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.