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Asakura M, Ogasawara M, Igarashi M, Takeshima K, Fukao E, Ikuta Y. Pediatric Tolosa-Hunt Syndrome with Ptosis and Transient Periorbital Headache. Neuropediatrics 2024; 55:270-271. [PMID: 38547906 DOI: 10.1055/s-0044-1782681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2024]
Affiliation(s)
- Mari Asakura
- Department of Pediatrics, Showa General Hospital, Tokyo, Japan
| | | | - Mizuho Igarashi
- Department of Pediatrics, Showa General Hospital, Tokyo, Japan
| | - Keigo Takeshima
- Department of Ophthalmology, Showa General Hospital, Tokyo, Japan
| | - Eri Fukao
- Department of Neurology, Showa General Hospital, Tokyo, Japan
| | - Yoji Ikuta
- Department of Pediatrics, Showa General Hospital, Tokyo, Japan
- Higashi-Koganei Child Neurology and Epilepsy Clinic, Tokyo, Japan
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2
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Kim HJ, Lee SU, Lee ES, Choi JY, Kim JS. Recurrence and long-term outcomes of Tolosa-Hunt syndrome. J Neurol 2024; 271:935-943. [PMID: 37853245 DOI: 10.1007/s00415-023-12044-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND AND PURPOSE Tolosa-Hunt Syndrome (THS) is a rare disorder, and detailed clinical information and treatment outcomes have yet to be fully elucidated. This study aims to investigate the clinical features and factors associated with the treatment outcomes of THS, as defined by the established diagnostic criteria. METHODS This study retrospectively recruited 91 patients with a diagnosis of THS from 2003 to 2020. We analyzed the clinical features and outcomes, the initial treatment response, recurrences, and the final treatment response. RESULTS Isolated ocular motor nerve palsy was the most common (82.4%) finding of ophthalmoplegia, involving the oculomotor nerve in more than half of the cases (52.0%). The MRI lesions were mostly observed in the cavernous sinus (94.5%) with an extracavernous extension in about one-third of them. Five patients showed only extracavernous lesions. A total of 25 (27.5%) patients experienced recurrence. Recurrence occurred during steroid tapering as part of the initial treatment in seven, while in 18 patients, it happened after the successful termination of the initial treatment. However, all patients achieved complete remission at the final. Age was associated with a decrease in initial symptom duration (HR = 1.023, CI = 1.004-1.044) as well as an increase in recurrence-free duration (HR = 0.944, CI = 0.911-0.978). High-dose corticosteroid treatment was associated with a decrease in initial symptom duration (HR = 1.642, CI = 1.001-2.695) and total treatment duration (HR = 2.203 CI = 1.302-3.730). CONCLUSIONS THS can recur frequently especially in younger but have a favorable prognosis. High-dose corticosteroids can be an effective initial treatment and reduce the total treatment duration.
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Affiliation(s)
- Hyun-Jae Kim
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Sun-Uk Lee
- Neurotology Laboratory, Korea University Anam Hospital, Seoul, Republic of Korea
- Department of Neurology, Korea University Medical Center, Seoul, Republic of Korea
| | - Eek-Sung Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Jeong-Yoon Choi
- Dizziness Center, Clinical Neuroscience Center and Department of Neurology, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.
