Incidence of pediatric Horner syndrome and the risk of neuroblastoma: a population-based study

Development and validation of a convolutional neural network to identify blepharoptosis

Blepharoptosis is a recognized cause of reversible vision loss and a non-specific indicator of neurological issues, occasionally heralding life-threatening conditions. Currently, diagnosis relies on human expertise and eyelid examination, with most existing Artificial Intelligence algorithms focusing on eyelid positioning under specialized settings. This study introduces a deep learning model with convolutional neural networks to detect blepharoptosis in more realistic conditions. Our model was trained and tested using high quality periocular images from patients with blepharoptosis as well as those with other eyelid conditions. The model achieved an area under the receiver operating characteristic curve of 0.918. For validation, we compared the model's performance against nine medical experts-oculoplastic surgeons, general ophthalmologists, and general practitioners-with varied expertise. When tested on a new dataset with varied image quality, the model's performance remained statistically comparable to that of human graders. Our findings underscore the potential to enhance telemedicine services for blepharoptosis detection.

Neuro-Ophthalmological Manifestations of Horner's Syndrome: Current Perspectives

Horner's syndrome (HS) is caused by a damage to the oculosympathetic pathway. HS may be congenital, but it is usually acquired and may reveal a life-threatening condition. According to the anatomic location of the underlying pathologic process, HS is classified as central, pre- or postganglionic, when the lesion affects the first, second or third-order neuron, respectively. Pharmacological testing, if available, can be used to differentiate HS from « pseudo-HS » in patients with mild symptoms. Given the financial burden that imaging of the entire oculosympathetic pathway represents, a targeted imaging approach is advised. Although in the majority of cases, clinical examination may predict etiology, in other cases pharmacological testing can help in the localization process. We searched PubMed data base for papers published before December 2022 that concerned Horner's syndrome, its neuro-ophthalmological manifestations and diagnosis. In this article, we describe the main neuro-ophthalmological manifestations of the three types of HS, the most common etiologies, and a targeted diagnostic strategy in each type.

A Rare Complication of Thoracic Spine Surgery: Pediatric Horner's Syndrome after Posterior Vertebral Column Resection-A Case Report

BACKGROUND

Horner's syndrome (HS) classically consists of the symptom triad of miosis, ptosis, and anhidrosis. It is caused by impairment of a certain pathway in the sympathetic nervous system. It may also appear as part of the clinical signs of other diseases and syndromes, including Pancoast tumors, intradural and/or epidural tumors, thoracic outlet syndrome, syringomyelia, brachial plexus injury, and aortic dissection. Here, we report a very rare complication of vertebral column resection in children, and we present the clinical findings of a case of Horner's syndrome with a current literature review.

CASE PRESENTATION

A five-year-old child with severe congenital kyphoscoliosis qualified for surgical treatment of the spinal deformity via a posterior approach, with three-column osteotomy and fusion.

RESULTS

After successful surgery, the patient presented with HS due to distraction of the sympathetic nerve trunk and, thus, innervation to the left eye. At the 4-year follow-up, the child had fully recovered.

CONCLUSIONS

Pediatric HS after posterior instrumented scoliosis correction surgery with posterior vertebral column resection of the thoracic spine is very rare. This is the first reported case of HS after posterior vertebral column resection and spinal fusion for congenital kyphoscoliosis without the use of epidural analgesia. Symptom resolution may be variable and, in some cases, delayed.

Child Neurology: Horner Syndrome in an Otherwise Well-Appearing Infant

We report an exemplary case of acquired Horner syndrome secondary to neuroblastoma in infancy. The patient presented with ptosis, miosis, and heterochromia. In reviewing the patient's laboratory and imaging workup, we highlight key etiologic differences between the pediatric and adult populations. Other important teaching points included in the discussion are a review of sympathetic neuroanatomy and oculosympathetic paresis, the appropriate and evidence-based diagnostic workup in infants and children, and a review of pharmacologic testing using cocaine and apraclonidine drops.

A rare presentation of Horner syndrome due to internal jugular phlebectasia

Horner syndrome occurs due to disruption of the oculosympathetic pathway. We present a case of acquired Horner syndrome in a 30-month-old boy due to phlebectasia of the internal jugular vein. To our knowledge, this rare entity has been reported only once before.

Advances in the genetics of congenital ptosis

Congenital ptosis, a birth defects presents at birth or by 1 year of age, is characterized by the drooping of the upper eyelid. either in isolation (non-syndromic) or with many different systemic disorders (syndromic). The estimated prevalence of ptosis (congenital & acquired) ranges from 0.79 to 1.99 per 10,000 people in different populations, and it is more prevalent in males. The underlying pathogenesis of congenital ptosis are myogenic and neurogenic, related to the development of muscles and nerves. Although most cases are sporadic, there are familial transmission characteristics, including autosomal dominant, recessive mode and X-linkage inheritance patterns. Moreover, some forms are due to chromosomal aberrations and mutations and deletions in mitochondrial DNA. Genes involved in simple congenital ptosis are ZFHX4 and COL25A1. The clinical aspects of various syndromes involving congenital ptosis are partly caused by single gene mutations. However, the pathogenesis of congenital ptosis is not fully understood. We review the reported epidemiology, genetics and clinical features of congenital ptosis and associated syndromes here.

