PMC3290035_01
Physical findings in our patient.
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F1
At the end of induction therapy, she presented with a 2-week history of progressively worsening headache, hearing loss and severe facial pain, all unilateral, left sided, and resembling acute trigeminal neuralgia. (Head CT with contrast was normal 3 weeks prior during workup for these milder symptoms.) Current physical exam showed left-sided facial sensitivity to light touch, moderate retraction of the left eardrum, and subtle weakness of the left lateral rectus muscle (VI) (see fig. 1, fig. 2).
CT showing soft tissue density surrounding the left sphenoid bone with complete cortical destruction and invasion of local structures.
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F3
Imaging now demonstrated massive destruction of the left sphenoid bone with extension to the left mastoid and left frontal bone (roof of left orbit) without any brain involvement (see fig. 3, fig. 4).
Illustration of several cranial nerves (III-VI) as they pierce the dura mater to enter the cavernous sinus. Note: The ophthalmic nerve (CN II) does not travel through the cavernous sinus. Visual symptoms are usually a secondary event due to impaired venous drainage from the eye itself leading to either retinal edema or severely increased intraocular pressures.
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F5
MRI confirmed these findings, with encasement of several CN of the left cavernous sinus (fig. 5, fig. 6).
HE. 40x. Nests of squamous cell carcinoma show marked nuclear pleomorphism and ample eosinophilic cytoplasm.
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F7
Frozen sections revealed squamous cell cancer, consistent with original cytology, with little or no radiation effect (see fig. 7, fig. 8).