Respectful Insolence

It figures.

I know, I like to start posts with “it figures,” and maybe I do it too often, but this time it really fits. For a moment I thought I was going to have a lot of egg on my face over this, but just for a moment. Yesterday, I wrote a rather extensive post about how some left wing bloggers are going into fits of paranoid conspiracy-mongering frenzy, claiming that John McCain’s melanoma was more extensive than advertised and that he is supposedly dying of recurrent melanoma and hiding it from everyone. I spent a lot of effort, not to mention verbiage, explaining why that scenario is incredibly unlikely. So what happens on the very same day that I shoot that issue down?

Another one pops up.

This time around, it’s a number of blogs wondering what’s wrong with John McCain’s left eye, starting with bellow ScienceBlogger Neurotopia. The speculation as based on this video:

First off, I thought the finding was fairly subtle. Second, I’m a little alarmed at how fast people are to jump to the conclusion that it must be due to a stroke or even worse. It’s pretty unlikely, too, as a stroke is unlikely to produce just a droopy eyelid (ptosis) and this strikes me as yet another example of people who don’t like John McCain being rather disturbingly eager to find something physically wrong with him.

Shadowfax over at Movin’ Meat has posted decent primer on potential reasons why McCain might have ptosis (complete with illustrations, yet!) but as usual I can’t resist putting my two cents in, mainly because I don’t think Shadowfax covered all the bases. (As a big-time J.R.R. Tolkien fan, I still can’t believe I just typed that sentence. On the other hand, Shadowfax could cover all the bases faster than anyone.) First off, it has to be remembered that ptosis is a physical sign. It’s a sign that can be caused by a fairly large number of processes, most of which are benign and do not involve having had a stroke, and what it means depends upon the clinical context, including the symptoms, if any, that might be associated with that sign.

Causes of ptosis can, in fact, be divided into two general types: neurogenic (involving nerve dysfunction or injury) and non-neurogenic. I could also add a third type, namely as a symptom of systemic disease (for instance, myasthenia gravis). Shadowfax covered the neurogenic causes fairly well, I will emphasize the non-neurogenic causes more, although I can’t resist mentioning one thing. Shadowfax observes:

Are these clearly visible neurologic deficits consistent with a stroke? Well, sort of but not exactly. There does not appear to be any motor abnormality of the lower part of the face, and his speech is quite clear. Updated: On closer viewing, I think there is some asymmetry of the lower face, with slight smoothing of the nasolabial fold, and reduced excursion of the mouth. It is subtle, and McCain’s face is asymmetric at baseline, so it’s hard to say whether it is significant. If the impairment were caused by a central lesion (i.e. in the brain), I would generally expect those areas to be affected also, since the motor cortex that controls that area is not usually broken down quite so discretely. But weird stuff can happen in neurology, so it’s certainly not conclusive, and a cerebrovascular accident is by no means excluded as a possible cause.

The problem with that analysis is that John McCain had a large hunk of the left side of his face removed due to his melanoma surgery; so it’s hard to make any real comments about “smoothing” of his nasolabial fold, which could just be from having had the skin of his face and scalp stretched and rotated as a tissue flap to cover the rather large (over 6 cm) defect near his temple that resulted from his melanoma surgery. He also had the superficial part of his left parotid gland removed, an integral part of a lymph node dissection for facial melanomas. What runs right under the superficial parotid? The facial nerve, of course! Indeed, head and neck surgeons who do superficial parotidectomies go to great lengths not to injure any of the branches of the facial nerve–and especially not its trunk, injuries to which result in paralysis of one side of the face. True, if the temporal branch of the facial nerve (the branch that supplies the upper face and region around the eyes) had been injured at surgery, the effect would have been immediate, not delayed eight years. However, it is possible that some scarring occurred and could have trapped the nerve. This is a pretty uncommon late complication of such operations, however. Another thing to consider is that McCain had what sounds like a modified radical neck dissection. One of the potential complications of a neck dissection is injury to the cervical sympathetic chain nerve chain in the neck, which could produce Horner’s syndrome, a syndrome involving ptosis, miosis (small pupil), and anhydrosis (inability to sweat in the affected area). Again, it’s possible that Horner’s syndrome could be a late complication of his neck dissection, but it’s also pretty unlikely.

