Braz. j. . vol.83 número6

BrazJOtorhinolaryngol.2017;83(6):720---722

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

CASE

REPORT

The

facial

palsy

as

first

symptom

of

the

temporal

bone

lung

cancer

metastasis

夽

A

paralisia

facial

como

primeiro

sintoma

de

metástase

de

câncer

pulmonar

no

osso

temporal

Dragoslava

Djeric

_,

_Ivan

_Boricic

_,

_Nada

_Tomanovic

_,

_Ljiljana

_Cvorovic

_,

Srbislav

Blazic

_,

_Miljan

_Folic

_,

_Igor

_Djoric

a_{UniversityofBelgrade,FacultyofMedicine,ClinicalCenterofSerbia,ClinicforOtorhinolaryngologyandMaxillofacialSurgery,}

Belgrade,Serbia

b_{UniversityofBelgrade,FacultyofMedicine,InstituteofPathology,Belgrade,Serbia} c_{ClinicalCenterofSerbia,DepartmentofRadiology,Belgrade,Serbia}

Received19August2015;accepted17September2015 Availableonline19December2015

Introduction

Lungcancerusuallyspreadsbylymphaticorhematogenous route;aroundonefifth ofnewlydiagnosedlung adenocar-cinomaspresent withdistantmetastasesinorganssuchas brain,adrenalglands,liverandbones.1_However,lung can-cer metastases in the temporal bone are quite rare,and assuch,present substantialdiagnostic challenge. Clinical manifestationsofmetastaticdiseaseinthetemporalbone areusuallyobscureandmayincludesymptomssuchas hear-ingloss,tinnitus,vertigo,facialpalsy,otalgia,otorrheaand headache.Theoccurrenceofanosteolyticlesioninthe tem-poralbone(evenintheabsenceofaknownprimarytumor) shouldalwaysbeconsideredasapossiblemetastasis,

espe-夽 _{Please citethis article as:Djeric D, Boricic I, Tomanovic N,}

CvorovicL,BlazicS,FolicM,etal.Thefacialpalsyasfirstsymptom ofthetemporalbonelungcancermetastasis.BrazJ Otorhinolaryn-gol.2017;83:720---2.

∗_{Correspondingauthor.}

E-mail:[email protected](M.Folic).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileirade OtorrinolaringologiaeCirurgiaCérvico-Facial.

cially inelderlypatients. The authorspresent ararecase ofan otogenicfacialpalsyandmetastasis inthetemporal boneasan initialmanifestationoflung canceranddiscuss potential diagnostic pitfalls. This paper wasapproved by theEthicsCommitteeofClinicforOtorhinolaryngologyand MaxillofacialSurgery.

Case

report

A 73-year-old female patient presented with peripheral facial palsy and otalgia that were treated for about two months in a primary health care center. After an incom-pleteresolutionofsymptoms,thepatientwasadmittedinto ourfacilityforadditionaldiagnosticsandfollow-up. Otomi-croscopic examinationontheleftearrevealed hyperemic tympanicmembranewithprominent parsflaccida.Patient also had left periphery facial palsy (House-Brackmann scale, grade3),conductivelefthearing loss(airbone gap 30dB), B-typetympanometry, high rateofC-reactive pro-tein(60mg/L)andleukocytosis(14×106L−1). Patienthad normalbodytemperature,andwaswithoutnauseaor dizzi-ness.Accordingtomedicalrecord,patientwastreatedfor chronicobstructivebronchitisandosteoporosis,withregular controlsandfollow-up.

http://dx.doi.org/10.1016/j.bjorl.2015.09.007

Thefacialpalsyasfirstsymptomofthetemporalbonelungcancermetastasis 721

Figure1 (A)TemporalboneCTscan:thickenedmucosawithinthemastoidaircells.(B)Presenceofanexpansiveosteolytic temporalbonelesion;notethedestructionofmastoidapex.

Figure2 Immunohistochemicalanalysis:atypicaltumorcells thatshowstronganddiffusenuclearpositivityforTTF-1 anti-body.Streptavidin-biotin,originalmagnification400×.

