-primitives-de-l-oreille. [6] Veillon F, et al. Imagerie de l’oreille et de l’os temporal – Tumeurs, nerf facial. Lavoisier; 2014. p. 1022–38. [7] Chen LY, Ni YB, Lacambra MD, et al. Skull bone metastasis with adjacent leptomeningeal involvement from pleomorphic lobular carcinoma of the breast. Histopathology 2015;66(7):1051–3.
Please cite this article in press as: Villeneuve A, et al. Bell’s palsy. European Annals of Otorhinolaryngology, Head and Neck diseases (2016), http://dx.doi.org/10.1016/j.anorl.2016.06.002