Tolosa-Hunt syndrome

Case contributed by Dr Wen Jak Ma

Presentation

Initial episode of left eye pain attributed to corneal ulcer. Painfree after that. Developed progressive left ophthalmoplegia that became increasingly complex in pattern, and also facial nerve symptoms.

Patient Data

Age: 70 years
Gender: Male
MRI

Asymmetrical increase in enhancement and bulk of the left cavernous sinus, extending laterally into superior orbital fissure, and into orbital apex.

Atrophy and edema (denervation or inflammation) of all extraocular muscles on the left. Asymmetrical increase in enhancement and edema in orbital fat.

Asymmetrical increase in enhancement of the left facial nerve along its horizontal segment within petrous bone.

MRI

One year prior

This is the study done 1 year earlier. Back then patient only had left abducens palsy.

Left cavernous sinus and superior orbital fissure enhancement were less, but present in retrospect. The edema in extraocular muscles and orbital fat were present, but subtle. No muscular atrophy back then.

Case Discussion

MRI and clinical features are suggestive of Tolosa-Hunt syndrome. Pain at the beginning, but lack of pain afterwards, is unusual, hence the delay in diagnosis. Involvement of the facial nerve is unexpected.

Sarcoid workup was negative. Lymphoma can give a similar appearance, but the clinical time course would be less typical.

The MR done on the first presentation has subtle findings. Would you have called it based upon isolated abducens palsy without other clinical cues?

Meningioma remains a differential diagnosis, even though no hyperostosis is seen.

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Case information

rID: 66643
Published: 28th Feb 2019
Last edited: 3rd Mar 2019
Inclusion in quiz mode: Included

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