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Can clubbing tell you about ears?
Case Report
Can clubbing tell you about ears? Richard S K Chang, Macy M S Lui, David C L Lam, Raymond T F Cheung, Shu-Leong Ho Lancet 2009; 373: 866 Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China (R S K Chang MRCP, M M S Lui MRCP, D C L Lam MRCP, Prof R T F Cheung FRCP, Prof S-L Ho FRCP) Correspondence to: Dr Richard S K Chang, 4/F Professorial Block, Department of Medicine, Queen Mary Hospital, Hong Kong, China [email protected]
In June, 2008, a 60-year-old man was admitted to our hospital, having had persistent pain in both ears for 10 days. He described the pain as dull, and radiating from inside the ears towards the auricles. Nothing seemed to change the intensity of the pain. The patient had no ear discharge, marked hearing loss, tinnitus, or fever. He seemed to have no relevant medical history, although he had smoked cigarettes for many years. A course of antibiotics had been ineffective. We saw no rash around the ears; the patient’s external auditory canals and eardrums looked normal. Neurological examination showed normal cranial nerve function, and unimpaired hearing; however, we found slight weakness (power 4/5) of the left arm and leg. We also noted finger clubbing. An otolaryngologist found nothing of note. Blood tests gave unremarkable findings, apart from an ESR of 46 mm/h. Radiography of both temporomandibular joints showed no abnormality. However, radiography and CT of the chest revealed a lobulated mass (6·5×4∙5 cm) in the left upper hilum, extending to the contralateral mediastinum (figure). CT of the brain showed lesions, more visible with contrast, in the right upper pons, both frontal lobes, and the right occipital lobe; we suspected brain metastases. By a transbronchial approach, we took a biopsy of the left-lung lesion; histopathological examination showed it to be an adenocarcinoma. Immunohistochemical staining showed positive nuclear staining with thyroid transcription factor 1, but not with cytokeratins CK7, CK20, or CDX2: this pattern was consistent with primary non-small cell lung cancer. Despite radiotherapy and treatment with gefitinib, the patient died in November, 2008.
Intracranial cancer can cause headache or facial pain by infiltrating parts of the brain involved in pain processing, increasing intracranial pressure (ICP), infiltrating the meninges, or changing hormone secretion from the hypothalamus or pituitary.1 Metastasis to the skull base can cause headache or facial pain, together with cranial nerve palsies.2 However, none of these mechanisms seems to account for our patient’s earache. His metastatic lesions were rostral to the medulla and, therefore, would have caused unilateral, not bilateral pain. He had no clinical features of raised ICP; moreover, raised ICP is not typically associated with earache. We saw no leptomeningeal enhancement on CT. Because of the brain metastases, we did not do a lumbar puncture, so cannot absolutely exclude carcinomatous meningitis. Nonetheless, carcinomatous meningitis (and, indeed, skull-base metastases)2 would be most unlikely to cause bilateral ear pain, without causing pain elsewhere. What about the sensory innervation of the ear? The ear’s somatosensory innervation is provided by the glossopharyngeal nerve, great auricular nerve, branches of the trigeminal and facial nerves, and the auricular branch of the vagus nerve. The somatic and visceral afferent fibres of the vagus nerve converge before entering the medulla. Therefore, visceral signals can cause referred pain in the sensory territories of the vagus. Lung cancer is known to cause referred facial pain, typically around the ipsilateral ear;3–5 patients with this syndrome commonly have finger clubbing and a high ESR. We conclude, therefore, that lung cancer caused the earache— and both ears were affected because both vagus nerves were infiltrated by the tumour. We think that infiltration of the glossopharyngeal nerve is unlikely to have caused the earache, because bilateral pain would be difficult to account for, and the base of the tongue, tonsillar fossa, and throat were unaffected. Referred facial pain from lung cancer is sometimes reduced by vagotomy, although treatment should focus on the tumour.4,5 Acknowledgments We thank Dr W Mak, Consultant in Neurology, Queen Mary Hospital. Contributors RSKC, MMSL, DCLL, RFTC, and SLH assessed and treated the patient. RSKC wrote the report. All authors have seen and approved the final version.
Figure: Double earache CT of the chest, showing how the tumour (arrowheads) could infiltrate both vagus nerves, the presumed courses of which are indicated by arrows.
866
References: 1 Headache classification subcommittee of the international headache society. The International Classification of Headache Disorders: 2nd edn. Cephalalgia 2004; 24 (suppl 1): 9–160. 2 Greenberg HS, Deck MD, Vikram B, Chu FC, Posner JB. Metastasis to the base of the skull: clinical findings in 43 patients. Neurology 1981; 31: 530–37. 3 Bindoff LA, Heseltine D. Unilateral facial pain in patients with lung cancer: a referred pain via the vagus? Lancet 1988; 1: 812–15. 4 Bongers KM, Willigers HM, Koehler PJ. Referred facial pain from lung carcinoma. Neurology 1992; 42: 1841–42. 5 Eross EJ, Dodick DW, Swanson JW, Capobianco DJ. A review of intractable facial pain secondary to underlying lung neoplasms. Cephalalgia 2003; 23: 2–5.
