Can cancer be ruled out in a 4-year-old with progressive facial asymmetry and a normal brain orbit MRI (Magnetic Resonance Imaging) without contrast?

Cancer Cannot Be Ruled Out with a Normal Brain/Orbit MRI Without Contrast in a 4-Year-Old with Progressive Facial Asymmetry

A normal brain/orbit MRI without contrast is insufficient to exclude malignancy in a child with progressive facial asymmetry, and the child requires immediate repeat imaging with contrast to properly evaluate for cancer. The imaging performed was inadequate for this clinical presentation.

Why the Current Imaging is Inadequate

The American College of Radiology explicitly states that MRI head (brain) without contrast has no role in evaluating suspected head and neck malignancies and that noncontrast imaging alone cannot adequately delineate soft tissue tumors from surrounding structures 1. The guidelines emphasize that combined pre- and postcontrast imaging provides the best opportunity to correctly identify and delineate tumors, distinguishing them from normal soft tissues 1.

Critical Coverage Gaps

• Standard brain MRI protocols do not adequately cover the face or orbits for detailed evaluation of facial asymmetry 2
• The coverage and sequences used in a typical brain MRI may be insufficient to completely evaluate pathology causing facial asymmetry 1
• Facial structures require dedicated imaging that is not included in standard brain protocols 2

What Malignancies Can Present This Way

Progressive facial asymmetry in a 4-year-old raises specific oncologic concerns that require contrast-enhanced imaging:

Plexiform Neurofibroma

• Most commonly presents before age 5 with periorbital asymmetry or facial distortion 3
• Can appear as a soft, "bag of worms" texture on palpation 3
• Should never be biopsied if suspected—requires MRI of brain and orbits with contrast to define extent 3
• Associated with neurofibromatosis type 1 in the majority of cases 3

Meningioma

• A documented case report describes a 4-year-old girl with sphenoid wing meningioma presenting initially with only facial asymmetry noticed by her mother 4
• This case emphasizes that dismissing facial asymmetry without thorough imaging could be disastrous 4
• The tumor was only detected on MRI of the brain with appropriate sequences 4

Other Pediatric Malignancies

• Rhabdomyosarcoma, lymphoma, and other soft tissue sarcomas can present with progressive facial asymmetry in young children 3
• Perineural tumor spread is more easily recognized with MRI compared to CT, particularly with contrast enhancement 1

The Correct Imaging Protocol

Order MRI orbits, face, and neck without and with IV contrast immediately 1, 2. This is the appropriate study for several reasons:

• The American College of Radiology consistently recommends "MRI orbits, face, and neck" as a unified protocol for evaluating orbital pathology and facial asymmetry, not "MRI orbits" or "MRI brain" alone 2
• This protocol captures all facial soft tissues in the imaging field from the orbits through the neck 2
• Contrast enhancement is essential for delineating tumor extent, detecting perineural spread, and distinguishing tumor from surrounding tissues 1
• The superior soft tissue contrast resolution of MRI with contrast can better distinguish tumors from inflammatory changes 1

Why Contrast is Non-Negotiable

• The absence of IV contrast limits the ability to accurately delineate the margins and soft tissue extent of tumor 1
• Contrast enhancement is critical for detecting subtle marrow involvement, perineural spread, and regional extension to neighboring structures 1
• Noncontrast sequences alone may miss early or infiltrative malignancies 1

Clinical Algorithm for This Patient

1. Obtain MRI orbits, face, and neck without and with IV contrast urgently (within days, not weeks) 2
2. Examine the child for stigmata of neurofibromatosis type 1 (café-au-lait spots, axillary freckling, Lisch nodules) 3
3. Palpate the facial asymmetry for texture (soft vs. firm, mobile vs. fixed, "bag of worms" texture) 3
4. Assess for upper versus lower motor neuron facial nerve involvement if any facial weakness is present, as this localizes the lesion 4
5. Do not biopsy any suspected plexiform neurofibroma before imaging and potential genetics consultation 3

Critical Pitfalls to Avoid

• Never assume a normal brain MRI without contrast excludes facial pathology—the coverage and sequences are inadequate 2
• Progressive asymmetry in a young child demands explanation—this is not a normal variant and requires definitive imaging 4
• Do not delay imaging while observing for further progression—early detection of pediatric malignancies significantly impacts outcomes 4, 5
• Do not order "MRI brain" when you need facial evaluation—specifically request "MRI orbits, face, and neck" 2
• Never biopsy before imaging if plexiform neurofibroma is in the differential 3