Neuroimaging in Children with Ophthalmological Complaints: A Review

Pediatric patients are commonly referred to imaging following abnormal ophthalmological examinations. Common indications include papilledema, altered vision, strabismus, nystagmus, anisocoria, proptosis, coloboma, and leukocoria. Magnetic resonance imaging (MRI) of the brain and orbits (with or without contrast material administration) is typically the imaging modality of choice. However, a cranial CT scan is sometimes initially performed, particularly when MRI is not readily available. Familiarity with the various ophthalmological conditions may assist the radiologist in formulating differential diagnoses and proper MRI protocols afterward. Although MRI of the brain and orbits usually suffices, further refinements are sometimes warranted to enable suitable assessment and accurate diagnosis. For example, the assessment of children with sudden onset anisocoria associated with Horner syndrome will require imaging of the entire oculosympathetic pathway, including the brain, orbits, neck, and chest. Dedicated orbital scans should cover the area between the hard palate and approximately 1 cm above the orbits in the axial plane and extend from the lens to the midpons in the coronal plane. Fat-suppressed T2-weighted fast spin echo sequences should enable proper assessment of the globes, optic nerves, and perioptic subarachnoid spaces. Contrast material should be given judiciously, ideally according to clinical circumstances and precontrast scans. In this review, we discuss the major indications for imaging following abnormal ophthalmological examinations.

Imaging of Horner syndrome in pediatrics: association with neuroblastoma

Neuroblastoma is the most common neoplasm associated with pediatric Horner syndrome. The laboratory and imaging evaluation of isolated pediatric Horner syndrome is controversial. We review the literature published in the last several decades and present the rationale for the imaging work-up in this patient cohort.

Case report and literature review: Horner syndrome subsequent to endoscopic thyroid surgery

Background

Horner syndrome (HS), mainly characterized by symptoms including ptosis, miosis, and anhidrosis on the affected face, is a condition that is well documented but rarely reported as a postoperative complication of thyroidectomy, particularly in endoscopic thyroid surgery (ETS). We hereby report a case of HS due to ETS with a brief literature review on this topic.

Case presentation

A 31-year-old female was admitted to our hospital with an unexpected physical examination finding of two thyroid nodules that were hypoechoic, had an irregular shape, and exhibited calcification. Subsequently, the results of a fine-needle aspiration (FNA) biopsy from the thyroid nodules and BRAF^V600E mutation further confirmed the malignancy of these nodules. Thus, total thyroidectomy combined with central lymph node dissection (CLND) by ETS via the bilateral axillo-breast approach was performed on this patient. Histology confirmed the diagnosis of papillary thyroid microcarcinoma (PTMC) concurrent with Hashimoto’s thyroiditis (HT). However, this patient developed HS with ptosis in her left eye on postoperative day 3. All symptoms gradually resolved before the 3-month follow-up.

Conclusion

HS subsequent to ETS is a rare complication. Thus, standardized and appropriate operative procedures, as well as subtle manipulation, are essential in preventing and reducing the occurrence of HS. In addition, the early diagnosis and management of this rare complication are also important for a favorable outcome.

Incidence of Horner syndrome associated with neuroblastic disease

PURPOSE

Horner syndrome (HS) manifests in unilateral ptosis, miosis, enophthalmos, and anhedonia. It is most commonly caused by trauma or surgical procedures, but can also occur in pediatric patients as a result of tumors, especially neuroblastoma (NBL). The objective of this study was to analyze the incidence of HS in patients diagnosed with NBL.

METHODS

A retrospective analysis of data collected at the Department of Pediatric Oncology, Hematology, and Transplantology from 2004 to 2019 was performed. The study group included 119 patients younger than 18 years old, with 62 girls and 57 boys. All of them were diagnosed with a neuroblastic tumor.

RESULTS

Among the 119 patients, eight children (6.72%) were diagnosed with HS associated with NBL. Three of these patients presented to the clinic with HS, whereas HS developed after the surgical procedure to remove the tumor in four patients. The adrenal gland was the most frequent localization of the tumor. However, HS occurred more frequently in patients with mediastinum tumors. As a presenting symptom, HS occurred in 2 of 11 cases (18.18%) with mediastinum localization. All of the patients with HS were younger than 2 years old.

CONCLUSION

Investigation of the cause of isolated HS is crucial because it can be the first symptom of NBL. However, the surgical procedure itself increases the risk of HS as a complication of NBL treatment.

