Área Técnica: Neuroftalmologia
Sinus Cavernous Syndrome due to Perineural Spread of Facial Squamous Cell Carcinoma: case report
to report a patient with painful ophthalmoplegia syndrome caused by cavernous sinus syndrome secondary to perineural spread (PNS) of squamous cell carcinoma of the forehead.
A 62 -year-old woman presented with painful right facial paresthesia in the right V1 and V2 distributions, diplopia and right ptosis, all progressing over four months. Examination revealed visual acuities of 20/100 in right eye (because macular epiretinal membranes) and 20/40 in left eye (prior severe diabetic retinopathy). There was complete right ptosis and ductions of the right eye were absent in all directions, with no mechanical restriction, associated to dilated pupil in same side. There was a presumed skin carcinoma on the right forehead. A magnetic resonance (MR) revealed subtle enhancement of the supraorbital branch of the right ophthalmic nerve, due to retrograde perineural tumor spread of the forehead squamous cell carcinoma. Six months later, MR showed massive invasion of the cavernous sinus and adjacent structures. The right pterygopalatine fossa and the right masticator space were involved because of anterograde tumor spread through the maxillary and mandibular trigeminal divisions. These findings were considered consistent with PNS presumably arising from right forehead squamous cell carcinoma. Biopsy of the skin tumor confirmed squamous cell carcinoma confined well within the surgical excisions margins.
A PNS is a severe manifestation of skin cancer similar to lymphatic and vascular metastases. The term describes the process by which a tumor reaches distant locations by crossing along the neural sheath besides its primary site. Squamous cell carcinoma is the most common tumor to present PNS, usually with the trigeminal and/or facial nerves involvement. The disease can involve orbit, orbital apex, cavernous sinus and others intracranial structures.Neuro-ophthalmic manifestations may occur before the diagnosis of the skin cancer or months or years after the resection of a head skin tumor.