Moving on to the dire insinuations I’ve been hearing, yes, a tumor or stroke could cause ptosis, but it would almost certainly be accompanied by other signs and symptoms; so I consider that pretty doubtful as a cause, too. I’m not even convinced that McCain really has all that much ptosis, but if he does, what might have caused it. Other non-neurogenic causes of ptosis can include:

  • Senescence, involutional changes, dehiscence, or disinsertion of the levator aponeurosis are common.
  • Chronic inflammation or intraocular surgery (eg, cataract surgery) can incite stretching of the levator aponeurosis and dehiscence from the anterior surface of the tarsal plate.
  • Long-term use of contact lenses has also been implicated. Patients maintain normal or near-normal levator function, with a high upper eyelid crease. The attachments from the levator to the skin remain intact, and this forms the crease.

Senescence. Old age, in other words. The muscles that elevate the eyelid include the levator palpebrae superioris and its aponeurosis and the Mueller muscle. (An aponeurosis is a sheet-like band of connective tissue.) Consequently, anything that compromises the function of these muscles and the aponeurosis can result in ptosis, which brings us back to senescence. It’s not uncommon for these muscles to become saggy or flabby just with age, and let’s not forget that John McCain had major surgery not too far from his eyelid, which could explain why that side is more likely to be effected than the right. If I were to bet money on the cause of his apparently droopy eyelid, old age, coupled with McCain’s extensive facial surgery, would be high on my list of what to bet on.

It also turns out that questions about McCain’s eyelid are not as new as the bloggers who suddenly noticed some droopiness think. In fact, it wasn’t difficult to find a discussion of this very issue on the discussion boards of Democratic Underground dating back over three months ago:

Why is John McCain’s right eye always so much more open than his left eye?

What could be wrong with him to cause that, or is he just doing a reverse Popeye?

In fact, take a look at this Wikipedia entry on ptosis. Note that it lists some famous people with ptosis. Note that John McCain is on the list. Looking into this, I get the feeling that McCain has had ptosis for a while and that it’s not new. Perhaps in the video above he was just tired. Maybe he’s better at hiding it normally. Who knows?

There’s one final possibility that’s kind of amusing if it were true. One of the possible side effects of a Botox injection around the forehead is ptosis. A too-generous Botox treatment of the frontalis muscle can result in ptosis, which can happen if Botox leaks beyond where it was injected and make its way to the levator palpebrae superioris, temporarily paralyzing it, as described here in instructions to patients on a plastic surgery website:

Another side effect when BOTOX® Cosmetic is used around the forehead is eyelid droop, known as ptosis. This temporary condition occurs in about 5% of patients. It usually appears 7 to 14 days after the injection and can last 4 to 6 weeks. A more speedy method of treating ptosis is the application of prescription eye drops (iopidine). In many cases, these drops will help resolve the droop within a few days. Dr. Pearsall is well aware of this potential side effect and takes all of the necessary precautions to reduce the risk of ptosis. It is also important for a patient to remain vertical for 4-6 hours after the injection. This allows the BOTOX® Cosmetic to be taken up in the treated area and reduces the chance of displacement to other muscles. It is also helpful to contract the treated muscles repeatedly (smile or squint depending on the area treated). Do not touch the injected sites for two to three hours.

If McCain’s ptosis is new (which I don’t think it is), it would be amusing to think it was a side effect of a Botox injection. I may have to look at tapes of him more closely to see how much his forehead muscles contract when he’s expressing himself.

It’s possible that McCain has some intracranial tumor or or has had a stroke causing his ptosis (if he even has much in the way of significant ptosis). However, as is the case for some bloggers and melanoma, I suspect that way too much is being made of this health issue as well. Again, this does not appear to be a new problem. For example, look at McCain’s official Senate portrait and this photo from before April 30, both of which show what looks like a possible mild ptosis of the left eyelid. Once again, assuming his apparent ptosis is from a benign cause, McCain has no one to blame but himself for not being more transparent with his medical records because withholding anything only encourages the conspiracy-minded to do what they do best and look for explanations for any little physical problem, no matter how benign. His choice of an utterly unqualified running mate also makes people wonder more about his health, given who might be succeeding him if he is elected.

Even so, it’s rather embarrassing to see to what lengths some will go to paint McCain as an unhealthy man, with one foot in the grave and another on a banana peel. It’s not necessary, and the glee with which some bloggers (with Matt Stoller and Maggie Jochild being the two looniest examples I’ve encountered thus far) leap on every new question about McCain’s health taints reasonable questions about McCain’s age and health with the stench of tinfoil hats that have been worn too long and stink of head sweat. There are many, many reasons not to vote for John McCain not involving any sort of reference to his health. His behavior, choices, and policies are reason enough. It’s not necessary to concoct all manner of dubious hypotheses about his health to justify not voting for him.

ADDENDUM: A real, honest-to-goodness neurologist has finally weighed in on this issue, namely Steve Novella. He’s looked at a bunch of pictures of John McCain going back a few years and has concluded that his ptosis has been there a while and is therefore of no concern.