- Department of Neurology, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Ji-Soo Kim
- Dizziness Center, Clinical Neuroscience Center and Department of Neurology, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, Republic of Korea
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Kmeid M, Medrea I. Review of Tolosa-Hunt Syndrome, Recent Updates. Curr Pain Headache Rep 2023; 27:843-849. [PMID: 38032539 DOI: 10.1007/s11916-023-01193-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE OF REVIEW We aim to present diagnostic considerations and management insights on Tolosa-Hunt syndrome. We highlight recent controversies in this field and emerging literature. RECENT FINDINGS The diagnostic categorization of Tolosa-Hunt syndrome remains controversial, with imaging negative cases described in the literature and an increasing literature of secondary causes falsely diagnosed as Tolosa-Hunt syndrome. Response to steroids can fulfill diagnostic criteria, but newer management strategies are available in treatment-resistant patients, such as steroid-sparing agents or radiotherapy. Tolosa-Hunt syndrome has become controversial; the entity of granulomatous inflammation of the cavernous sinus and possible extension into orbital fissure and posterior orbit of late has been re-evaluated. Recent case series and reviews have outlined multiple false positive (neoplasm or infection) and negative (no imaging findings) diagnoses. In the future, when assessing whether a patient has this entity, we caution readers to closely follow patients for secondary causes and consider this entity in differential even if MRI is non-revealing. Additionally, biopsy should be regarded as a gold standard for diagnosis and utilized, especially in uncertain cases. The diagnostic categorization of Tolosa-Hunt syndrome may need reconsideration in future versions of the ICHD.
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Affiliation(s)
- Michael Kmeid
- Division of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Ioana Medrea
- Division of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA.
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Kasarabada H, Singh D, Iyenger S, Praveena K. Tolosa Hunt syndrome: A rare cause of headache. Med J Armed Forces India 2023. [DOI: 10.1016/j.mjafi.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Bowman S, Helming A. Complete ophthalmoplegia diagnosed as Tolosa-Hunt syndrome on interval MRI. BMJ Case Rep 2022; 15:e252727. [PMID: 36328364 PMCID: PMC9639049 DOI: 10.1136/bcr-2022-252727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Tolosa-Hunt syndrome is a rare cause of painful ophthalmoplegia, most commonly presenting with retro-orbital pain and eye motor nerve palsy, most often affecting a single eye. The condition is characterised by an idiopathic process causing granulomatous inflammation to the cavernous sinus affecting, one or multiple cranial nerves that pass therein. The mechanism underlying the inflammation is not well understood, but patients have been observed to respond to steroids during a flare. We present this as a unique case where a multidisciplinary team diagnosed Tolosa-Hunt syndrome despite non-specific MRI findings in the cavernous sinus 1 day following an initially normal MRI.
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Affiliation(s)
- Shane Bowman
- School of Medicine, Western University of Health Sciences College of Osteopathic Medicine of the Pacific-Northwest, Lebanon, Oregon, USA
| | - Andrew Helming
- Department of Radiology, Oregon Health and Science University, Portland, Oregon, USA
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6
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Alhakeem A, Elziny MM, Elmahdi M. A Case Report on a Unique Explanation for Headache With Ophthalmoplegia: The Tolosa-Hunt Syndrome. Cureus 2022; 14:e26093. [PMID: 35875300 PMCID: PMC9296152 DOI: 10.7759/cureus.26093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2022] [Indexed: 11/05/2022] Open
Abstract
Tolosa-Hunt syndrome (THS) is an extremely rare disorder characterized by painful unilateral ophthalmoplegia triggered by idiopathic inflammation of the cavernous sinus affecting the third, fourth, and/or sixth cranial nerve. Corticosteroid therapy effectively improves THS symptoms; thus, early clinical suspicion and diagnosis are essential. We report the case of a 37-year-old patient who presented with left-sided eye pain and double vision for four days. Physical examination was significant for oculomotor, trochlear and abducent nerves palsies on the left eye with slow light reflex. Contrast-enhanced magnetic resonance imaging of the head displayed mild asymmetry of the cavernous sinus regions with fullness on the left side and focal lateral thickening, confirming the THS diagnosis. The patient’s symptoms improved dramatically upon starting oral corticosteroid therapy.
