We report a 27-year-old female patient with prior history of Graves' disease and relapsing episodes of tachycardia, hyperpyrexia, muscular rigidity and coma. With the subsequent manifestation of an acute schizophreniform psychotic disorder unresponsive to neuroleptics, the primary syndrome was re-classified as febrile catatony. Hyperthyroidism was ruled out with normal serum thyroid hormone levels, as were toxic effects of thyrostatic treatment, drug-induced hypothyroidism and a malignant neuroleptic syndrome. All psychiatric symptoms subsided completely following subtotal thyroidectomy. Febrile catatatony has to be added to the spectrum of psychotic phenomena that may be caused by Graves' disease, irrespective of serum thyroid hormone levels.

Summary

The management of thyroid-associated eye disease is reviewed with particular reference to surgical management and its implications for anaesthetists. Experience from a unit undertaking such surgery is presented.

Orbital decompression for dysthyroid eye disease is traditionally performed either through an external approach or transantrally. The introduction of endoscopic sinus surgery over the last decade has led to a better understanding of the intranasal surgical landmarks of orbital walls and the development of endoscopic orbital decompression. We have adopted the endoscopic technique as the treatment of choice for orbital decompression in dysthyroid eye disease for the last two years. The surgical technique is described and illustrated, and the results of our first series of 15 patients (30 orbits) are presented.

An unusual case of recurrent frontal sinusitis with abscess formation secondary to orbital decompression for Graves' disease is described. The infection was refractory to antibiotics treatment, external drainage and the sinus obliteration procedure. Since the sinus outflow was obstructed by prolapsing tissue following excessive removal of the orbital walls, sinus re-aeration by supporting the prolapsed tissue with a silastic sheet and stenting the sinus drainage tract was attempted. This led to a complete resolution of the infection with an excellent long-term result.