Abstract
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Background: Orbital apex syndrome (OAS) is a rare condition involving multiple cranial nerves, often resulting from neoplastic, infectious, or inflammatory causes. Paraneoplastic presentations are infrequently reported.
Case Presentation: A 57-year-old man presented with binocular diplopia and left-sided cranial nerve palsies. Serial imaging and examinations revealed left-sided orbital apex syndrome with progressive cranial nerve involvement. PET-CT and CSF studies were inconclusive. A biopsy of a subcutaneous lesion in the left cheek confirmed poorly differentiated squamous cell carcinoma with perineural invasion. Immunohistochemistry showed strong PD-L1 expression (CPS 100), suggesting suitability for pembrolizumab therapy.
Conclusion: This case illustrates the diagnostic complexity of orbital apex syndrome of neoplastic origin and highlights the importance of maintaining a high index of suspicion for malignancy in atypical cranial neuropathies.
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