A 61-year-old man presented with a 13-year history of slowly progressing left-sided facial weakness, numbness and pain, otitis media, and postnasal drainage. At presentation, the cause remained undiagnosed. Physical examination revealed left-sided facial swelling, with displacement of the zygoma laterally. The anterior wall of the left external auditory canal (EAC) was bowed posteriorly, with mucopurulent otorrhea. There were incomplete left eye closure; complete numbness in the distribution of left mandibular nerve, with asymmetry of the ophthalmic and maxillary nerve areas; and twitching in the distribution of the left facial nerve. Fiberoptic laryngoscopy revealed mucoid postnasal drainage. Magnetic resonance imaging demonstrated a vague soft-tissue enhancing mass within the left infratemporal fossa, involving the parotid gland, and atrophy of the ipsilateral muscles of mastication. Positron emission tomography and computed tomography showed abnormal hypermetabolism in the left masticator space correlating with the magnetic resonance imaging findings. A computed tomographic–guided core needle biopsy specimen was then obtained. Pathologic analysis showed infiltrating malignant epithelial cells arranged in clusters, with atypical nuclei and abundant eosinophilic cytoplasm (Figure 1). There were perineural invasion, necrosis, and an intense lymphoplasmacytic inflammatory response. Glandular differentiation, consisting of luminal secretory cells with decapitation-type secretions and abluminal basal cells, was evident. Focal in situ carcinoma involving the external ear glands was seen (Figure 2). Basal cells were positive for cytokeratin 5/6 and p63 (Figure 3), while the luminal cells were positive for cytokeratin 7 (Figure 4). The cells were negative for hormone receptors, smooth muscle actin, calponin, S-100 protein, and glial fibrillary acidic protein. View LargeDownload Figure 1. View LargeDownload Figure 2. View LargeDownload Figure 3. View LargeDownload Figure 4. What is your diagnosis?
Archives of Otolaryngology - Head & Neck Surgery
– American Medical Association
Published: Sep 1, 2012
Keywords: actins,magnetic resonance imaging,smooth muscle,carcinoma,physical examination,hormone receptors,atrophy,bodily secretions,cell nucleus,cytoplasm,external auditory canal,external ear,facial nerve,glial fibrillary acidic protein,hypesthesia,keratins,mandibular nerve,masticatory muscles,maxillary nerve,necrosis,s100 proteins,otitis media,pain,eye,parotid gland,phenobarbital,zygomatic bones,zygomatic arch,posterior rhinorrhea,hypermetabolism,epithelial cells,facial paresis,computed tomography/positron emission tomography imaging,infratemporal fossa,masticator space,basal cells,inflammatory response,fiberoptic laryngoscopy,otorrhea,core needle biopsy,calponin