62-year-old woman with facial numbness and an uneven smile
A 62-year-old woman comes to the office for evaluation of a 3-week history of numbness on her left cheek. She also reports a 'pins-and-needles' sensation in the same area and that her daughter recently commented that her smile looked 'uneven.' Her medical history is notable for a squamous cell carcinoma on her left cheek, treated with electrodesiccation and curettage one year ago. She works part-time shelving books at a local library. On examination, there is mild flattening of the left nasolabial fold and slight weakness when asked to puff out her cheeks. Sensation to light touch is decreased over the left maxilla. Examination of the skin reveals a 1-cm, flat, hypopigmented scar at the site of the prior procedure, with no ulceration, induration, or scaling. Vital signs are normal. Which of the following is the most appropriate next step in management?
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D
Explanation
Clinical Pearl:
New-onset focal neurologic deficits, such as numbness or weakness, in a patient with a history of cutaneous squamous cell carcinoma of the head and neck should raise strong suspicion for perineural invasion. This is a high-risk feature requiring imaging to define the extent of disease before treatment.
Explanation:
This patient's presentation of new, focal neurologic deficits (facial weakness and sensory loss in the V2 distribution) in the vicinity of a previously treated cutaneous squamous cell carcinoma is highly suspicious for recurrent cancer with perineural invasion. The most appropriate next step is to define the anatomic extent of the suspected tumor. According to current oncologic guidelines, magnetic resonance imaging (MRI) of the face and skull base is the preferred imaging modality to visualize the nerves and soft tissues to assess for perineural spread, which is critical for staging and planning treatment. Prescribing oral prednisone would be appropriate for Bell's palsy, but the sensory deficits in a trigeminal nerve distribution make this diagnosis unlikely. Referral for Mohs surgery is premature as the extent of deep involvement must be determined by imaging first. A punch biopsy of the scar is unlikely to be diagnostic because the recurrence is likely deep along the nerve, not on the surface. Electromyography can confirm nerve dysfunction but does not provide the anatomic detail needed for surgical planning.
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