Paediatric Horner syndrome. A case series of 14 patients in a tertiary hospital

BACKGROUND

Horner syndrome (HS) is characterised by the triad of upper eyelid ptosis, miosis, and facial anhidrosis. Due to its wide variety of causes, it can occur at any age, and is uncommon in paediatrics. The aetiology and diagnostic approach of paediatric HS (PHS) is controversial.

OBJECTIVE

The purpose of this study is to describe the clinical characteristics of a 14 case series, focusing on the aetiology of HS and the clinical evolution the patients presented.

METHODS

A retrospective observational study was conducted on patients under 14 years-old (enrolled between 1st January 2009 and 30th April 2020). Depending on the age at diagnosis (before or after the first 5 months of life), the study cases were divided into two groups: congenital or acquired.

RESULTS

Fourteen patients, with a mean age of 8.5 months, were enrolled. The most frequent cause of PHS were tumours (6/14), with the most representative neoplasm being neuroblastoma (4/14). Of the acquired cases (8/14), the most frequent cause was iatrogenic (5/8), mainly secondary to cervical or thoracic surgery. The main origin of congenital HS (6/14) was neuroblastoma (4/6), being the first manifestation of the disease in 50% of patients (2/4).

CONCLUSION

HS may be the first sign of a major underlying disease, such as neuroblastoma. For this reason, children presenting with HS of unknown origin require imaging studies to exclude a life threatening disease. A thorough examination is essential for early diagnosis of these patients.

Congenital Horner and Scimitar syndrome in a newborn: a previously unreported combination

Here we report a case of a term newborn presenting with left palpebral ptosis, anisocoria and heterochromia as well as cleft palate and heart murmur. Congenital Horner syndrome was suspected and a thoracoabdominal CT scan was performed to rule out neuroblastoma. This revealed an anomalous drainage of right pulmonary veins to a collector that drains to the inferior vena cava, leading to the diagnosis of Scimitar syndrome. Echocardiogram showed an ostium secundum atrial septal defect, enlarged right chambers and a dilated coronary sinus due to a persistent left superior vena cava. The combination of Horner and Scimitar syndrome has never been described before. This case should encourage clinicians to use a multidisciplinary approach in order to guarantee an adequate diagnosis and management.

Paediatric Horner Syndrome: How much further to investigate?

We report an infant with an early-onset Horner syndrome and normal urinary catecholamine levels. Further investigations with Nuclear medicine imaging with ¹²³I-MIBG (meta-iodo benzyl-guanidine) confirmed a right thoracic inlet mass consistent with a neuroblastoma, a tumor of neural crest origin. The authors emphasize the need for investigating idiopathic acquired pediatric Horner syndrome and the value of an MIBG scan as a diagnostic test for suspected neuroblastoma.

Nationwide population-based incidence and etiologies of pediatric and adult Horner syndrome

PURPOSE

To determine age- and sex-specific incidence and possible etiologies of pediatric and adult Horner syndrome in South Korea.

METHODS

A nationwide, population-based, cohort study using data from the Korean National Health Claims database from 2007 to 2018. All patients with Horner syndrome from the entire Korean population (n = 51,629,512) were included. To find possible causes of Horner syndrome, we searched concurrent codes for systemic diseases, trauma, or surgical procedures.

RESULTS

A total of 139 pediatric patients (59.7% male) and 1331 adults (51.0% male) were newly diagnosed as having Horner syndrome. The cumulative incidence was 2.12 (95% CI 2.08-2.17) per 100,000 pediatric population and 2.95 (2.94-2.96) per 100,000 adults. The peak incidence occurred at 0-4 years of age in the pediatric population, and at 50-54 years in the adult population. A total of 835 (56.8%) patients had underlying conditions or related surgical procedures associated with Horner syndrome. The underlying causes were recognized in 695 (83.2%) patients before the diagnosis of Horner syndrome, in 75 (9.0%) patients at the same time as the Horner syndrome diagnosis, and in 65 (7.8%) patients after the diagnosis of Horner syndrome. There were four cases of Horner syndrome that preceded neuroblastoma diagnosis. The most common tumor related with Horner syndrome was that of the thyroid in the adult population.

CONCLUSIONS

This study determined the estimated incidence and possible causes of pediatric and adult Horner syndrome. As Horner syndrome with unknown etiologies may harbor serious malignancy, extensive evaluations are required, especially in children.

The risk of a serious etiology in pediatric Horner syndrome: indications for a workup and which investigations to perform

PURPOSE

To report the risk of a serious etiology in a cohort of children with Horner syndrome without a known cause at presentation.

METHODS

The medical records of children (<18 years of age) with Horner syndrome of unknown etiology at presentation who underwent a workup at a single tertiary-care pediatric hospital over a 20-year period were reviewed retrospectively.

