Sep 26 2008

McCain’s Ptosis

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Comments: 9

This has gone around the science blogs already, but as a practicing neurologist I thought I should weigh in. Moving Meet seems to have started the rumor, and Neurotopia has also added to the speculation.  Some people have just noticed that presidential candidate John McCain has left ptosis – which is a slight drooping of his left eyelid. From this they speculate that he may have had a stroke, or worse a brain tumor.

Orac has already done a fine job of dissecting this claim, pointing out that there are many causes of ptosis, most of which are benign. The one correction I would make (which is not his fault as he lifted it from a reliable resource) is that forehead Botox (the location of treatments used for cosmetic purposes) does not cause eyelid ptosis. It may cause brow ptosis (drooping of the brow, which is not what McCain has) but not lid ptosis. Injections of the eyelids themselves for things like blepharospasm (involuntary blinking) can cause lid ptosis. It would take ridiculously poor technique to cause lid ptosis from a forehead injection.

First, I think it is very irresponsible for non-specialists to speculate in public about the significance of a physical finding they don’t understand. It seems that the purpose is to generate rumors disguised as speculation.

Further, the medical information in the speculation was quite poor. Isolated ptosis would be an extremely uncommon presentation of a stroke or tumor, other signs would almost certainly be present. Ptosis is most often physiological – meaning normal for that person. This type of ptosis can also come and go, so it may be more noticable at some times than at others.

I see patients with ptosis all the time. It is ususally benign. The first thing I do is ask if it is old, and if possible look at old pictures to see. If the ptosis has been present for a long time we don’t worry about it. If it is new, then we rely upon other exam findings to determine the location of the problem and the cause.

Some have speculated that McCain also has subtle left facial droop. I don’t think he has, and Orac pointed out that his prior surgery can explain the subtle asymmetry. This is a good example of the perils of speculating based upon some information, but lacking expertise. A stroke causing facial weakness would not cause lid ptosis. It may cause drooping of the lower eyelid – but not the upper eyelid. There are two locations where a stroke can cause lid ptosis – the brainstem and the sympathetics along the carotid artery. In the case of a third cranial nerve involvement causing ptosis, there would also be problems with eye movements and pupil size. If the ptosis were due to a lesion in the carotic artery (which in turn caused a stroke), where the sympathetic fibers to the eyelid travel, then that could occur with a stroke on the same side – but then the weakness would be on the opposite side, which he does not have. The same would apply to a tumor or any cause.

Is the ptosis old? I have looked through many pictures of McCain, including many good closeups of his face, an they all show left sided ptosis to varying degrees. This is an old finding, and therefore of no signficance. People just did not notice it before. I am trained to notice even subtle ptosis, and often I will find it in patients who were not even aware of it themselves. Also, the ptosis appears to be more prominent in some pictures than in others, so it varies and was probably just more noticeable than usual that day.

The probable political motivation for the speculation asside, what this episode shows is that expertise matters. Having most of the information, but not all, and not having the experience to put it into a meaningful context, often means coming to a wrong or misleading conclusion, and having unwarranted confidence in that error.

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9 responses so far

9 Responses to “McCain’s Ptosis”

  1. [...] Steve Novella (academic clinical neurologist at Yale University School of Medicine) and Orac (surgical oncologist) provide expert analysis of a harmless (benign) clinical finding – John McCain’s left eyelid droop (ptosis). [...]

  2. JustinWilsonon 26 Sep 2008 at 12:12 pm

    While I could care less about his condition, I find your review of this information fascinating. Thanks for clearing up some misconceptions and enlightening us with this analysis.

  3. Minon 26 Sep 2008 at 12:29 pm

    I looked around the net a bit and I am not sure I understand what exactly lid ptosis is. Its the lid drooping, I understand that. Are we looking for a change in exposed eyeball (compared to the other one)? I just went and looked in the mirror and I was a little disturbed to notice that while my right lid doesn’t seem to hang any lower than the left, the skin above it DOESn and nearly completely overlaps the lid. Is that what you’re talking about here? If not, is that an issue?