Comments

  1. #1 DNA Lady
    September 26, 2008

    I noticed the droopy left eye when I saw the film clip. I assumed it was do to fatigue. One of my eyes is slightly smaller than the other, it’s a family trait. When I am very tired, that eye looks even smaller. His speech was not slurred and even though his face is asymmetrical due to past surgery, I could not see other tell tale signs of a stroke.

  2. #2 I am so wise
    September 26, 2008

    That Letterman screw up and his belief that he needed to go save the monetary system has me thinking he actually experienced brain death.

  3. #3 Interrobang
    September 26, 2008

    What disturbs me isn’t the droopiness of his eyelid; he’s always seemed to have that to a certain degree, it’s that in recent close-up pictures, his one eye or the other seems to have developed strabismus. In other words, don’t look at his eyelid, look at his eyes. I’ve seen two different close-up photographs of him now where his eyes are pointing in different directions. I notice this probably more than most people because I have strabismus myself, but I must’ve looked at a hundred pictures of him to see if I wasn’t either seeing things, or just noticing something that’s always been there. In the older pictures, he doesn’t have it.

  4. #4 Jennifer Ouellette
    September 26, 2008

    It’s not necessarily that people hate McCain (although many do). A lot of moderate conservatives are so shocked by the radical change in McCain’s behavior this campaign, that it’s almost inevitable there will be whispers about dementia, stroke, etc. — exacerbated by the fact that he’s the oldest presidential candidate in our history (I think), and refuses to release to his full medical records. I noted the droopy eye, promptly went online, and found the bit on ptosis, noting that there’s over 300 likely “causes”. So I came to the same conclusion as Orac: he’s had the condition for awhile, it’s just more noticeable because he’s in such a glaring national spotlight, and it’s not likely to be serious.

    But that doesn’t mean there couldn’t be something physically wrong with McCain. I would never speculate, but nor would I be surprised if, after the election, he suddenly develops a condition of some sort.

  5. #5 S. Rivlin
    September 26, 2008

    While it is probably true that many bloggers on the left will see any sign of disease in McCain as a reason to reject his fitness to serve as a president, his temperament, decisions, and reactions are the signs that give me reasons to question his fitness. Moreover, the man appears to abandon any drop of decency and honesty. Being elected as president is much more important to him and his handlers than country. The hell with the country as long as John McCain is elected president. I think his whole brain is droopy.

  6. #6 Bruce Small
    September 26, 2008

    Skin cancers, droopy eyelid, arms badly damaged in the war, whatever. For anyone else the liberal left would be screaming outrage at the attacks on someone with a medical condition, or handicap.

  7. #7 Lucas McCarty
    September 26, 2008

    “For anyone else the liberal left would be screaming outrage at the attacks on someone with a medical condition, or handicap. ”

    As a left-leaning kind of person my first instinct is to take offense, but as a disabled person my experience says this is sometimes true.

    In any liberal pledge on equality they always manage to leave out disability. It tends to go “I will not discriminate against anyone on grounds of sex, race, religion or sexuality” and I’m always left wondering why disability isn’t included. The typical answer given is “well because you have to discriminate on ability because some people are just not suitable for certain jobs”, but it’s revealing of the type of non-thinking behind it. Do they believe disabled people don’t know what they can and can’t do and that they’re so stupid they’ll apply for jobs that are unsuitable?

    Somewhat reminded of the Dudley Moore and Peter Cook sketch where the one-legged man turns up to audition for the role of Tarzan. It’s meant to be a joke, but some people seem to believe it really happens.

  8. #8 LC
    September 26, 2008

    I dont pretend to understand how the US presedential elections work (not being from the US).

    But when the economy is totally screwed, a couple of wars are dragging on, religious nutters swarming, infrastructure crumbling, disease outbreaks, and a natural disaster or two – why are people obsessing over twitchy eyes/skin colouration/genetalia/whatever, as opposed to the candidates policies and solutions to said problems?

  9. #9 Jennifer Yanoschak, MD
    September 26, 2008

    Food for thought. If we were at this point in the election 6 months ago and Tim Russert was a candidate, would anyone be questioning his health? The point is that anyone can die from anything at anytime. Let’s stick to the issues.

  10. #10 Robert W. Donnell
    September 26, 2008

    Very erudite, all this, but why don’t we start with the basics? Given that the 7th nucleus representing the upper facial muscles has bilateral corticobulbar representation what kind of a “stroke” could possibly cause these findings? Cortical? Impossible. Brain stem? A stretch to say the least. Inherent in the definition of a stroke (and again, this is Neuro 101)is that a vascular territory is represented.

