Tolosa Hunt

HISTORY

EXAM  Afebrile L

hp  Decreased EOM, no visual change, excessive tearing  Mild sinus TTP

LABS  8/9

UA, C&S: >100,0000 proteus m.  8/9 WBC=17.3  8/10 CT  8/13 MRI  8/19 CTA  8/19 MRA

ANATOMY OF CAVERNOUS SINUS

DDX OF CAVERNOUS SINUS LESIONS  Orbital

cellulitis  Opthalmoplegic Migraine  Carotid Cavernous Sinus Fistula  Mucormycosis  Tolosa Hunt Syndrome

 Temporal

arteritis  Orbital Pseudotumor  Carotid Artery Dissection or aneurysm  Neoplasm: lymphoma, meningioma

CSL SYMPTOMS  PTOSIS,

PROPTOSIS, CHEMOSIS, PAINFUL OPTHALMOPLEGIA W/O PROPTOSIS  HEADACHE: UNILATERAL OR RETROORBITAL  DECREASED VISUAL ACUITY AND DIPLOPLIA  SENSORY LOSS: FACE, FOREHEAD, PERIORBITAL REGIONS

CSL SIGNS  PERIORBITAL

EDEMA  PTOSIS  PROPTOSIS  OPTHALMOPLEGIA  CHEMOSIS  FEVER  PAPILLEDEMA  TACHYCARDIA

 TACHYCARDIA  FACIAL

CELLULITIS  DECREASED VISUAL ACUITY  NUCHAL RIGIDITY  SEIZURES

CSL DIAGNOSTIC WORKUP  DIAGNOSIS

OF EXCLUSION

 H&P  MRI/MRA  CBC  CT  SPECIALIST

CONSULT: NSG, ID, GS

CSL M&M  VISUAL

LOSS

 DEATH  THROMBOTIC

EVENTS  COGNITIVE DEFICITS

TOLOSA-HUNT SYNDROME  EPIDEMIOLOGY  PATHOPHYSIOOLOGY  MORBIDITY

AND MORTALITY  TREATMENT  PROGNOSIS

THS PATHOPHYSIOLOGY  Cause

unknown  Granulomatous or primarily lymphocytic infiltration of cavernous sinus and superior orbital fissure

THS EPIDEMIOLOGY  Uncommon  Men=women  Age>20  Usually

around age 60

THS SYMPTOMS  HA  ARTHRALGIA  FEVER  VERTIGO  DOUBLE

VISION

THS SIGNS/SYMPTOMS  PTOSIS

 HA

 EXOPTHALMOS

 ARTHRALGIA

 OPTHALMOPLEGIA

 FEVER

 DIPLOPLIA  VERTIGO  CHRONIC

FATIGUE

THS DIAGNOSIS PEARLS  DIAGNOSIS

OF EXCLUSION

THS TREATMENT  IMMUNOSUPPRESSION  STEROIDS  METHOTREXATE

 RADIOTHERAPY  PAIN

CONTROL

 ACETOMINOPHEN  STEROIDS

THS PROGNOSIS  Benign  Spontaneous

resolution may occur  Relapses (30-40%)  Nearly always improves w/ steroids  Pain(

24-72 hrs)  Visual loss possible if untreated  Vision

and facial numbness resolves in weeks to months

UPDATE