RESULTS

A total of 48 patients with Horner syndrome were included. Median age at diagnosis was 12 months (range, 1 month to 17 years). A serious etiology was discovered in 7 (15%): neuroblastoma in 5, nasopharyngeal carcinoma in 1, and desmoid tumor in 1. Other causes were congenital/idiopathic (27 [56%]), acquired/idiopathic (10 [21%]), and likely birth trauma (4 [8%]). In 3 patients with a serious etiology, there were significant clinical manifestations of the pathology in addition to Horner syndrome. In the other 4 cases with a serious etiology (all neuroblastoma), the patients presented with Horner syndrome in isolation, and the tumor was discovered during a routine workup. All 5 neuroblastoma cases presented before 5 years of age; urine catecholamines were elevated in 4 of the 5. Imaging revealed mass lesions in the neck or upper chest in all 7 cases with a serious etiology.

CONCLUSIONS

In children presenting with Horner syndrome of unknown cause, there is a small but nontrivial risk of a serious underlying etiology. When a young child presents with Horner syndrome in isolation, urine catecholamine testing and imaging of the oculosympathetic pathway are recommended to rule out neuroblastoma.

Atypical Horner's syndrome: frequency, features and aetiology in a paediatric population

BACKGROUND/OBJECTIVES

Paediatric Horner's syndrome (HS) may present atypically with incomplete or intermittent clinical features, yet could represent sinister pathology including neuroblastoma. We aim to report the frequency and features with which atypical HS presents in our population (Northern Ireland) and to propose an investigation algorithm to aid diagnosis in these challenging cases.

SUBJECTS/METHODS

Retrospective chart review of all paediatric anisocoria and HS cases presenting to Belfast, Northern Ireland, between 2012 and 2018, identified through searching our paediatric ophthalmology database.

RESULTS

Sixty-one eligible cases of anisocoria or HS were analysed. Ten cases of HS were identified, four (40%) of which presented atypically with incomplete or intermittent features. Two of these four atypical cases were secondary to neuroblastoma. Overall incidence of paediatric HS in Northern Ireland during the study period was at least 2.54 per 100,000.

CONCLUSIONS

Paediatric HS may present atypically in a significant number of cases. Accordingly, clinicians should consider HS in children with a history of anisocoria or ptosis and have a low threshold for use of pharmacological tests to aid diagnosis.

Paediatric Horner's syndrome: is investigation for underlying malignancy always required?

OBJECTIVE

Horner's syndrome (HS) is characterised by a triad of ocular miosis, ptosis and anhidrosis. HS may be a subtle sign of occult pathology in otherwise asymptomatic children, neuroblastoma (NBL) being the the most common associated malignant tumour. Despite such knowledge, the incidence of underlying malignancy in children with HS remains unclear and robust evidence to guide best clinical practice is sparse. We performed a systematic review of the literature with the aim of identifying the incidence of NBL in children with HS of unknown aetiology, and establishing if screening for NBL should be routinely performed in this patient population.

METHODS

Systematic review of the literature (PubMed and Ovid/Medline database, 1961-2018).

RESULTS

The initial search identified 334 manuscripts, of which 8 studies were included in the final analysis. All reports were single-centre retrospective studies without control groups and included a total of 152 patients (age range 0-20 years). All studies investigated patients with HS but without previously established diagnosis. In the studies included, 17 out of a total of 152 patients were diagnosed with a space-occupying lesion. 12 out of the 152 patients were subsequently detected with NBL.

CONCLUSION

HS in children may be the first sign of occult malignancy. We report the first systematic review that comprehensively investigates the incidence of malignancy in this unique patient cohort. We show that HS of unknown aetiology in children warrants further investigation(s) to exclude an underlying space-occupying lesion. This should include cross-sectional imaging of the brain, neck and thorax, plus urinary catecholamines for prompt diagnosis and treatment.

Horner Syndrome from a Pediatric Otolaryngology Perspective

INTRODUCTION

Horner syndrome is described as the clinical triad of miosis, ptosis, and anhidrosis. In pediatric patients the condition may be congenital or acquired from neoplastic, infectious or traumatic conditions, including birth trauma. Most cases of pediatric Horner syndrome present first to a pediatric ophthalmologist however since the neural pathways involve the cervical sympathetic chain otolaryngologists should understand the pathophysiology to avoid delay in management of potentially malignant cases.

OBJECTIVES

To aid otolaryngologists in recognizing and managing pediatric Horner syndrome by describing 3 unique cases from malignant, traumatic and/or congenital causes.

METHODS

Case report of 3 pediatric patients with Horner syndrome presenting to our pediatric otolaryngology department.

RESULTS

Case #1 is 5-month-old female with ptosis and a left level II 1.5 cm neck mass. Magnetic resonance imaging showed the mass displacing the common carotid artery and excisional biopsy revealed a poorly differentiated neuroblastoma. Case #2 is a 9-year-old female with anisocoria appearing after suffering a severe playground injury. Case #3 is a 3-year-old-male who developed ptosis and anisocoria following re-excision of a recurrent cervical lymphatic malformation.

