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In January 2009, an 89-year-old Caucasian man was referred to our hospital for progressive multiple cranial neuropathies. His past medical history included arterial hypertension, acute pancreatitis, heart failure, and in situ cutaneous squamous cell carcinoma (SCC) in the left temporal scalp, which was treated with total local excision (negative margin) in 2001. Two years later (2003), a right temporal SCC was diagnosed and treated with surgery and local radiotherapy (54 gray). In June 2006, a recurrence occurred on the same side, and pathology from the surgical excision revealed negative margins. In September 2007, he was admitted to the otolaryngology department for right facial nerve palsy; Bell palsy was diagnosed and treated with oral steroids, but this regimen was ineffective. To avoid eye complications, botulinum toxin was injected in the right levator palpebrae muscle. The patient progressively complained of right crawling paresthesias and numbness only of the right cheek. In January 2009, the right eyelid was still closed, despite the disappearance of botulinum toxin effects. A thorough neurologic examination revealed the following: hypesthesia and pain in the territory of the right V1 cranial nerve (CN), right peripheral facial palsy (CN VII), right deafness (CN VIII), complete right ophthalmoplegia, and right unreactive mydriasis (CNs III, IV, and VI). The examination was otherwise unremarkable.

Clinical Reasoning: An unusual cause of multiple cranial nerve impairment