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Contiguous spread along perineural and endoneural spaces, that is, perineural tumor extension, in cutaneous squamous cell carcinoma is fairly common. Infrequently, these tumors spread and involve intracranial structures. One consequence of this complication is meningeal carcinomatosis which is underrecognized. Herein described is a patient with recurrent cutaneous squamous cell carcinoma with perineural invasion along the maxillary nerve that was subsequently shown by magnetic resonance imaging to the trigeminal root. The patient initially presented with a cavernous sinus syndrome but despite aggressive treatment, extensive meningeal carcinomatosis and cauda equina dysfunction developed. Awareness of perineural invasion and proper evaluation are crucial. Perineural spread intracranially worsens the prognosis and limits treatment options to palliation.

Vacuum disorders of the paranasal sinuses are well described. Patients with facial pain in the distribution of the infraorbital nerve are often labelled as suffering from a "vacuum maxillary sinusitis" and empirically treated by intranasal antrostomy. A variety of mechanisms have been postulated for the production of symptoms in this condition, but all ignore the fact that the maxillary sinus is a relatively insensitive structure. This article introduces a dehiscence of the bony infraorbital nerve canal within the antrum as an anatomic variant and suggests that it may provide the anatomic basis for vacuum sinusitis in the presence of a small natural ostium. Definitive diagnosis is made by outpatient antroscopy, and surgical treatment takes the form of a middle or inferior meatal antrostomy. Persistent symptoms may benefit from an infraorbital neuropexy to provide added protection to the exposed nerve.

Neurotropic melanoma is a variant of desmoplastic melanoma which, in addition to a spindle-cell vertical component and fibrosis, exhibits a fascicular growth pattern and invades cutaneous nerves. Here we describe a neurotropic melanoma which arose in a small lentigo maligna melanoma and invaded the maxillary nerve for a distance of 5 cm. Ultrastructural features were similar to those of previously described neurotropic melanomas and tumor fascicles contained S-100 protein and neuron-specific enolase immunoreactivity.