CONCLUSION

Pediatric Horner syndrome may be a benign finding that is easily overlooked but may reflect a serious underlying condition. Otolaryngologists should be aware of the pathophysiology and differential diagnosis, including malignant causes, to appropriately manage patients.

Don't Miss This! Red Flags in the Pediatric Eye Exam: Pupils

The pupillary exam in the pediatric population is a vital part of any clinician's workup. In the right clinical setting, pupillary abnormalities such as anisocoria, light-near dissociation, an afferent pupillary defect, and paradoxic pupillary constriction in the dark can be red flags that trigger further examination and workup. Through both careful physical examination and detailed history-taking and observation, potentially vision- and life-threatening conditions can be detected.

Neuro-ophthalmological presentation of giant intracavernous carotid artery aneurysm in a child

An otherwise healthy, 11-year-old boy presented with a long-standing history of right eye esotropia associated with a right head turn. Following a mild blunt facial trauma, he was brought to an ophthalmologist for binocular horizontal diplopia. Cranial CT scan revealed a large, enhancing lesion in the right cavernous sinus. Neuro-ophthalmological evaluation showed abduction deficit of the right eye, right corneal anaesthesia, right upper lid ptosis and a smaller right pupil suggesting involvement of the intracavernous segments of the right abducens nerve, ophthalmic nerve and oculosympathetic fibres. Cerebral angiography confirmed a large aneurysm involving the petrous, lacerum and cavernous segments of the right internal carotid artery. The child underwent successful clipping of the aneurysm by the neurosurgery service.

Horner Syndrome as a Rare Complication of Radiofrequency Tonsil Ablation

Horner syndrome is a rare but likely underdiagnosed complication of tonsillary surgery. The authors report the case of a 2.5-year-old boy who developed miosis and mild ptosis after radiofrequency tonsil ablation surgery. Pharmacologic testing with apraclonidine 0.5% eye drops confirmed left Horner syndrome. This case highlights the close anatomical relationship between the tonsils and cervical sympathetic trunk and draws attention to the occurrence of Horner syndrome after tonsillectomy. [J Pediatr Ophthalmol Strabismus. 2018;55:e14-e15.].

A Retrospective Study of Horner Syndrome in Australian Wild Birds, 2010-2016

Horner syndrome was identified in 25 of 30 777 avian admissions to Currumbin Wildlife Hospital during 2010-2016. Unilateral ptosis and erection of facial feathers were distinct findings on physical examination and consistent across 9 species. Affected birds were biased toward adults (64%) suffering traumatic injuries (88%). Concurrent injuries requiring treatment were present in 38% of cases, and 76% had additional neurologic deficits. Prognosis for release was poor, with an overall success rate of 32%. Resolution of clinical signs increased to 44% with higher doses of meloxicam and required an average hospitalization of 22 days (range, 3-78 days). Further investigation of the underlying causes of Horner syndrome in birds to provide treatment and prognostic guidelines is warranted.

Unilateral Straight Hair-A Symptom of Acquired Horner's Syndrome in a Neonate

A multicystic tumor of the right neck was detected in a girl at 29 weeks of gestation by fetal ultrasound and magnetic resonance imaging (MRI). The baby was delivered by cesarean section at week 37 of gestation. The newborn adapted well, with minimal compromise of breathing and drinking. Postnatal ultrasound and MRI revealed a cervical lymphangioma measuring 60.5 × 60.6 × 41.2 mm. We performed subtotal resection of the tumor when the girl was 34 days. As a complication of surgical resection, the girl developed ipsilateral Horner's syndrome. In the postoperative period, her curled hair turned straight at the side of the head affected by Horner's syndrome. At the age of 2.5 years, ultrasonic imaging revealed the presence of three cysts measuring 3 mm in diameter each. Horner's syndrome had improved, and the texture of the girl's hair had become curly again on both sides.

Horner Syndrome After Epidural Catheter Placement in a 4-Month-Old Child

Although there are reports of iatrogenic Horner syndrome in the adult population, pediatric cases are rare. The current report presents a case of acquired Horner syndrome that occurred after an epidural catheter was placed for pain control. Horner syndrome completely resolved after removing the catheter and no imaging or further work-up was necessary. [J Pediatr Ophthalmol Strabismus. 2018;55:e1-e3.].

Long-Term Follow-Up in Children with Anisocoria: Cocaine Test Results and Patient Outcome

Background

Evaluation of anisocoria including pharmacological testing for Horner's syndrome in the pediatric population is challenging in view of potential serious underlying disease. We describe cocaine test results, outcome of systemic investigation, and long-term follow-up in children with anisocoria.

Methods

Retrospective review of medical records and phone interview of consecutive pediatric patients (<18 years old) who underwent cocaine testing from August 2007 to July 2015 at a tertiary referral centre.