www.thelancet.com Vol 373 March 7, 2009
Can clubbing tell you about ears? Richard S K Chang, Macy M S Lui, David C L Lam, Raymond T F Cheung, Shu-Leong Ho Lancet 2009; 373: 866 Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China (R S K Chang MRCP, M M S Lui MRCP, D C L Lam MRCP, Prof R T F Cheung FRCP, Prof S-L Ho FRCP) Correspondence to: Dr Richard S K Chang, 4/F Professorial Block, Department of Medicine, Queen Mary Hospital, Hong Kong, China [email protected]
In June, 2008, a 60-year-old man was admitted to our hospital, having had persistent pain in both ears for 10 days. He described the pain as dull, and radiating from inside the ears towards the auricles. Nothing seemed to change the intensity of the pain. The patient had no ear discharge, marked hearing loss, tinnitus, or fever. He seemed to have no relevant medical history, although he had smoked cigarettes for many years. A course of antibiotics had been ineffective. We saw no rash around the ears; the patient’s external auditory canals and eardrums looked normal. Neurological examination showed normal cranial nerve function, and unimpaired hearing; however, we found slight weakness (power 4/5) of the left arm and leg. We also noted finger clubbing. An otolaryngologist found nothing of note. Blood tests gave unremarkable findings, apart from an ESR of 46 mm/h. Radiography of both temporomandibular joints showed no abnormality. However, radiography and CT of the chest revealed a lobulated mass (6·5×4∙5 cm) in the left upper hilum, extending to the contralateral mediastinum (figure). CT of the brain showed lesions, more visible with contrast, in the right upper pons, both frontal lobes, and the right occipital lobe; we suspected brain metastases. By a transbronchial approach, we took a biopsy of the left-lung lesion; histopathological examination showed it to be an adenocarcinoma. Immunohistochemical staining showed positive nuclear staining with thyroid transcription factor 1, but not with cytokeratins CK7, CK20, or CDX2: this pattern was consistent with primary non-small cell lung cancer. Despite radiotherapy and treatment with gefitinib, the patient died in November, 2008.
Intracranial cancer can cause headache or facial pain by infiltrating parts of the brain involved in pain processing, increasing intracranial pressure (ICP), infiltrating the meninges, or changing hormone secretion from the hypothalamus or pituitary.1 Metastasis to the skull base can cause headache or facial pain, together with cranial nerve palsies.2 However, none of these mechanisms seems to account for our patient’s earache. His metastatic lesions were rostral to the medulla and, therefore, would have caused unilateral, not bilateral pain. He had no clinical features of raised ICP; moreover, raised ICP is not typically associated with earache. We saw no leptomeningeal enhancement on CT. Because of the brain metastases, we did not do a lumbar puncture, so cannot absolutely exclude carcinomatous meningitis. Nonetheless, carcinomatous meningitis (and, indeed, skull-base metastases)2 would be most unlikely to cause bilateral ear pain, without causing pain elsewhere. What about the sensory innervation of the ear? The ear’s somatosensory innervation is provided by the glossopharyngeal nerve, great auricular nerve, branches of the trigeminal and facial nerves, and the auricular branch of the vagus nerve. The somatic and visceral afferent fibres of the vagus nerve converge before entering the medulla. Therefore, visceral signals can cause referred pain in the sensory territories of the vagus. Lung cancer is known to cause referred facial pain, typically around the ipsilateral ear;3–5 patients with this syndrome commonly have finger clubbing and a high ESR. We conclude, therefore, that lung cancer caused the earache— and both ears were affected because both vagus nerves were infiltrated by the tumour. We think that infiltration of the glossopharyngeal nerve is unlikely to have caused the earache, because bilateral pain would be difficult to account for, and the base of the tongue, tonsillar fossa, and throat were unaffected. Referred facial pain from lung cancer is sometimes reduced by vagotomy, although treatment should focus on the tumour.4,5 Acknowledgments We thank Dr W Mak, Consultant in Neurology, Queen Mary Hospital. Contributors RSKC, MMSL, DCLL, RFTC, and SLH assessed and treated the patient. RSKC wrote the report. All authors have seen and approved the final version.
Figure: Double earache CT of the chest, showing how the tumour (arrowheads) could infiltrate both vagus nerves, the presumed courses of which are indicated by arrows.
866
References: 1 Headache classification subcommittee of the international headache society. The International Classification of Headache Disorders: 2nd edn. Cephalalgia 2004; 24 (suppl 1): 9–160. 2 Greenberg HS, Deck MD, Vikram B, Chu FC, Posner JB. Metastasis to the base of the skull: clinical findings in 43 patients. Neurology 1981; 31: 530–37. 3 Bindoff LA, Heseltine D. Unilateral facial pain in patients with lung cancer: a referred pain via the vagus? Lancet 1988; 1: 812–15. 4 Bongers KM, Willigers HM, Koehler PJ. Referred facial pain from lung carcinoma. Neurology 1992; 42: 1841–42. 5 Eross EJ, Dodick DW, Swanson JW, Capobianco DJ. A review of intractable facial pain secondary to underlying lung neoplasms. Cephalalgia 2003; 23: 2–5.
www.thelancet.com Vol 373 March 7, 2009