Abstract
Background
Only 1–2 per 1,000,000 individuals are diagnosed with Tolosa Hunt Syndrome (THS). While most will present with unilateral symptoms, 4.6% have bilateral involvement, often affecting cranial nerves III, IV and VI incompletely.[2] Only 2 papers published cases with simultaneous and complete ophthalmoplegia and ptosis, both resolved either spontaneously or with high dose steroids. This case highlights a THS case with bilateral complete cavernous sinus syndrome initially on the right, followed several months later on the left.
Case Report:
Here we report a 78 years old female who was diagnosed with right sided then followed 3 months later by left sided THS while on low to moderate dose of steroids. She had bilateral painful ophthalmoplegia, hyperesthesia on the ophthalmic and maxillary branches of cranial nerve V and absent direct and consensual pupillary eye reflexes. She had prolonged bilateral R1, R2 and R2’ on blink reflex confirming affection of CN V, and enhancement on the right parasellar area on contrast-enhanced cranial CT indicating presence of granulation tissue.
Conclusion
THS should be considered in a patient presenting with bilateral painful ophthalmoplegia whether this happens simultaneously or in succession. Pulse therapy or high dose oral steroid is recommended as initial treatment for THS unless there are contraindications.