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7
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Etheridge T, Jones J, Caskey EL, Digre KB, Warner JEA, Seay MD. Tolosa-Hunt syndrome after COVID-19 infection. CEPHALALGIA REPORTS 2022. [DOI: 10.1177/25158163221078977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Tolosa-Hunt syndrome (THS) is a rare, idiopathic, non-specific inflammation within the cavernous sinus and/or superior orbital fissure leading to painful ophthalmoplegia. The authors describe the first case of a 12-year-old otherwise healthy girl who presented with painful ophthalmoplegia after a documented COVID-19 infection. Neuroimaging revealed inflammation within the ipsilateral cavernous sinus, Meckel’s cave, and orbital apex. After a comprehensive work-up was negative, the patient experienced prompt clinical and radiographic improvement with high-dose corticosteroids, and a diagnosis of THS was made.
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Affiliation(s)
- Tyler Etheridge
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Jordan Jones
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Eric L Caskey
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Kathleen B Digre
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Judith EA Warner
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Meagan D Seay
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
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Oghene J, Boppana SH, Reddy P, Beutler BD, Dalal D. Double Down on Double Vision: An Unusual Case of Painful Diplopia. Cureus 2021; 13:e20838. [PMID: 35111483 PMCID: PMC8794403 DOI: 10.7759/cureus.20838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2021] [Indexed: 11/06/2022] Open
Abstract
Tolosa-Hunt syndrome (THS) is a rare neuro-immunological disorder characterized by severe periorbital headaches and ophthalmoplegia. In some patients, THS may occur in parallel with other autoimmune disorders. The underlying etiology of THS remains to be definitively established. However, inflammation of the cavernous sinus or orbital apex represents a hallmark feature; magnetic resonance imaging, therefore, plays a key role in establishing a diagnosis. We describe a patient who presented with concomitant THS and granulomatosis with polyangiitis. In addition, we describe the clinical and imaging findings of THS and review treatment options for this rare condition.
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Affiliation(s)
- John Oghene
- Department of Internal Medicine and Primary Care, Brown University, Warren Alpert Medical School, Providence, USA
| | - Sri Harsha Boppana
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, USA
| | - Pooja Reddy
- Department of Rheumatology, Brown University, Warren Alpert Medical School, Providence, USA
| | - Bryce D Beutler
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, USA
| | - Deepan Dalal
- Department of Rheumatology, Brown University, Warren Alpert Medical School, Providence, USA
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Ata F, Yousaf Z, Arachchige SNM, Rose S, Alshurafa A, Muthanna B, Bilal ABI, El Beltagi A, Zahid M. The demographics of Tolosa-Hunt syndrome in Qatar. eNeurologicalSci 2021; 24:100359. [DOI: https:/doi.org/10.1016/j.ensci.2021.100359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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10
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Dutta P, Anand K. Tolosa-Hunt Syndrome: A Review of Diagnostic Criteria and Unresolved Issues. J Curr Ophthalmol 2021; 33:104-111. [PMID: 34409218 PMCID: PMC8365592 DOI: 10.4103/joco.joco_134_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 11/04/2022] Open
Abstract
Purpose: To review the diagnostic criteria for Tolosa–Hunt syndrome (THS) and utility of recent modifications. Methods: We searched PubMed for keywords Tolosa Hunt and magnetic resonance imaging. We compared the three editions of International Classification of Headache Disorders and isolated case reports and case series with the assessment of cavernous internal carotid artery (ICA) caliber to find the prevalence of vascular anomalies. We also evaluated cases of THS with the involvement of extracavernous structures and the possible role of idiopathic hypertrophic pachymeningitis (HP). Cases diagnosed falsely as THS were also reviewed for the presence of atypical features and relevance of criterion D. We assessed nonconforming cases (those with normal neuroimaging benign THS) and idiopathic inflammatory orbital pseudotumor (IIPO). Results: Vascular abnormalities were found in 36.36% of THS cases. Benign THS may also show changes in ICA caliber. Evidence suggestive of idiopathic HP could be found in 57% of cases with the involvement of extracavernous structures, such as facial nerve and pituitary gland. Both THS and IIPO are steroid-responsive pathologies with similar clinical and radiological features. False-positive diagnosis of THS results from early labeling, based solely on clinical features and symptom resolution after steroid therapy. Conclusions: Benign THS may be a result of limitation of resolution of available neuroimaging technique or early testing. Early and late vascular changes can be seen in both THS and its benign variant; some of them are not innocuous. THS may be considered a type of focal idiopathic HP. IIPO may represent an anterior variant of THS. In the absence of histopathological diagnosis, steroid-induced resolution of symptoms should be confirmed radiologically and followed-up.