  4. Steven Novellaon 26 Sep 2008 at 1:29 pm

    Min – lid ptosis is drooping of the lid itself. The best way to see this is to look for where the upper lid falls in relation to the iris and pupil. If the skin above the lid is hanging down, that is brow ptosis. This is almost always a result of simple aging and loose skin.

  5. mark passeyon 26 Sep 2008 at 1:38 pm

    Steven,

    I only began to notice McCain’s ptosis a few days ago, so I just Googled ptosis and McCain today to see what’s others have noticed. If you say he’s had it all along that’s OK with me.

    But coincidentally I just saw that political video clip that shows a photo of McCain’s melanoma prior to surgery and it suprised me how advanced it appeared in that photo; I’d never seen that. It was multinodular and multifocal. The first thing that I thought of when I noticed McCain’s ptosis was not stroke or brain tumor, but rather local recurrence. Especially if he’s had ptosis for a while, a local recurrence could just be causing non-specific tissue edema. Just saying…

    By the way, I usually vote republican so I’m not grinding any political ax here. Also, I’m an MD, just for disclosure…

  6. Oracon 26 Sep 2008 at 5:18 pm

    But coincidentally I just saw that political video clip that shows a photo of McCain’s melanoma prior to surgery and it suprised me how advanced it appeared in that photo; I’d never seen that. It was multinodular and multifocal. The first thing that I thought of when I noticed McCain’s ptosis was not stroke or brain tumor, but rather local recurrence. Especially if he’s had ptosis for a while, a local recurrence could just be causing non-specific tissue edema. Just saying…

    No, John McCain’s facial asymmetry is a result of his melanoma surgery, the rotation of a full thickness skin flap to cover the defect left when his melanoma was excised, and his superficial parotidectomy. Also, he had a modified radical neck dissection on the left, which impairs the lymphatic drainage from that side of his face.

    In any case, a recurrence large enough to cause facial edema would be very difficult to miss and almost impossible to cover up. So sayeth this surgical oncologist, anyway.

    Finally, John McCain’s melanoma was a Stage IIA, and I discussed it in detail here. To boil it all down, it’s unlikely that McCain has recurred after eight years of no recurrence. Is it possible for him to have a recurrence? Yes. But his having survived eight years without one makes it fairly unlikely that he will suffer one in the next five years.

  7. Oracon 26 Sep 2008 at 5:19 pm

    The one correction I would make (which is not his fault as he lifted it from a reliable resource) is that forehead Botox (the location of treatments used for cosmetic purposes) does not cause eyelid ptosis. It may cause brow ptosis (drooping of the brow, which is not what McCain has) but not lid ptosis.

    That’s why you’re a neurologist, and I’m a surgical oncologist. ;-)

  8. shadowfaxon 26 Sep 2008 at 7:22 pm

    First, I think it is very irresponsible for non-specialists to speculate in public about the significance of a physical finding they don’t understand.

    Nice. More polite than STFU, I admit, but the message is the same, neh?

    I concede the finding is clearly not new, and thus of no concern. I viewed the video of the “suspension” speech and the convention speech side by side — McCain’s face looked dramatically different between the two, so I assumed the deficit was new. Clearly it’s a waxing & waning phenomenon, which should have but did not occurred to me.

    As I correctly indicated in the OP, the evidence suggested a peripheral lesion. But based on the highly limited video evidence at hand, I disagree with your implication that stroke was an impossible cause. It may not have been the fact today, which is fortunate, but it remains a possible and reasonable etiology and in a candidate who has so jealously guarded his medical records, the concern is valid.

    Moreover, I take issue with the implication that this is somehow an unseemly, partisan, or out-of-bounds question to raise. When an aspirant to the highest office develops an (apparently) new deficit, it is highly relevant to his fitness to serve.

  9. Steven Novellaon 27 Sep 2008 at 2:25 pm

    Shadowfax – I did not say stroke was “impossible”, I said such a presentation would be “extremely uncommon.” That is quite different, and I was very careful in the words that I chose.

    I agree that the health of the presidential candidates is fair game. I did not criticize anyone for addressing this issue. What I criticized was trying to diagnose him, or speculating in public about diagnosis, from video evidence without having the proper expertise to put this limited evidence into the context of clinical experience.

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