Raising awareness of acute onset of swelling and lip paraesthesia in a teenage patient

A 19-year-old female patient initially presented to her GDP with an acute onset of loss of sensation to the right side of her chin and lip. Her dentist referred her for an OPG at the local hospital, which was reported as unremarkable (Figure 1). She was also experiencing vomiting, fatigue and night sweats. Her GP requested routine bloods and a head CT, which were both reported as normal. No obvious neurological causes were noted. Three weeks after the onset of her facial numbness, she developed ipsilateral facial swelling in the right masseter region. She returned to the GDP who diagnosed pericoronitis, which was managed with irrigation of the area and antibiotics. The patient's symptoms failed to improve despite several courses of antibiotics, and they persisted during a planned trip to the USA. While in the US, she sought the attention of an oral surgeon who proceeded to extract all wisdom teeth. During the operation, he noted an unusual mass in the LR8 region, which was biopsied. The post-operative OPG revealed a radiolucency extending up to the sigmoid notch (Figure 2). The histopathology was of an adenocarcinoma that was likely to be a metastasis of a primary, which was unknown at the time. She urgently flew back to the UK and underwent further imaging that showed a 7-cm mass in the right kidney, numerous bilobar liver, lytic bone, mediastinal lymph node and bilateral adrenal metastases. A liver and supraclavicular node biopsy revealed Type 2 papillary renal cell carcinoma as the primary source. An MRI of the mandible showed a metastatic lesion surrounding the right ramus of the mandible and extending into the infratemporal fossa and to the greater wing of the sphenoid. (Figure 3).