Bilateral Severe Tolosa-Hunt Syndrome in an Elderly Filipino Female: A Case Report

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 (CN) III, IV, and VI incompletely. 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. Here, we report a 78-year-old female who was diagnosed with right-sided THS and 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 CN 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 computed tomography (CT) indicating the presence of granulation tissue. 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.