Results

A total of 35 patients were included with a positive, negative, or inconclusive cocaine test in 12/35, 19/35, and 4/35, respectively. Systemic investigation was performed in 11 of the patients with a positive and in 2 of the patients with an inconclusive cocaine test result. Mediastinal Hodgkin lymphoma was found in one patient with an inconclusive cocaine test result. Two other cases were presumably related to birth trauma and surgical trauma. None of the other children further developed any pathology during the follow-up period of 34.8 months (range 0–106.6).

Conclusions

In most children with anisocoria and a positive cocaine test result, systemic investigation did not reveal any underlying etiology. The only malignant disease was diagnosed in a patient with a suspicion of Horner's syndrome but with an inconclusive cocaine test result in our cohort.

Ptosis, miosis and cats

Horner's syndrome (HS) is caused by a disruption in the oculosympathetic pathway. Both congenital and acquired HS are unusual in children. Acquired HS can be caused by trauma, surgical intervention, tumours, vascular malformations or infection.We describe the case of a 6-year-old boy who was brought to our emergency department with ptosis, miosis, painful cervical lymphadenopathy and a cat scratch on a hand. The diagnosis of a cat scratch disease was confirmed by serology. A full recovery was observed on antibiotic treatment and cervical lymphadenomegaly reduction 3 weeks later.

Clinical manifestations of neuroblastoma with head and neck involvement in children

OBJECTIVE

The purpose of our study is to review our 15-year experience with pediatric patients who have been diagnosed with neuroblastoma, and to determine their most frequent head and neck manifestations and symptoms.

STUDY DESIGN

Retrospective chart review of electronic medical record.

SETTING

An academic, tertiary care pediatric hospital.

SUBJECTS AND METHODS

IRB approval from the Office of Research Integrity at Children's Mercy Hospital was obtained. The hospital tumor database was analyzed to identify patients with neuroblastoma, ganglioneuroblastoma, and esthesioneuroblastoma diagnosed between 1997 and 2012. We recorded the various clinical signs and symptoms these patients displayed at their initial presentation, focusing on patients with head and neck involvement. We then determined the relative incidence of these various findings.

RESULTS

Our review yielded 118 patients diagnosed with neuroblastoma, ganglioneuroblastoma, or esthesioneuroblastoma over our 15 year study period. 7 of the 118 patients were diagnosed with primary tumors of the head and neck. Another 19 patients had metastatic head and neck involvement. For those with primary disease, presence of a neck mass and signs of Horner's syndrome were the most common findings. For metastatic disease, craniofacial bony metastasis was the most frequent finding in our study.

CONCLUSIONS

Based on our data, there are a handful of findings that occur frequently in pediatric head and neck neuroblastoma. Any persistent neck mass, unexplained Horner's syndrome, or periorbital ecchymosis should be carefully evaluated. This study should serve as an aid for the otolaryngologist to be aware of the possible manifestations of this malignancy in children.

Didymin: an orally active citrus flavonoid for targeting neuroblastoma

Neuroblastoma, a rapidly growing yet treatment responsive cancer, is the third most common cancer of children and the most common solid tumor in infants. Unfortunately, neuroblastoma that has lost p53 function often has a highly treatment-resistant phenotype leading to tragic outcomes. In the context of neuroblastoma, the functions of p53 and MYCN (which is amplified in ~25% of neuroblastomas) are integrally linked because they are mutually transcriptionally regulated, and because they together regulate the catalytic activity of RNA polymerases. Didymin is a citrus-derived natural compound that kills p53 wild-type as well as drug-resistant p53-mutant neuroblastoma cells in culture. In addition, orally administered didymin causes regression of neuroblastoma xenografts in mouse models, without toxicity to non-malignant cells, neural tissues, or neural stem cells. RKIP is a Raf-inhibitory protein that regulates MYCN activation, is transcriptionally upregulated by didymin, and appears to play a key role in the anti-neuroblastoma actions of didymin. In this review, we discuss how didymin overcomes drug-resistance in p53-mutant neuroblastoma through RKIP-mediated inhibition of MYCN and its effects on GRK2, PKCs, Let-7 micro-RNA, and clathrin-dependent endocytosis by Raf-dependent and -independent mechanisms. In addition, we will discuss studies supporting potential clinical impact and translation of didymin as a low cost, safe, and effective oral agent that could change the current treatment paradigm for refractory neuroblastoma.

