				Using the search form

Dramatic signs with cranial nerve deficit

If you prefer to view this article in PDF form, click here.

Dramatic signs with cranial nerve deficit

Colette L. Caputo, MCMS, PA-C

The author practices at A Center for Dermatology in Pompano Beach, Fla. She has indicated no relationships to disclose relating to the content of this article. Joe Monroe practices in the dermatology department of the Warren Clinic, Tulsa, Okla, and is the founder and president of the Society of Dermatology Physician Assistants.

The patient, a 54-year-old-woman, presents to the dermatology office for evaluation of a possible skin infection on her left ear which has been ongoing for several weeks. She denies any fever or chills; however, she has noted occasional drainage from the ear (see Figure 1, left). Ten years ago, the patient was treated for basal cell carcinoma (BCC), but she is in otherwise good health. Most recently she has been experiencing minimal left ear pain and difficulty hearing, as well as left-sided facial drooping (see Figure 1, right).

Physical examination reveals mild ptosis of the left upper eyelid with facial drooping observed on the lower left side of her face. Two thirds of the left ear concha extending inferiorly to the lobule demonstrates erosion with ulceration overlying an erythematous, purulent base. Decreased hearing and sensation on her left side are noted. Shave biopsy is performed.

The history and physical examination suggest that the patient has
• Pyoderma gangrenosum (PG)
• Recurrent invasive BCC
• Malignant otitis externa
• An infiltrating abscess

Dicussion

The correct answer is recurrent invasive BCC, which was confirmed by the biopsy. This is the most common nonmelanoma malignant neoplasm of the skin. Accumulation of ultraviolet light exposure is the most significant etiologic factor. In the majority of cases, BCC occurs on the head and neck, with light-eyed, fair-skinned individuals being at greatest risk. If not diagnosed and treated in its early stages, subcutaneous BCC infiltrates into the bone and brain, contributing to cranial nerve deficit, and destroys the patient’s facial structure.

PG is a rare, destructive, ulcerating lesion of the skin commonly evolving in patients with underlying inflammatory conditions such as Crohn’s disease, ulcerative colitis, rheumatoid arthritis, and gammopathies. PG lesions appear most often on the lower extremities but may occur anywhere on the skin.

Malignant otitis externa occurs most often in elderly patients with diabetes who have a recurrent history of nonresolving otitis externa. Pseudomonas aeruginosa is the predominant organism that causes this life-threatening infection. Edema, ear pain, and pronounced erythema cascade into cellulitis, chrondritis, and osteomyelitis of the temporal bone, ultimately resulting in cranial neuropathies, meningitis, or a brain abscess.

An abscess is a localized, walled-off collection of purulent material, which may manifest as an erythematous, tender, indurated, or fluctuant mass remaining deeply seated or rupturing at the skin’s surface. Staphylococcus aureus is the predominant pathogen isolated in abscesses. Without timely treatment, the abscess may aggressively infiltrate into deeper underlying anatomic structures.

Treatment This patient did not present to the dermatology office early enough to prevent metastasis. She was referred to surgical oncology to have the BCC resected, her lymph nodes explored, and then radiation treatment or chemotherapy performed. In a follow-up phone call 1 week later, the patient refused to pursue any further treatment.