John McCain a “dead man walking”? Not so fast, ptosis-boys!

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.