Persisting facial nerve palsy or trigeminal neuralgia – red flags for perineural spread of head and neck cutaneous squamous cell carcinoma (HNcSCC)

Abstract

BackgroundPerineural spread (PNS) of head and neck cutaneous squamous cell carcinoma (HNcSCC) is a unique diagnostic challenge, presenting with insidious trigeminal (CN V) or facial nerve (CN VII) neuropathies without clinically discernible primary masses. These patients are often sub‐optimally investigated and misdiagnosed as Bell's palsy or trigeminal neuralgia. This case series highlights the red flags in history and pitfalls that lead to delays to diagnosis and treatment.MethodsA retrospective case series of 19 consecutive patients with complete clinical histories with HNcSCC PNS without an obvious cutaneous primary lesion at time of presentation to a quaternary head and neck centre in Australia were identified and included for analysis.ResultsFifteen had CN VII PNS, 17 had CN V PNS, and 13 had both. The overall median symptom‐to‐diagnosis time was 12‐months (IQR‐15 months). Eight patients had CN VII PNS and described progressive segmental facial nerve palsy with a median symptom‐to‐diagnosis time of 9‐months (IQR‐11.75 months). Eleven patients had primary CN V PNS and described well localized parathesia, formication or neuralgia with a median symptom‐to‐diagnosis time of 19‐months (IQR 27.5 months).ConclusionPNS is often mistaken for benign cranial nerve dysfunction with delays in diagnosis worsening prognosis. Red flags such as progressive CN VII palsy or persistent CN V paraesthesia, numbness, formication or pain, particularly in the presence of immuno‐compromise and/or a history of facial actinopathy should raise suspicion for PNS. Gadolinium‐enhanced MR Neurography should be obtained expediently in patients with persistent/progressive CN V/CN VII palsies in patients with red flags, with low threshold for referral to a Head and Neck Surgeon.