RLIP76 Inhibition: A Promising Developmental Therapy for Neuroblastoma

Refractory and relapsed neuroblastoma (NB) present with significant challenges in clinical management. Though primary NBs largely with wild-type p53 respond well to interventions, dysfunctional signaling in the p53 pathways in a MYCN oncogene driven background is found in a number of children with NB. The p53-mutant NB is largely unresponsive to available therapies and p53-independent targeted therapeutics represents a vital need in pediatric oncology. We analyzed the findings on mercapturic acid pathway (MAP) transporter RLIP76, which has broad and critical effects on multiple pathways as essential for carcinogenesis, oxidative stress and drug-resistance, is over-expressed in NB. RLIP76 inhibition by antibodies or depletion by antisense causes apoptosis and sensitization to chemo-radiotherapy in many cancers. In addition, recent studies indicate that the interactions between p53, MYCN, and WNT regulate apoptosis resistance and protein ubiquitination. RLIP76 and p53 interact with each other and colocalize in NB cells. Targeted depletion/inhibition of RLIP76 causes apoptosis and tumor regression in NB irrespective of p53 status. In the present review, we discuss the mechanisms and the role of RLIP76 in oxidative stress, drug-resistance and clathrin-dependent endocytosis (CDE), and analyze the molecular basis for the role of RLIP76 targeted approaches in the context principal drivers of NB pathogenesis, progression and drug-resistance. The evidence from RLIP76 studies in other cancers, when taken in the context of our recent RLIP76 focused mechanistic studies in NB, provides strong basis for further characterization and development of RLIP76 targeted therapies for NB.

The Degree of Anisocoria in Pediatric Patients With Horner Syndrome When Compared to Children Without Disease

PURPOSE

To study the magnitude of anisocoria in pediatric patients using the plusoptiX A08 (plusoptiX GmbH, Nuremberg, Germany) photoscreener as compared to a literature review of pediatric patients with known Horner syndrome to determine if anisocoria alone should raise suspicion for the diagnosis.

METHODS

The medical records of 592 consecutive patients, neonates to 9 years old, were collected and analyzed. All patients had complete ophthalmic examinations that included photoscreening with the plusoptiX A08. Data included age, pupil sizes, and anisocoria. A complete literature search of documented pupillary size in pediatric patients with the diagnosis of Horner syndrome was performed. This was then compared to the normative pediatric pupil data from the study.

RESULTS

Of the 592 children without Horner syndrome, 372 had an anisocoria of 0.1 to 0.5 mm (62.84%), 167 had an anisocoria of 0.6 to 1.2 mm (28.16%), and 21 had an anisocoria of 1.3 mm or greater (3.70%). There was no correlation between increasing age and severity of anisocoria (P = .55). For pediatric patients with a diagnosis of Horner syndrome, the average level of anisocoria was 1.37 mm in room light and 2 mm in darkness. In room light, three children had anisocoria of 0.1 to 0.5 mm (9.4%), 14 had anisocoria of 0.6 to 1.2 mm (43.8%), and 15 had anisocoria of 1.3 mm or greater (46.9%). In darkness, the level of anisocoria increased in 19 patients, causing the first category, 0.1 to 0.5 mm, to include 1 patient (3.1%), the second group to include 5 patients (15.6%), and the last group to include 26 patients (81.3%). Other associated signs/symptoms included ptosis (100%), heterochromia (28.1%), anhidrosis (9.4%), straight hair on affected/curly on unaffected side (9.4%), and neck mass (6.3%). In 37.5% of cases, imaging results were negative and no specific etiology was determined.

CONCLUSIONS

In a study of 592 children without Horner syndrome, the average pupillary size increased with age, but the degree of anisocoria remained stable with increasing age. Over half of the children studied had anisocoria up to 0.5 mm (62.84%), but rarely had anisocoria greater than 1.3 mm (3.70%). In children with a diagnosis of Horner syndrome, the majority had anisocoria greater than 1.3 mm, with the discrepancy in pupil size becoming more apparent in low levels of light intensity. Anisocoria greater than 1.3 mm is unlikely to be physiologic in a child; therefore, he or she should be carefully evaluated for other localizing signs, such as ptosis, anhidrosis, and neck mass. [J Pediatr Ophthalmol Strabismus. 2016;53(3):186-189.].

Neuroimaging experience in pediatric Horner syndrome

BACKGROUND

Horner syndrome in children is rare. The frequency and spectrum of malignancy as the cause of Horner syndrome in children remains unclear. Also unclear is whether the imaging work-up should include the entire oculo-sympathetic pathway or should be more targeted. In addition, the value of cross-sectional angiographic imaging in Horner syndrome is uncertain.

OBJECTIVE

To review imaging pathology in a cohort of children with Horner syndrome at a major academic pediatric medical center.

MATERIALS AND METHODS

We reviewed a 22-year period of CT and MR imaging studies in children with a clinical diagnosis of Horner syndrome referred for imaging.

RESULTS

We found 38 patients who fulfilled study criteria of Horner syndrome and 6/38 had relevant imaging findings: 2/6 etiologies were neoplastic (congenital neuroblastoma and central astrocytoma), 1/6 had a vascular abnormality (hypoplastic carotid artery), 1/6 had maldevelopment (Chiari I malformation), and 2/6 had inflammatory/traumatic etiology (viral cervical lymphadenopathy, post jugular vein cannulation). There was a similar number of congenital and acquired pathologies. The malignancies were found at any level of the oculosympathetic pathway.

