That fall, a friend told the patient about a clinic at New York University that specialized in facial palsies. She quickly found it on the internet: the Facial Paralysis and Reanimation Center. She studied the faces of the doctors at the clinic. Dr. Judy Lee was a specialist in disorders of the ear, nose and throat and a plastic and reconstructive surgeon. She had a warm smile and a kind face. The patient made an appointment to see her.
Lee listened to the woman’s story. She too questioned the diagnosis of Bell’s palsy. Although the patient’s symptoms were consistent with Bell’s, the story didn’t quite fit. That type of nerve damage comes on quickly — usually over hours, sometimes days. This woman described a process that took months. The two M.R.I.s proved she hadn’t had a stroke — the most common cause of a droopy cheek and lip. Shingles could also cause this sort of palsy, but the patient didn’t have other symptoms of the illness so that seemed unlikely. Lee ordered yet another M.R.I. She, too, was worried about a mass, and she had only seen the reports of the previous M.R.I.s.
A Brightness in the Nerve
Lee presented the new M.R.I. to her colleagues the following week. It was a meeting they held monthly to discuss the toughest cases. The neuroradiologist pointed out a brightness in the nerve that looked like inflammation. It 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 you would usually see inflammation in Bell’s palsy. 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. Was this brightness, this inflammation, evidence of a tumor? Probably, the team 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 proposed. “We can’t see anything, but we know it 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, she asked, why do you think it’s there? Because, Lee explained, nothing else makes sense.
The surgery took place a few weeks later. In the operating room, Dr. David Friedmann cut away the bone behind the ear. He identified the nerve and traced its course as it made its way toward the facial muscles. No mass was visible anywhere. He cut out a few tiny segments of nerve. Testing indicated that the nerve was already dead, but he didn’t want to risk causing any additional injury. Friedmann sent the samples to the lab. The answer came back within the week. She had a squamous-cell carcinoma growing in her nerve.
That answer provoked more questions. Where had this come from? It was unlikely to have started there in the nerve. Was it spread from a 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. The doctors at N.Y.U. ordered a PET scan. There was no sign of cancer anywhere else.
Even so, the cancer cells in her facial nerve had to have come from someplace. As the doctors well knew, just because a cancer isn’t seen doesn’t mean there’s no cancer. She was treated for what is called a metastatic disease with an unknown primary: She had radiation and chemotherapy that lasted until early this summer. 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. 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 her whole life will never be back. But she hopes that the surgery, plus physical therapy, will at least let her smile again.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a solved case to share, write her at [email protected]