No abstract

A 67-year-old-white woman presented with a 3-month history of anorexia (loss of 10 kg), and a left preauricular tumoral mass. A few days after the first clinical evaluation, a left peripheral facial paralysis was noted. The biopsy of the tumoral mass showed an epidermoid parotid gland adenocarcinoma. A complete left parotidectomy, with unilateral cervical ganglionectomy was performed. After surgery the patient received local (left parotid area and ipsilateral neck and shoulder areas) radiation therapy during three months. Eighteen days after the end of the radiotherapy sessions, she complained of a right forehead and temporal headache, more intense in the retro-orbital region. The headache was excruciating and described as throbbing or stabbing pain. The attacks usually last about 20 min, associated with tearing, conjunctival injection and Horner's sign ipsilateral to the pain side and their frequency ranges from 10 to 20 attacks per day. There were diurnal and nocturnal attacks. During the attacks the patient prefers to stay alone in a quiet room. A dull background pain persists in the right retro-orbital area between the attacks. The patient denied any precipitating factor.The neurological examination was unremarkable except for a left peripheral facial paralysis. Analgesics and oxygen-inhalation administration were worthless. A trial with Indomethacin at 75 mg/day led to absolute pain control.One month later, however, it was necessary to raise the indomethacin dosage to 150 mg/day and the patient developed an abducent nerve paralysis on the right side. A MRI study showed T1 hypointense lesions and T2 hyperintense lesions, with ring-like -peripheral reinforcement in the right cerebellar hemisphere, vermis, right corpus callosus and right cavernous sinus, suggestive of metastasis ( Fig. 1). Three months later, the pain became continuous, moderate in intensity, without associated autonomic signs and was no longer responsive to indomethacin. The patient received chemotherapy but death occurred one month later.