Bell’s Palsy in a Treated Case of Breast Cancer—a Rare Presentation of Recurrence

Introduction

Bell’s palsy is a condition in which the muscles on one side of face become weak or paralyzed. It is usually temporary and is believed to be due to viral infections [1]. Bell’s palsy as the only symptom in oncologic patients is rare and has been reported in association with chemotherapy administration [2], as a first sign of recurrence in leukemia [3] and very rarely as the first sign of malignancy in breast cancer patients [4]. We here in present a case of treated breast cancer who developed unilateral facial nerve paralysis on follow-up and was subsequently diagnosed to have recurrence.

Case Report

A 29-year-old pre-menopausal female presented with left otalgia and left facial weakness of 2 months duration. She had completed her treatment for locally advanced breast cancer (cT4bN2bM0) 3 months back consisting of neoadjuvant chemotherapy with 4 cycles of 5-fluorouracil, epirubicin, and cyclophosphamide, and four cycles of docetaxel followed by left modified radical mastectomy (MRM). Histopathology had revealed invasive carcinoma with ductal carcinoma in situ (DCIS): ER+ve, PR+ve, and HER2-ve (Fig. 1). She had also received adjuvant radiotherapy of 50 Gy in 25 fractions over 5 weeks. After that, she had been started on hormonal therapy with tamoxifen and was receiving the drug at time of presentation. She did not complain of any pain in back, headache, vomiting, jaundice, or tingling in extremities. She also did not give any history suggestive of viral infection in the past 3 months. On examination, otoscopy revealed a slight bulge in middle part of the tympanic membrane, but the membrane was intact. Physical examination was essentially unremarkable except for a left facial paralysis. Examination did not reveal any tenderness on the axial or appendicular skeleton. Pure tone audiometry revealed a conductive hearing loss. To rule out recurrence, a contrast enhanced MRI of brain and face was done. It revealed a hyperintense soft tissue thickening with destruction (3.5 × 3.2 cm) seen in the posterior aspect of the left mastoid bone reaching until the left occipital condyle and the left side of the arch of the C1 vertebra. The soft tissue thickening was extra dural extending into the retro-cerebellar hemisphere region (Fig. 2). Positron emission tomography (PET) scan was done to identify other metastatic sites. PET–CT scan confirmed the temporal bone lesion and identified one more lesion in ribs. No other site of metastasis was found (Fig. 3). In view of oligometastases, she received conformal radiotherapy by volumetric modulated arc therapy (VMAT) to the mastoid mass of 50 Gy in 20 fractions over 4 weeks. She also underwent bilateral oophorectomy followed by hormonal therapy with letrozole. The patient has a good partial response with improvement in facial palsy and is on regular follow-up.

Fig. 1.

Hematoxylin and eosin (a H&E, × 100; b H&E, × 200) shows sheets, nests, cords, and individual tumor cells in a desmoplastic stroma. The tumor cells exhibiting marked nuclear pleomorphism, coarse chromatin, and inconspicuous nucleoli. c The tumor cells showing strong nuclear positivity for estrogen receptor (ER) 8/8. d The tumor cells showing nuclear positivity for progesterone receptor (PR) 6/8

Fig. 2.

MRI showing temporal bone recurrence

Fig. 3.

PET–CT revealing FDG-avid temporal bone disease

Discussion

The temporal bone is an uncommon site for bony metastasis. When it occurs, it mostly arises from a breast or lung primary [5, 6]. Gloria-Cruz et al. examined temporal bones of 212 patients with solid malignancies. Histologically, metastatic deposits in temporal bone were seen in 47 (22.2%) patients [7]. Interestingly, no patient had only temporal bone metastases. All 47 patients had other sites of metastases. Hearing loss was the most common otologic symptom due to temporal bone metastasis seen in 40% of patients. Facial asymmetry was seen in less than 15% of patients emphasizing the rarity of such a presentation. Otalgia was seen in < 10% of patients [7]. Our patient presented with these rare symptoms, but on testing also revealed a conductive hearing loss. These symptoms mimic the symptoms of mastoiditis and chronic inflammation; hence, prolonged symptoms not responding to antibiotics should be evaluated properly [14]. Temporal bone metastasis predominantly occurs through the hematogenous route, but may be caused by direct extension, meningeal carcinomatosis, or leukemic infiltration [8–13]. The areas of the temporal bone frequently involved are the petrous apex, internal auditory canal, and mastoid [7]. For diagnosis of temporal bone metastasis, radiological examination is crucial. CT scan may show osteolytic and destructive lesions or sclerosing and bone-forming lesions. Differential diagnoses for osteolytic lesion in the temporal bone include metastasis, cholesteatoma, primary neoplasms, glomus tumors, and paragangliomas. CT scan may also reveal only a soft tissue density in the middle ear and mastoid cavity leading to the misdiagnosis of chronic otitis media, particularly in diabetic patients. It is therefore difficult to diagnose metastatic deposit in the temporal bone early [15]. PET–CT may be useful for confirming the primary origin of tumor and detecting other sites of metastasis. Biopsy of the temporal bone lesion would confirm the diagnosis, but it is difficult to obtain an adequate amount of tissue due to difficult access to some parts of the temporal bone, such as petrous apex and internal auditory canal. Therefore, the diagnosis of temporal bone metastasis usually solely depends upon imaging tests. Our patient was diagnosed with oligo-metastatic disease with the help of MRI and PET–CT, and underwent salvage treatment with radiotherapy and hormonal therapy (Fig. 3).

Conclusion

Temporal bone metastasis is very rare. It is even rarer to find facial nerve palsy as the sole presenting symptom. Oncologists should consider a metastatic tumor versus infection as a differential diagnosis in patients with persistent otologic symptoms or facial nerve disorders. Identifying and treating these patients early can result in better survival.

Compliance with Ethical Standards

Informed Consent

Informed consent was obtained from a participant in the presence of two neutral witnesses.

Conflict of Interest

The authors declare that they have no conflict of interest.

Disclosures

The authors have nothing to disclose.