    In my view a decent neuro primer concerning McCain’s ptosis, forehead wrinkling (or lack thereof) and eyebrow malfunction would have to acknowledge these fundamental aspects of neuroanatomy.

    Orac, you’re being uncharacteristically kind. :-)

  11. #11 Robert W. Donnell
    September 26, 2008

    Very erudite, all this, but why don’t we start with the basics? Given that the 7th nucleus representing the upper facial muscles has bilateral corticobulbar representation what kind of a “stroke” could possibly cause these findings? Cortical? Impossible. Brain stem? A stretch to say the least. Inherent in the definition of a stroke (and again, this is Neuro 101)is that a vascular territory is represented.

    In my view a decent neuro primer concerning McCain’s ptosis, forehead wrinkling (or lack thereof) and eyebrow malfunction would have to acknowledge these fundamental aspects of neuroanatomy.

    Orac, you’re being uncharacteristically kind.

  12. #12 Alex
    September 26, 2008

    There is always the possibility John McCain’s ptosis, like mine, is congenital, but he has had it surgically corrected, and the effect of the surgery has been wearing off with age and other intrusive facial surgery.

  13. #13 Jennifer Yanoschak, MD
    September 26, 2008

    Dr. Donnell,

    Eyelid opening is innervated by cranial nerve III. Strokes involving the midbrain at the level of the Edinger-Westphal nucleus can cause ptosis. As we also know, the sympathetic chain that ascends the carotid artery also contributes to this innervation which is why carotid dissections can cause ptosis. In addition, pressure on CN III, most commonly from a PCOM aneurysm, can cause ptosis.

    CN VII closes the eyelid. So damage here cause difficulty closing the eye and the eyelid can actually appear retracted. This is most common in peripheral VIIth nerve damage like is seen with Bell’s palsy. However, an infarct in the distribution of the basilar artery perforators at the VIIth nerve nucleus in the pons will cause upper and lower face weakness. Regardless, this is not involved in ptosis.

  14. #14 Natalie
    September 26, 2008

    For anyone else the liberal left would be screaming outrage at the attacks on someone with a medical condition, or handicap.

    While I find the speculation about McCain’s health stupid and pointless, I fail to see how speculation or questioning = attacks.

  15. #15 sailor
    September 26, 2008

    I thought the following democratic ad was disgraceful, with it clear implication that McCain could drop dead any time from melanoma. I emailed the dfa to that effect.

    http://www.youtube.com/watch?v=DHvJPGnkQxE

  16. #16 Metro
    September 26, 2008

    I don’t think anyone’s “disturbingly eager to find something physically wrong with him”.

    Terrified of winding up with Alaska’s answer to Mahmoud Ahmadinejad for president, maybe.

  17. #17 sus
    September 26, 2008

    He has chosen Sarah Palin as his VP. That makes it even more important to people, even to the far right. The droopy eye is close to where the band-aid appears in the newsweek photo of him after his surgery. He won’t release all his medical records. People are concerned. More concerned than if he’d have chosen a different running mate.

  18. #18 Metro
    September 26, 2008

    I don’t think anyone’s “disturbingly eager to find something physically wrong with him”.

    Terrified of winding up with Alaska’s answer to Mahmoud Ahmadinejad for president, maybe.

    Had some difficulty posting. I hope this doesn’t arrive twice.

  19. #19 sus
    September 26, 2008

    Sorry about the double posting. I keep getting a message saying my comment didn’t post. Please forgive.

  20. #20 Robert W. Donnell
    September 26, 2008

    Dr. Yanoschak,

    Thanks for the explanation.

    I should have specified that I was referring primarily to the Shadowfax (Movin’ Meat) post which emphasized the peripheral CN VII manifestations including impaired eyebrow lifting, asymetric blinking lag and lack of forehead wrinkling. The ptosis (yes, his left palpebral fissure does look narrow) may be a red herring.

    How likely is it that a stroke could produce ptosis without some other manifestation, e.g. hemiparesis?

  21. #21 Orac
    September 26, 2008

    You may be interested in what Steve Novella has to say about the issue:

    http://www.theness.com/neurologicablog/?p=386

    He is, after all, an academic neurologist.

  22. #22 Jennifer Yanoschak, MD
    September 26, 2008

    Dr. Donnell,

    In my years in training and as an academic stroke neurologist, I have never seen isolated ptosis as a sign of stroke. I have of course seen it with carotid dissections and as a sign of a PCOM aneurysm (with an associated dilated pupil).

  23. #23 shadowfax
    September 26, 2008

    Orac,

    Thanks for a generally well-reasoned response.

