Sudden painful third nerve palsy due to Tolosa–Hunt syndrome – A diagnostic dilemma

Tolosa–Hunt syndrome (THS) is caused by idiopathic granulomatous inflammation of the cavernous sinus, superior orbital fissure, or orbit, presenting with painful ophthalmoplegia due to palsy of one or more ocular motor nerves. It may be associated with autoimmune and systemic inflammatory conditions such as lupus, sarcoidosis, and Wegener’s granulomatosis. The diagnosis is based on the clinical presentation, neuroimaging with a magnetic resonance imaging of the brain with contrast, which shows cavernous sinus thickening, isointense tissue on T1, hypo- or isointense on T2, contrast enhancement, and lateral convexity of the cavernous sinus, with possible extension into the orbital apex; and a rapid response to steroids. As a diagnosis of exclusion, blood and cerebrospinal fluid studies are performed to rule out other causes of painful ophthalmoplegia when THS is suspected. We are reporting a challenging and intriguing case of THS successfully managed with a multidisciplinary approach.