Dinaki Konstantina, Sarafidou Anastasia, Papadopoulos Constantinos, Triaridis Stefanos, Karkos Petros
ENT resident, 1st Academic ORL Department, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Academic fellow, 1st Academic ORL Department, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Maedica (Bucur). 2024 Sep;19(3):634-640. doi: 10.26574/maedica.2024.19.3.634.
Tolosa-Hunt syndrome (THS) is a disorder related to inflammation of cavernous sinus and superior orbital fissure that usually presents with ophthalmoplegia and oculomotor nerve palsies. The etiology of the syndrome is unknown and the diagnosis is set by exclusion of other clinical conditions that manifest in a similar way. Intracranial aneurysms, such as intracavernous ones, should be included in the differential diagnosis as they can compress cranial nerves leading to similar clinical presentation.
We present a case of a 51-year-old woman who was referred to our clinic after 24-hour hospitalization in an ophthalmology clinic due to periorbital cellulitis in her right eye. A nose and paranasal sinuses computed tomography (CT) scan with contrast revealed sinusitis affecting the maxillary sinus, the ethmoidal cells and the sphenoid sinus on the right side. The patient underwent endoscopic sinus surgery on the right side, where middle meatal antrostomy, anterior and posterior ethmoidectomy and Draf I frontal sinus drainage were performed. There was an immediate improvement of the orbital edema and the neuro-opthalmologic examination of the right eye was normal. However, on the ninth postoperative day she presented headache, retro-orbital pain and diplopia of her left eye. In 24 hours, the symptoms progressed to ophthalmoplegia and ipsilateral palpebral ptosis. Intravenous treatment with corticosteroids was initiated under the suspicion of Tolosa-Hunt syndrome, without resolution of her symptoms. Emergency CT and CT-angiography scans revealed a possible intracavernous carotid artery aneurysm on the left side. The diagnosis was confirmed by a magnetic resonance imaging (MRI) scan and the patient was referred to neurosurgery department, where a cerebral angiography was performed and the giant intracavernous aneurysm was treated with guglielmi detachable coils.
Our case indicates that an intracavernous aneurysm can present with painful ophthalmoplegia in all directions, mimicking the Tolosa-Hunt syndrome. One must underline the importance of radiological examination focusing on the vascular structures, as it is essential for the differential diagnosis, defining the course of treatment applied in such cases.
托洛萨-亨特综合征（THS）是一种与海绵窦和眶上裂炎症相关的疾病，通常表现为眼肌麻痹和动眼神经麻痹。该综合征的病因不明，诊断需排除其他表现相似的临床病症。颅内动脉瘤，如海绵窦内动脉瘤，应列入鉴别诊断，因为它们可压迫脑神经导致相似的临床表现。
我们报告一例51岁女性病例，该患者因右眼眶周蜂窝织炎在眼科诊所住院24小时后转诊至我院。增强鼻窦计算机断层扫描（CT）显示右侧上颌窦、筛窦和蝶窦有鼻窦炎。患者接受了右侧鼻窦内镜手术，进行了中鼻道上颌窦造口术、前后筛窦切除术和Draf I型额窦引流术。眶周水肿立即改善，右眼神经眼科检查正常。然而，术后第九天，她出现头痛、眶后疼痛和左眼复视。24小时内，症状进展为眼肌麻痹和同侧眼睑下垂。怀疑为托洛萨-亨特综合征，开始静脉注射皮质类固醇治疗，但症状未缓解。急诊CT和CT血管造影扫描显示左侧可能存在海绵窦内颈动脉动脉瘤。磁共振成像（MRI）扫描确诊，患者被转诊至神经外科，进行了脑血管造影，并使用 Guglielmi 可脱卸弹簧圈治疗巨大海绵窦内动脉瘤。
我们的病例表明，海绵窦内动脉瘤可表现为全方位疼痛性眼肌麻痹，酷似托洛萨-亨特综合征。必须强调针对血管结构进行放射学检查的重要性，因为这对于鉴别诊断至关重要，可确定此类病例的治疗方案。
