Painful ophthalmoplegia
Introduction
Introduction to painful ophthalmoplegia Painful ophthalmoplegia, also known as painful ophthalmoplegia, painful ophthalmoplegia syndrome, Tolosa-Hunt syndrome, is a non-specific chronic inflammation of the cavernous sinus and its vicinity, with severe pain after the ball A syndrome characterized by ophthalmoplegia. basic knowledge Sickness ratio: 0.05% Susceptible people: no specific population Mode of infection: non-infectious Complications: meningitis, brain abscess, hyponatremia
Cause
Causes of painful ophthalmoplegia
(1) Causes of the disease
In the past, the disease was thought to be caused by syphilis and tuberculosis. It is generally considered that this disease belongs to the category of idiopathic orbital inflammatory pseudotumor, except that the lesion is mainly in the cavernous sinus, and then invading the sacral sinus. In some cases, the apical apex is involved, and the true cause Little is known, it may be an autoimmune disease, corticosteroid treatment has special effects, it also proves that the disease is an immune disease.
(two) pathogenesis
The exact pathogenesis of painful ophthalmoplegia is still unclear. There are two inferences based on pathological examination and clinical application of corticosteroids:
Hunt reviewed Tolosa's autopsy in 1957 and concluded that it was a non-specific chronic inflammation of the cavernous sinus. A case of a 47-year-old female patient reported by Tolosa, right sputum pain, nausea, vomiting, III, IV, VI neurological invasion Carotid angiography revealed that the siphon was narrow. The craniotomy revealed no significant changes in the saddle area. Three days after the operation, no aneurysm was found at the autopsy. The tumor was opened and the cavernous sinus was opened. The carotid artery was surrounded by granulation tissue. The sinus cavity was not completely completed. Obstruction, this segment of the carotid artery is narrow, the artery is yellow, the wall is brittle, microscopic examination shows carotid adventitia thickening, non-specific granulation around the artery, and affecting the adjacent cranial nerve trunk, Lake reported a case of 47-year-old male In patients, X-rays showed an increase in the density of the right sphenoid winglet. Surgery revealed a thin layer of gray-red granulation tissue on the outside of the cavernous sinus, thickening of the sphenoidal winglet periosteum, and biopsy to see the cavernous sinus wall as inflammatory tissue, including polymorphonuclear nucleus. Cells, necrosis of the dura mater on the supracondylar sulcus, granulation tissue on the surface, containing polymorphonuclear cells and monocytes, Smith supports the inferior sacral fissure and chronic inflammation of the cavernous sinus It is noteworthy that in some cases the cerebrospinal fluid examination revealed an increase in the total number of white blood cells and Kyle Nigel zhengzheng was positive, with patients with nausea, vomiting and other symptoms of meningeal irritation, inflammation may be extended to the base of the skull caused by the arachnoid.
Of the 10 patients reported by Cui Guoyi in China, 6 underwent CT and MRI examinations. 4 cases of bilateral cavernous sinus asymmetry, sinus density was abnormal, 5 cases of sphenoid winglet density increased, and 3 cases of cerebrospinal fluid white blood cells total >30/mm3. Shi Dapeng et al reported the results of MRI in 17 patients: 5 cases showed patchy or nodular shadows in the supraorbital area, and 7 cases showed widening and enlargement of the cavernous sinus area, resulting in asymmetrical shape of the cavernous sinus .
Mathew suggested that it may be related to defects in the immune system. Hallpike found that the disease is the same as that seen in the sputum inflammatory pseudotumor, presumably an immune-reactive disease. This hypothesis is supported by the successful use of immunosuppressive steroids.
The pathogenesis of this disease should be summarized as follows:
1 Chronic inflammatory stimulation of the sphenoid sinus, involving the cavernous sinus and internal carotid artery, producing non-specific granulation tissue, which affects the typical clinical symptoms of adjacent nerve trunks;
2 internal carotid aneurysm, nasopharyngeal tumor, sellar tumor and acoustic neuroma and other adjacent nerve trunk;
3 Hypertensive arteriosclerosis leads to thickening of the internal carotid artery wall, and the stenosis involves the nerve trunk;
4 immune dysfunction, corticosteroid treatment sensitive support this doctrine.
Prevention
Painful ophthalmoplegia prevention
1. Pay attention to enhance physical fitness and prevent facial and upper respiratory tract infections.
2. Early comprehensive treatment to reduce recurrence.
Complication
Painful ophthalmoplegia complications Complications meningitis brain abscess hyponatremia
There may be cavernous sinus inflammation, non-specific inflammation of the cavernous sinus wall, collagen tissue disease, giant cell vasculitis, peripheral neuronal metastasis of squamous cell carcinoma, chronic infectious diseases and other primary manifestations.
If inflammatory cavernous sinus thrombosis occurs, the corresponding symptoms and signs may appear. Common complications include meningitis, brain abscess, internal carotid arteritis and pituitary infection, necrosis and dysfunction, water retention and hyponatremia.
Symptom
Painful ophthalmoplegia symptoms Common symptoms Meningeal irritation brain cerebral palsy corneal reflex dull lacrimal gland sweat glands and parotid glands... Tinnitus allergies re-listening Arroa pupil nausea
Painful ophthalmoplegia, also known as painful ophthalmoplegia, painful ophthalmoplegia syndrome, Tolosa-Hunt syndrome, is a non-specific chronic inflammation of the cavernous sinus and its vicinity.
1. Painful eye muscle paralysis is accompanied by pain before and after. It is a kind of persistence, acupuncture or tearing pain, and some severe pain is unbearable. The painful part occurs in the posterior eyelid of the ball or radiates to the temporal side and forehead. It is repetitive, the earliest appearance of this symptom, and the disappearance is also the earliest, which is the result of stimulation of the nerve branch of the V-brain nerve.