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Affiliation(s)
- Paromita Dutta
- Guru Nanak Eye Centre, Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India
| | - Kamlesh Anand
- Guru Nanak Eye Centre, Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India
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Thu PW, Chen YM, Liu WM. Recurrent Tolosa-Hunt syndrome. Tzu Chi Med J 2021; 33:314-316. [PMID: 34386372 PMCID: PMC8323652 DOI: 10.4103/tcmj.tcmj_137_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/29/2020] [Accepted: 07/15/2020] [Indexed: 11/06/2022] Open
Abstract
The Tolosa–Hunt syndrome (THS) is caused by granulomatous inflammation in the cavernous sinus, superior orbital fissure, or orbit characterized by painful ophthalmoplegia. Here, we report a case of recurrent THS in a 48-year-old female, who initially showed a poor response to low-dose steroids. Each episode involved different cranial nerves and painful ophthalmoplegia. Neuroimaging showed enhancement in the right cavernous sinus. The patient was treated with glucocorticoid pulse therapy and azathioprine. THS was previously considered to be responsive to glucocorticoids. This report demonstrates a case of THS with poor response to steroids and unique presentation of frequent recurrence with different cranial nerve involvement.
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Affiliation(s)
- Phyo-Wai Thu
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Yu-Ming Chen
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Weng-Ming Liu
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,Doctoral Degree Program in Translational Medicine, Tzu Chi University and Academia Sinica, Hualien, Taiwan
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12
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Ata F, Yousaf Z, Arachchige SNM, Rose S, Alshurafa A, Muthanna B, Bilal ABI, El Beltagi A, Zahid M. The demographics of Tolosa-Hunt syndrome in Qatar. eNeurologicalSci 2021; 24:100359. [PMID: 34355072 PMCID: PMC8325092 DOI: 10.1016/j.ensci.2021.100359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/19/2021] [Indexed: 11/20/2022] Open
Abstract
Background Tolosa Hunt syndrome (THS) is a rare disease that manifests mainly as painful unilateral ophthalmoplegia. It is caused by an inflammatory process of unknown aetiology within the cavernous sinus with a rare intracranial extension. The International Classification of Headache Disorders (ICHD)- 3 diagnostic criteria aids in its diagnosis. There is limited literature on its varied presentations, diagnosis, and management. Steroids are used in the treatment of THS with varied success. Methods We conducted a single-center-retrospective-study and included all patients admitted with a diagnosis of THS from January 2015 to December 2020. Descriptive and summary statistics were used to describe the study cohort's socio-demographic parameters. Results Among 31 THS patients (predominantly Asians (18) and Arabs (9)), visual disturbance was commonest presenting complaint. Third-nerve paralysis was seen in 70.9% cases. Magnetic-resonance-imaging (MRI) was abnormal in 64.5%. 93.5% patients received steroids, with a response-rate of 70.9% and a recurrence-rate of 9.7%. A previous history of THS and female gender were associated with recurrence (p-value 0.009 and 0.018). Recurrence was seen in 66.7% fully recovered and 33.3% partially recovered cases (p-value 0.04). Among the benign and inflammatory subtypes of THS, the ICHD-3 criteria were applicable in 85% of inflammatory THS. Conclusions THS is a rare disease with ethnic variation in presentation and response to treatment. In our cohort female gender and a previous history of THS were associated with recurrence. ICHD-3 diagnostic criteria had a higher validity in our patients compared to prior studies, especially among the inflammatory THS. We represent the largest cohort of THS patients from the Middle eastern population. In our cohort, medium dose steroids (60 mg daily) had a good recovery rate (71%). Female gender and a prior history of THS were associated with recurrence. Recurrence rate was low in our cohort compared to international trends (9.7%).
