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September 30, 2022

This woman's face 'looked flat and droopy.' What was wrong?

Daily Briefing

    After a 64-year-old woman was diagnosed with Bell's palsy, she waited months for her symptoms to improve—but they never did. Then, doctors found a squamous-cell carcinoma growing in her facial nerve, Lisa Sanders writes for the New York Times Magazine.

    A changing face

    During a massage, the woman noticed that the left side of her face hurt when she rested in on the cushion. While she thought it was strange, she dismissed the pain—until she noticed concerning changes in her face a few months later.

    The woman noticed that her left eye was irritated and was watering frequently, particularly when she wore a mask to follow Covid-19 protocols. Initially, she believed that the mask was irritating her eyelid—but the eye watering and irritation occurred no matter what kind of mask she wore or how she wore it.

    By the end of summer 2020, the woman could tell that her face was changing even more. "Sure, she was getting older, but it was more than that," Sanders writes. "The lower lid of her left eye sagged, and the edge was red and looked irritated—even when she hadn't worn a mask for days. And her smile was different, crooked. Her whole mouth seemed pulled over to the right, as if the left side had just given up. That side of her face now looked flat and droopy, like her eyelid."

    She went to see her primary-care doctor, who referred her to a neurologist. When the neurologist asked the woman to raise her eyebrows and smile, her left eyebrow would not go up and the left side of her mouth did not move when she smiled.

    The neurologist told the woman her condition looked like Bell's palsy. "The drooping is caused by an inflammation of a related nerve—often because of a virus," Sanders writes. "The source of the injury, however, is rarely identified. It can take weeks, occasionally months, for the nerve to start to recover."

    To rule out any other cause, the neurologist ordered an MRI. "Sometimes a brain tumor could press on the nerve, causing these same sorts of changes, and missing that would be disastrous," Sanders notes. However, when the woman's MRI did not detect any sign of a mass, the neurologist assured her that she had Bell's palsy.

    'We can't see anything, but we know it has to be there'

    After she was diagnosed with Bell's palsy, the woman waited for months—but her symptoms were still showing no signs of improvement.

    When a friend asked her if her drooping face could be a symptom of Lyme disease, her primary-care doctor tested her for Lyme disease—but it came back negative.

    Then, the woman went to see a "Lyme literate" doctor, who ordered special tests that he told her could detect hidden Lyme infections.

    Surprisingly, the test came back positive. He prescribed several antibiotics the woman needed to take over the course of four months. However, the antibiotics did not help. "If she did have Lyme disease, it wasn't what caused her face to droop," Sanders writes.

    Two years had passed since her face started to change, and her symptoms still weren't improving. Typically, Bell's palsy will start to improve within a few weeks. While patients may not recover completely from the condition, the woman's neurologist did not understand why her symptoms had not improved at all.

    When the neurologist ordered a second MRI there was still no mass.

    One of the woman's friends told her about the New York University Facial Paralysis and Reanimation Center—a facility that specializes in facial palsies. She made an appointment with one of the doctors at the center—Judy Lee, a specialist in disorders of the ear, nose, and throat and a plastic and reconstructive surgeon.

    While Lee acknowledged that the patient's symptoms were consistent with Bell's, she noted that something was not adding up.

    "That type of nerve damage comes on quickly—usually over hours, sometimes days. This woman described a process that took months," Sanders writes.

    Lee ordered a new MRI and showed it to her colleagues the following week. During the meeting, the neuroradiologist noticed a brightness in the woman's facial nerve that looked like inflammation.  

    According to Sanders, the bright spot "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."

    Notably, "[t]hat's not where you would usually see inflammation in Bell's palsy," Sanders adds. "Moreover, that type of inflammation, caused by injury to the nerve, should be healed after a year and a half. And there was still no visible mass."

    Ultimately, the team of doctors agreed that the inflammation on the woman's MRI was likely evidence of a tumor. Lee then called the patient and explained the situation. "We can't see anything, but we know it has to be there," Lee said.

    A few weeks later, David Friedmann performed the woman's surgery. As he cut the bone behind her ear, he identified the nerve and noted that no mass was visible. He sent the samples of the dead nerve to the lab for a biopsy. Within a week, lab tests confirmed that the woman had a squamous-cell carcinoma growing in her facial nerve.

    Hoping that treatment 'will at least let her smile again'

    Notably, squamous cells can be found almost anywhere in the body. However, when the woman's doctors ordered a PET scan, they did not find signs of cancer anywhere else.

    They treated her for a metastatic disease with an unknown primary. "She had radiation and chemotherapy that lasted until early this summer," Sanders writes. "But even before being treated for the cancer, she had an operation to fix her face. A muscle from her leg was carefully positioned over the atrophied muscle in her left cheek."

    While it will take months for the woman's muscles to replace the ones destroyed by her cancer, she has accepted that her face will never go back to the way it used to be. "But she hopes that the surgery, plus physical therapy, will at least let her smile again," Sanders writes. (Sanders, New York Times Magazine, 9/29)

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