2. Ophthalmoplegia can occur before or after pain, usually multiple eye muscle paralysis, or a single nerve paralysis, often involving the third, IV, VI cranial nerves, mostly starting from the third cranial nerve, lighter It is characterized by ocular paralysis of the eye muscles, total paralysis of the eye muscles, and ophthalmoplegia. The second essential symptom of Tolosa-Hunt syndrome is the result of inflammation of the nerve trunk of the cavernous sinus and/or supracondylar fissure. In general, they can naturally resolve or heal, and a few cases have residual neurological insufficiency.
3. Perceptual change The first and second branches of the V-brain nerve pass through the side wall of the cavernous sinus. Tolosa-Hunt syndrome can invade the nerve trunk and cause hypersensitivity in the corresponding area. The perception is reduced or disappeared, which is manifested as corneal reflex and forehead. The skin feels allergic or dull.
4. Vision loss When inflammation invades the optic nerve, there is visual acuity change. The lighter only shows different degrees of visual loss. The severe ones only have index, light sense or vision loss. There may be optic neuritis during the onset of inflammation. Some cases have optic nerve atrophy. This kind of visual impairment accounts for about 20%, and most of them recover after treatment.
5. Eyeballs are less common symptoms, accounting for about 10%. It is believed that the eye muscles may be paralyzed, the muscles lose tension, and the eyeballs protrude forward. If the tip of the eye is invaded, it may cause eyeballs to protrude.
6. Hearing changes Inflammation invading the third cranial nerve or combined with acoustic neuroma can occur in tinnitus and auditory.
7. Nausea, vomiting is the only systemic symptom, often accompanied by headache and meningeal irritation.
Examine
Examination of painful ophthalmoplegia
The necessary selective examinations are based on possible causes.
1. Blood routine, blood electrolytes.
2. Blood sugar, immune items, cerebrospinal fluid examination, if abnormal, there is a differential diagnosis.
The following check items have abnormal diagnostic significance:
3. CT, MRI, DSA examination, often no obvious abnormalities; can also be expressed as soft tissue swelling in the sputum.
4. There is no special finding in intracranial angiography.
5. EEG.
6. Skull base film, paranasal sinus film.
7. Eye examination.
Diagnosis
Diagnosis and differentiation of painful ophthalmoplegia
Diagnostic criteria
Painful ophthalmoplegia in addition to the third, fourth, and sixth cranial nerves, the first and second episodes of the V-brain nerve, and other objective signs, so the diagnosis is based on the entire process of the disease, eye performance and In response to corticosteroid treatment, Cui Guoyi based on the diagnostic opinions of Hunt and Smith, comprehensive domestic literature reported more than 50 cases to propose five diagnostic criteria:
1. Pain is a continuous acupuncture or tear-like pain in the posterior part of the eye and is radiated to the forehead or ankle.
2. Ophthalmoplegia may be associated with cranial nerve dysfunction, which may be associated with cranial nerves, in addition to the third, fourth, or second, VII, cerebral nerve damage. The above-mentioned cranial nerve palsy may occur in pain. A few days before or after.
3. Brain CT, MRI can show asymmetry on both sides of the cavernous sinus or abnormal density in the sinus. Carotid angiography can show irregular stenosis of the end of the internal carotid artery, and laboratory tests exclude other diseases.
4. Most of the symptoms in middle-aged and elderly people last for several days or weeks, can be resolved or cured by themselves, but can recur after several months or years.
5. Particularly sensitive to corticosteroid treatment, such as the application of prednisone 60 ~ 80mg / d, should be effective within 48h, post-ball pain and ophthalmoplegia is characterized by a syndrome.
Differential diagnosis
The two main symptoms of painful ophthalmoplegia are pain and ophthalmoplegia. The main causes of similar symptoms are the following:
Internal carotid aneurysm
An aneurysm located near the cavernous sinus can cause unilateral III, IV, VI cranial nerves and the first V-brain nerve damage, eyeball protrusion, conjunctival edema, ophthalmoplegia after migraine, most often For subarachnoid hemorrhage, aneurysm bleeding accounts for 80% to 91.3%, so the cerebrospinal fluid is bloody, and cerebral arteriography can show that it is not difficult to make a differential diagnosis.
2. Ophthalmoplegia migraine
Migraine occurs before ophthalmoplegia, pain is located at the top of the forehead or frontal forehead, is paroxysmal pulsating pain or jumping pain, is not a continuous acupuncture or tearing pain, eye muscle paralysis is more than the third brain damage See, rarely involved other cranial nerves, cerebral arteriography was negative.
3. Orbital inflammatory pseudotumor
Pathologically, the pseudotumor is a non-specific granuloma, similar to Tolosa-Hunt syndrome. The clinical manifestations of orbital pseudotumor are mainly ocular protrusion, the pain is dull and painful, and the sacral area can touch hard lumps or strips. A lump, with eyelids and conjunctival edema, about one-third of patients with bilateral onset, B-ultrasound can be seen in the sacral mass and extraocular muscle hypertrophy.
4. Nasopharyngeal tumor
Nasopharyngeal carcinoma occurs mostly in the posterior pharyngeal wall. Because it is concealed, there is often a skull base invasion before local symptoms, and 35% to 40% of cases cause eye-neuronal symptoms.
5. Carotid cavernous fistula
The disease is characterized by eyeballs, eyeball pulsation and intracranial murmur. It can be accompanied by ophthalmoplegia, conjunctival congestion and edema, visual impairment, headache and eye pain. Most patients have a history of traumatic head and neck. An angiography can be used to identify.
6. Diabetic ophthalmoplegia
Such patients often have typical clinical symptoms of diabetes, fasting blood glucose, glucose tolerance test can be identified.