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Affiliation(s)
- Fateen Ata
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Zohaib Yousaf
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Saman Rose
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Awni Alshurafa
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Bassam Muthanna
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ammara Bint I Bilal
- Department of Radiology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed El Beltagi
- Department of Neuroscience and Neuroradiology, Hamad Medical Corporation, Doha, Qatar.,Weill-Cornel Medicine, Qatar
| | - Muhammad Zahid
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Weill-Cornel Medicine, Qatar
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Corredor MM, Holmberg PJ. Ophthalmoplegia and cranial nerve deficits in an adolescent with headache. SAGE Open Med Case Rep 2021; 9:2050313X211024487. [PMID: 34178348 PMCID: PMC8202257 DOI: 10.1177/2050313x211024487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/24/2021] [Indexed: 11/25/2022] Open
Abstract
Tolosa–Hunt syndrome is an idiopathic, inflammatory condition involving the cavernous sinus and is characterized by unilateral, painful ophthalmoparesis. The condition often begins with retro-orbital pain followed by select cranial nerve involvement. We report the case of a 17-year-old female whose presentation with progressive left-sided headache and ophthalmoparesis culminated in the diagnosis of Tolosa–Hunt syndrome. While many of her signs and symptoms have been previously reported in the rare pediatric cases of Tolosa–Hunt syndrome described in the literature, this case illustrates a unique presentation involving cranial nerves V and VII in addition to the more commonly reported cranial nerve III, IV, and VI palsies.
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Affiliation(s)
- Margarita M Corredor
- Division of Pediatric Hospital Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Peter J Holmberg
- Division of Pediatric Hospital Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
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Abstract
This article provides an overview of rare orbital diseases. Congenital
malformations, inflammatory diseases, benign and malignant neoplasias are
described. Although it represents a relatively small area of the body the
orbit contains multiple different tissues. Therefore, a great variety of
diseases can be found within the orbital space. That is the reason, why both
the completeness and the level of detail in the description of particular
diseases must be somewhat limited. Nevertheless, clinical manifestations,
important aspects of diagnosis, treatment strategies, and, when specific
data are available, the prognosis are described. The authors tried to
highlight the most characteristic aspects of the different diseases to
describe their relevant aspects in spite of the brevity of the
subsections.
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Affiliation(s)
- Ulrich Kisser
- Universitätsklinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Halle/S. (Klinikdirektor: Prof. Dr. med. S. Plontke)
| | - Jens Heichel
- Universitätsklinik und Poliklinik für Augenheilkunde, Halle/S. (Klinikdirektor: Prof. Dr. med. A. Viestenz)
| | - Alexander Glien
- Universitätsklinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Halle/S. (Klinikdirektor: Prof. Dr. med. S. Plontke)
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Rafique Ali AA, Iqbal T, Yeak J, Ramli N. Tolosa-Hunt Syndrome with underlying latent tuberculosis: a diagnostic dilemma. Int J Ophthalmol 2021; 14:633-635. [PMID: 33875960 DOI: 10.18240/ijo.2021.04.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/19/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- Abdullah Ashraf Rafique Ali
- University Malaya Eye Research Centre, Department of Ophthalmology, University of Malaya, Kuala Lumpur 50603, Malaysia.,Department of Ophthalmology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.,Ophthalmology Department, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor 47000, Malaysia
| | - Tajunisah Iqbal
- University Malaya Eye Research Centre, Department of Ophthalmology, University of Malaya, Kuala Lumpur 50603, Malaysia.,Department of Ophthalmology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Justin Yeak
- University Malaya Eye Research Centre, Department of Ophthalmology, University of Malaya, Kuala Lumpur 50603, Malaysia.,Department of Ophthalmology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Norlina Ramli
