Cranial-Nerve Palsies and Oral Cancer

Posted by • September 21st, 2012

In the latest Case Record of the Massachusetts General Hospital, a 49-year-old man had fever, pain, and cranial-nerve deficits 4 days after completion of chemoradiation for squamous-cell cancer of the oral cavity. Imaging revealed dural thickening and abnormalities of the cavernous sinuses and skull base.

Most squamous-cell carcinomas of the head and neck are locally advanced at the time of diagnosis and require multidisciplinary treatment. The location of the cancer is integral to the understanding of its natural history and the development of a multidisciplinary treatment approach.

Clinical Pearls

What is the initial approach to squamous-cell carcinoma of the oral tongue?

Cancer of the oral tongue, one of the most common subsites of squamous-cell carcinoma of the head and neck, is best approached with surgery first, in view of the surgical accessibility of the oral cavity and current techniques for resection and reconstruction that yield good speech and swallowing outcomes.

How does human papillomavirus (HPV) positivity effect the prognosis of squamous cell-carcinomas of the head and neck?

HPV-related squamous-cell carcinomas of the head and neck tend to occur in the oropharynx and typically do not have the extensive lymphovascular and perineural invasion. Expression of p16 is a strong predictor of human papillomavirus positivity. Patients with HPV-positive squamous-cell carcinoma of the head and neck tend to be younger and to have had less exposure to tobacco and alcohol than those with classic (HPV-negative) squamous-cell carcinoma of the head and neck, and have a better prognosis than do patients with HPV-negative tumors, in part because HPV-positive tumors tend to be sensitive to both chemotherapy and radiation.

Morning Report Questions

Q: What is cavernous sinus syndrome?

A: Cavernous sinus syndrome refers to deficits of the third through sixth cranial nerves and has multiple etiologies. The presence of bilateral cavernous sinus syndrome should focus attention to the skull base, and it indicates a process that involves the skull base diffusely. The cavernous sinuses are one of the dural sinuses, and are positioned lateral to the sella turcica. The internal carotid artery and cranial nerves III, IV, V (branches V1 and V2) and VI all pass through the cavernous sinus. Facial infections increase the risk of cavernous sinus thrombosis, which may be manifested with fever, headaches, proptosis, and ocular motor palsies.

Q: How often do patients with metastatic cancer present with leptomeningeal involvement, and how is that manifested?

A: Leptomeningeal involvement occurs in about 5% of patients with metastatic cancer. The hallmark manifestation of this condition is focal neurologic deficits involving the cranial and spinal nerves; symptoms often include headache, difficulty walking, and bowel or bladder dysfunction. Patients with dural spread of cancer often have concurrent leptomeningeal or brain involvement. Results of laboratory tests of the CSF are normal in approximately 15% of patients with leptomeningeal metastases.

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