Temporal bone computed tomography (CT) revealed mucosalthickeningwithinthemastoidaircells, osteolytic lesionin theleftmastoidandoccipitalbone andthe het-erogeneous mass in the middle ear structures (Fig. 1). Treatment with intravenous antibiotics ensued (Ceftria-xone2g/perday),withoutanyimprovementofsymptoms. Patienthadnosignsorsymptomsofthemalignantdisease; chestradiographyshowednosignsoflungcancer.

During surgery, the mastoidectomy, paracenthesis and ventilation tube implantation were performed. We noted presenceof soft,friable,granulation tissueintheantrum andinthemastoid;fragmentsweresentfor histopatholog-icalanalysis.

Histopathological and immunohistochemical analysis revealed presence of rare atypical cells that were cytokeratin-andTTF-1positive(Fig.2).Therefore,thecase wasdiagnosedasthemetastasisoflungcarcinoma.ChestCT scan, bronchoscopy and histopathological analysis of lung samples ensued; these additional analyses confirmed the diagnosis of a lung adenocarcinoma that waslocalized in theapicalsegmentoftheleftlung. Inaveryshortperiod of time, our patient---who at the time also had bilateral

mediastinallymphnode enlargement---diedsuddenly, prior toanyspecificoncologicaltreatment.

Discussion

Metastases in the temporal bone are relatively rare; the most common primary sites usually are breast, lung, kidney and stomach cancers.2---5 _{The pattern of} metastaticspreadtoward the temporal bone mayinvolve lymphatic/hematogenous route, diffuse metastatic lep-tomeningealcarcinomatosisor directextensionoftumor.2 Lung cancer usually spreads via hematogenous route, in headandneckregionusuallytowardbrain.1,2,5_Inourcase, metastatic spread was due to lymphatic/hematogenous spread of tumor cells that also caused mediastinal lym-phadenopathy. Due to hematogenous spread, tumor cell embolimayfavorthepetrous apexof thetemporalbone, whichhasbonemarrowthatisirrigatedbyaslow-flow cap-illarynetwork.

Clinical examination of patients with temporal bone metastasismayshowvariousfindings,suchasretroauricular softtissueswellingorswellingofthetissuestructuresinthe externalauditorycanal,inflammation(suchasotitismedia witheffusion),perforationoftympanicmembrane,otalgia, facialparalysisandseveralothers;insomecases,metastasis inthetemporalbonemayevenbewithoutsymptoms.6,7

Facialnervepalsycanbecausedbyamyriadofcauses; in about two-thirds of the cases etiology is idiopathic or infective.8 _{Other causes include trauma, inflammatory} and/or autoimmune diseases and primary or secondary tumors. Considering the sudden onset of facial paralysis andclinicalpresentation,ourpatientwasinitiallydiagnosed as an acute otitis with otogenic facial palsy. In absence of response to treatment (antibiotics, antiviral agents or steroids), CTscan is obligatory. Cases of prolonged facial paralysisareindicativeoffacialnerveexploration.9_During surgeryof elderly patients withosteolytic temporal bone lesions,samples for histopathological analysis are obliga-tory;wefoundasoft,friabletissuepronetohemorrhagein themastoidthatwassentforhistopathologicalanalysis.

722 DjericDetal.

immunohistochemical analysis enabled accurate diagnosis withprimarysiteidentification.FurtherCT,bronchoscopic andhistopathologicalexamination confirmedthediagnosis of a primary lung adenocarcinoma. The whole diagnostic processlasted nearlythree months,and our patientdied withoutspecificcancertreatment.

Conclusion

Metastaticdiseaseshouldalwaysbeconsideredinpatients withfacialnerveparalysiswhoalsohadahistoryof malig-nantdisease.Ourcaseisquiteunique:otogenicfacialpalsy wasaninitialmanifestationoflungcancer;thefacialpalsy wastheresultoftemporalbonemetastasis.Therefore,one shouldalways excludea possible temporal bone metasta-sis in elderly patients with and even without the history ofmalignantdisease,especiallywhenthereisevidenceof temporalboneosteolysis.4---7

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgement

Thispaperwassupported,inpart,bytheSerbianMinistry ofScience(ProjectNo.175026).

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