CASE REPORT:
Presentation and history of symptoms
The patient is a 45-year-old businessman with no history of Hypertension or Diabetes mellitus. There is no history of cancer in his family. He is an occasional smoker. The patient presents with pain on the right side of the face and hoarseness of voice for the past month. The patient also complained of losing appetite and weight for the past three months. The hemifacial pain had an insidious onset and was gradually progressing. The patient described it as a “constant, dull ache.” It was more prominent over the molar region, jaw, ear, and neck, all on the right side. Suspecting dental cause, he even underwent tooth extraction but had no relief.
There is no history of eye congestion or numbness of the face. No earache, tinnitus, or hearing loss was observed. The pain was not precipitated by chewing/swallowing. There is no positive history of jaw claudication, myalgias, or visual changes. No phonophobia or photophobia with vomiting and no family history of headache was observed. There was no history of cough, dyspnoea, haemoptysis, and epistaxis. There was also no history of memory loss, behavioural disturbances, dysphagia, dysarthria, or cranial nerve (CN) deficits. Motor, sensory deficits, or ataxia was not found. There was no history of fever, diarrhoea, melaena, or jaundice in the anamnesis.
General and organ-specific examinations
On general examination, the patient was afebrile. The pulse was 88/minute, and blood pressure (BP) was 150/90 Hg. There was no sign of pallor, clubbing, icterus, or lymph node enlargement. There was no scalp tenderness. The systemic examination started with the cardiovascular system, and the first and second heart sounds were normal. In the respiratory system, the lung fields were clear. Per abdominal examination, no hepatosplenomegaly or masses/free fluid was found. There was mild hoarseness of voice with the uvula in the central position. The palatal movements and gag reflex were normal. There were no abnormal tongue movements, motor/sensory deficits/cerebellar signs, or neck stiffness. The skull and spine appeared normal, and the Hypo Geomagnetic field (HMF) was normal. In the ophthalmological examination, the fundus appeared normal. The extraocular movements and corneal/conjunctival reflex were normal. There was no abnormal sensation over the face or paresis of muscles of mastication.
Investigations
The Erythrocyte Sedimentation Rate (ESR) was 44 mm at 1 Hr. The remaining blood investigations were normal. The CSF study showed Protein at 22, glucose was 94, and no abnormal cells were found. The CSF cytology showed no malignant cells. The Computed Tomography (CT) scan of the brain showed a hypodense lesion in the Left Occipital region (Figure 1). An MRI scan of the neck and mediastinum was performed to rule out structural causes for the hoarseness of the voice. After extensive imaging, no structural cause of hemifacial pain syndrome was found. The ENT consultation revealed right vocal cord palsy. Given the suspicious cerebral lesion search for primary malignancy was made. CECT scan of the thorax showed a relatively well-defined enhancing soft tissue density lesion in the right lung with contiguous mediastinal lymphadenopathy (Figure 2). Squamous cell carcinoma was confirmed to be the diagnosis after the biopsy.