That fall, a friend told the patient about a clinic at New York University that specialized in facial paralysis. He quickly found it on the Internet: the Center for Facial Palsy and Resuscitation. He studied the faces of the doctors in the clinic. dr Judy Lee was a specialist in ear, nose and throat disorders and a plastic and reconstructive surgeon. She had a warm smile and a friendly face. The patient made an appointment to see her.
Lee listened to the woman’s story. She also questioned the diagnosis of Bell’s palsy. Although the patient’s symptoms matched Bell’s, the story didn’t quite add up. That kind of nerve damage comes on quickly, usually within hours, sometimes days. This woman described a process that took months. The two MRIs showed that she had not had a stroke, the most common cause of sagging cheeks and lips. Shingles could also cause this type of paralysis, but the patient had no other symptoms of the disease, so it seemed unlikely. Lee ordered another MRI. She was also worried about a mass and had only seen the previous MRI reports.
A sparkle on the nerve
Lee presented the new MRI to his colleagues the following week. It was a monthly meeting to discuss the most difficult cases. The neuroradiologist noted a glow on the nerve that looked like inflammation. He was at the point after the nerve passes through the inner ear and enters the temporal bone, on its way to the muscles of the face. That’s not where he would normally see swelling in Bell’s palsy. Also, that kind of inflammation, caused by nerve injury, should heal after a year and a half. And there was still no mass visible. Was this glow, this swelling, evidence of a tumor? The team probably agreed. They just had to find it. The patient needed a biopsy. If a tumor was visible, they would have their diagnosis. And no matter what else they saw, they would biopsy the nerve itself.
Lee called the patient and explained what they were proposing. “We can’t see anything, but we know he has to be there,” she said. A biopsy would show exactly what they were up against. The patient was reluctant. If you can’t see anything, he asked, why do you think he’s there? Because, Lee explained, nothing else makes sense.
The surgery was carried out a few weeks later. In the operating room, Dr. David Friedman cut the bone behind her ear. She identified the nerve and followed its course as she progressed to the facial muscles. She was nowhere to be seen mass. She cut a few small segments of nerve. Tests indicated that her nerve was already dead, but she didn’t want to risk causing any further injury. Friedmann sent the samples to the laboratory and the answer came within a week. She had a squamous cell carcinoma growing on his nerve.
That answer prompted more questions. Where does this come from? It was unlikely that she had started there on the nerve. Did it spread from skin cancer, one of the most common forms of squamous cell carcinoma? The patient had several skin cancers removed when she was younger, so that was possible. Still, squamous cells are found almost everywhere in the body. Doctors at NYU ordered a positron emission tomography scan. There were no signs of cancer anywhere else.
Still, the cancer cells in her facial nerve had to have come from somewhere. As doctors knew, just because you don’t see cancer doesn’t mean there isn’t cancer. She was treated for what is called metastatic disease with an unknown primary: she received radiation and chemotherapy that lasted until early this summer. But even before she was treated for cancer, she had an operation to fix her face. She carefully placed a muscle from her leg over the atrophied muscle in her left cheek. It will take months for those muscles to start working to replace the ones destroyed by the cancer. She realizes that the face she had known of hers all her life will never return. But she hopes the surgery, plus physical therapy, will at least let her smile again.
Lisa Sanders, MD, is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Perplexing Medical Mysteries.” If you have solved a case to share, write here to Lisa.Sandersmdnyt@gmail.com.