    A couple of minor points, in response of my own.

    First of all, do note that while I lead with the provocative possibility that this might have been due to a stroke, I did conclude that this is probably a peripheral lesion.

    Second, as it was noted in my comments, the history of the wikipedia article shows that McCain was added to the list of people with Ptosis yesterday.

    Third, I watched the two videos of McCain’s “suspension” speech and his convention speech side by side. There is a dramatic difference in the muscle activity of his left forehead. I admit that I assumed that this was a new deficit, and did not look any further back. It is true that some deficits will wax and wane over time, so I suppose that if McCain were particularly tired or stressed or ill, it might more be prominent now than before. If older video (I’m less impressed by stills, but haven’t looked extensively at them) were to show similar asymmetry, that would indeed be reassuring. Can anybody provide a link to such a video? McCain has been on TV countless hours, and I have never noticed it before.

    Fourth, I think you overstate the case when you write, a “stroke could cause ptosis, but it would almost certainly be accompanied by other signs and symptoms; so I consider that pretty doubtful as a cause.” A lacunar infarct can be highly selective in its distribution, and an isolated facial droop is not uncommon in my experience in the ER. Yes, a detailed neurologic exam might find associated subtle associated defects, but we haven’t any idea whether that exam has taken place, do we?

    While you do not quite consign me to the tinfoil hat bin, please, you must concede that if a presidential candidate were to develop a highly visible new neurologic deficit, this is a point of legitimate inquiry, and it is not out of bounds to ask for an explanation.

  24. #24 shadowfax
    September 26, 2008

    I looked at some more stills. Yeah, it’s pretty clearly an old finding. Must come and go.

    So I concede the point, but it frustrates me that questions like this are viewed as unseemly, or out of bounds attacks. This may, fortunately, not have been the real deal, but were it genuine, it would be highly relevant.

    Cheers,

    SF

  25. #25 snerd
    September 26, 2008

    Bell’s Palsy, clearly.

    I too can be an armchair physician, I hereby claim my five pounds.

  26. #26 Orac
    September 26, 2008

    Shadofax,

    Dude, if you didn’t want a little taste of Respectful Insolence, you shouldn’t have e-mailed me your post. :-)

    In any case, yes, I do think you overreacted, mainly because it wasn’t hard to go back and look at McCain’s official friggin’ portrait for the Senate and see that he had some mild ptosis in it, not to mention several other older pictures. Steve Novella did it. I did it (although not as extensively as Steve). Everyone’s so anxious to find something physically wrong with McCain that they don’t even bother to do the minimal due diligence. That one guy on your blog saying that it must absolutely be Horner’s syndrome shows that in abundance.

    I will admit you got me on the Wikipedia reference, though. I forgot to go and look at the edit history.

  27. #27 shadowfax
    September 27, 2008

    No offense taken — I was wrong in the thesis of my post, and there’s no disguising that fact. I blame my itchy trigger finger. I’m not gonna roll over entirely, though!

    I think you said it well:
    McCain has no one to blame but himself for not being more transparent with his medical records because withholding anything only encourages the conspiracy-minded to do what they do best and look for explanations for any little physical problem

    As for the perils of video-diagnosis — clearly I need to go back to the Bill Frist School of Medicine for recurrent training!

    Cheers,

    SF

  28. #28 kraant
    September 27, 2008

    Really,

    Who cares?

    On pure actuarial odds, IIRC it’s a 1 in 6 chance (Same odds as Russian roulette) that someone of his age will drop dead in the next 4 years…

    And that’s without the pressures of the presidency.

  29. #29 Nurse K
    September 27, 2008

    FYI–As the person who posted the Wiki link on Shadowfax’s blog, I have to say that I did read some other posts which referred to the droopy eyelid back in May/June of 2008, for instance, before posting it, despite not knowing how to look at an “edit history”. I didn’t just throw that out there.

  30. #30 Samantha Vimes
    October 1, 2008

    I’m not a neurologist. But I did wonder about the possibility of a mini-stroke, not only because of the facial asymmetry (which I had already heard good reasons for), but the apparently erratic/impaired decision making he seems to show. I have often read that a mini-stroke could cause personality changes and what not.

    But the better explanation seems to be he just was better at putting on a moderate facade in 2000, and tricked a lot of people into thinking he was something he really wasn’t, and this is the man he’s always really been.

  31. #31 Outis
    October 1, 2008

    On the other hand, Shadowfax could cover all the bases faster than anyone.

    I’m not sure about that. Shadowfax might cover an equivalent distance faster than anyone else, but the bases are laid out in a diamond pattern. How good is Shadowfax’s turning radius?