CONCLUSION

There are treatable causes, including malignancies, in children presenting with Horner syndrome, which justify imaging work-up of the entire oculosympathetic pathway, unless the lesion level can be determined clinically.

Horner syndrome: clinical perspectives

Horner syndrome consists of unilateral ptosis, an ipsilateral miotic but normally reactive pupil, and in some cases, ipsilateral facial anhidrosis, all resulting from damage to the ipsilateral oculosympathetic pathway. Herein, we review the clinical signs and symptoms that can aid in the diagnosis and localization of a Horner syndrome as well as the causes of the condition. We emphasize that pharmacologic testing can confirm its presence and direct further testing and management.

Cervical lymphadenopathy secondary to rhabdomyosarcoma presenting as Horner syndrome in an infant

A 4-week-old boy with left ptosis, anisocoria, and a mass on his left hand was diagnosed with Horner syndrome. The diagnosis precipitated a work-up for a possible malignant etiology. Magnetic resonance imaging demonstrated enlarged left cervical and axillary lymph nodes. A biopsy of the hand lesion confirmed embryonal rhabdomyosarcoma, but a biopsy of the axillary lymph node was negative. Mechanical pressure by noncancerous enlarged lymph nodes is hypothesized to cause the Horner syndrome.

Isolated Horner syndrome and syringomyelia in a child

Horner syndrome can be caused by a variety of etiologies that interrupt the sympathetic innervation of the eye, including but not limited to central mass lesions. Recently, it has been debated whether neuroimaging has a place in the diagnostic algorithm of isolated pediatric Horner syndrome given the low incidence of neuroblastoma. We present a case of a 19-month-old girl with an isolated Horner syndrome, likely caused by a lower cervical syrinx, that was diagnosed by magnetic resonance imaging.

Ophthalmology manifestations of pediatric cancer treatment

PURPOSE OF REVIEW

Advances in pediatric oncology care have increased survival rates for children with malignancy. As a result, ophthalmologists are seeing more short-term and long-term complications associated with the treatment of these conditions. Ophthalmologists need to be aware of cancer treatment-related eye disorders.

RECENT FINDINGS

Multiple eye findings are associated with cancer treatment, including chemotherapy, radiation, bone marrow transplantation, and newer modalities such as intra-arterial chemotherapy. Malignancy and treatment cause immunodeficiency that can lead to infectious disease manifestations, including eye involvement. Our understanding of the prevalence of eye involvement in infectious diseases is changing due to newer antimicrobial treatment modalities and earlier screening. Paraneoplastic conditions may manifest with eye findings either before the diagnosis of the primary malignancy or as a late finding. The evolution of IVF has raised concerns of increased cancer risks, including ocular tumors.

SUMMARY

Ophthalmologists who are involved with the care of children undergoing cancer treatment need to be aware of the many eye manifestations that may result.

Didymin induces apoptosis by inhibiting N-Myc and upregulating RKIP in neuroblastoma

Neuroblastomas arise from the neural crest cells and represent the most common solid tumors outside the nervous system in children. The amplification of N-Myc plays a primary role in the pathogenesis of neuroblastomas, whereas acquired mutations of p53 lead to refractory and relapsed cases of neuroblastomas. In this regard, dietary compounds which can target N-Myc and exert anticancer effects independent of p53 status acquire significance in the management of neuroblastomas. Hence, we investigated the anticancer properties of the flavonoid didymin in neuroblastomas. Didymin effectively inhibited proliferation and induced apoptosis irrespective of p53 status in neuroblastomas. Didymin downregulated phosphoinositide 3-kinase, pAkt, Akt, vimentin, and upregulated RKIP levels. Didymin induced G(2)/M arrest along with decreasing the levels of cyclin D1, CDK4, and cyclin B1. Importantly, didymin inhibited N-Myc as confirmed at protein, mRNA, and transcriptional level by promoter-reporter assays. High-performance liquid chromatography analysis of didymin-treated (2 mg/kg b.w.) mice serum revealed effective oral absorption with free didymin concentration of 2.1 μmol/L. Further in vivo mice xenograft studies revealed that didymin-treated (2 mg/kg b.w.) animals had significant reductions in tumors size compared with controls. Didymin strongly inhibited the proliferation (Ki67) and angiogenesis (CD31) markers, as well as N-Myc expression, as revealed by the histopathologic examination of paraffin-embedded section of resected tumors. Collectively, our in vitro and in vivo studies elucidated the anticancer properties and mechanisms of action of a novel, orally active, and palatable flavonoid didymin, which makes it a potential new approach for neuroblastoma therapy (NANT) to target pediatric neuroblastomas.