- University Malaya Eye Research Centre, Department of Ophthalmology, University of Malaya, Kuala Lumpur 50603, Malaysia.,Department of Ophthalmology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
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Gama BP, Silva-Néto RP. Tolosa-Hunt Syndrome in Childhood and Adolescence: A Literature Review in the Last 10 Years. Neuropediatrics 2021; 52:1-5. [PMID: 32892335 DOI: 10.1055/s-0040-1715632] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The aim of the study is to review the articles published in the last 10 years on Tolosa-Hunt syndrome (THS) in childhood and adolescence to learn about its clinical and epidemiological characteristics and its therapeutic management. METHODS Based on the literature search in the major medical databases and using the descriptors "Tolosa-Hunt syndrome and children" and "Tolosa-Hunt syndrome and adolescent" we included articles published between 2009 and 2019. We found 51 articles, but only 11 met the inclusion criteria. RESULTS There were eight women and four men with THS, whose average age was 12.0 ± 4.3 years, ranging from 4 to 17 years. Magnetic resonance imaging showed inflammation in the cavernous sinus (100%), orbit (25%), and superior orbital fissure (8.3%), unilateral in all patients. The internal carotid artery (58.3%), third (66.7%), sixth (33.3%), and fourth (25%) cranial nerves were injured. Headache was located in the orbital region, ipsilaterally to nerve involvement and had mild to severe intensity. Corticosteroid was the treatment used in 91.7% of the patients. They were followed for an average of 13.4 ± 12.4 months. Only two patients had recurrence of the disease. CONCLUSION THS is infrequent in childhood and adolescence and knowledge of its clinical and epidemiological characteristics and its therapeutic management is necessary for pediatricians.
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Affiliation(s)
- Bárbara Pinheiro Gama
- Department of Neurology, Federal University of Delta of Parnaíba, Fátima, Parnaíba, Brazil
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Piamonte BLC, Ong KL, Cenina AR. Tolosa-Hunt syndrome relapse during pregnancy following chronic intake of combined oral contraceptives. BMJ Case Rep 2021; 14:14/1/e238944. [PMID: 33462037 PMCID: PMC7816897 DOI: 10.1136/bcr-2020-238944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Tolosa-Hunt syndrome (THS) is a rare syndrome of painful ophthalmoplegia secondary to an idiopathic granulomatous inflammation affecting the cavernous sinus, superior orbital fissure or orbit. Pregnancy and pregnancy-related hormones have been identified as potential triggers. A 39-year-old gravida-2 para-1 woman with prior chronic intake of combined oral contraceptives (COC) suffered two episodes of painful ophthalmoplegia-the first event with spontaneous remission and the relapse occurring during pregnancy and with complete resolution following steroid treatment. MRI revealed a postinflammatory mass at the junction of the left orbital apex and anterior cavernous sinus, supporting the diagnosis of THS. To our knowledge, this is the first report of a THS relapse occurring during pregnancy following a chronic history of COC intake. This case adds to the growing evidence supporting the relationship between immune and hormonal factors that may be present during pregnancy and the disease pathogenesis of THS.
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Affiliation(s)
- Bernadeth Lyn Cal Piamonte
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Metro Manila, Philippines
| | - Keno Lorenzo Ong
- Department of Obstetrics and Gynecology, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Metro Manila, Philippines
| | - Alvin Rae Cenina
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Metro Manila, Philippines
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Mikhail M, Basilious A, Jabehdar Maralani P, Sundaram AN. Tolosa-Hunt syndrome: case series on the timed use of diagnostic magnetic resonance imaging. Can J Ophthalmol 2020; 55:e135-e139. [DOI: 10.1016/j.jcjo.2020.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 12/26/2019] [Accepted: 01/12/2020] [Indexed: 11/30/2022]
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Douedi S, Awad M, Shenouda D, Mack P, Carson MP. Tolosa-Hunt Syndrome: A Non-Classical Presentation of a Rare Cause of Unilateral Headache and Painful Ophthalmoplegia. J Clin Med Res 2020; 12:266-268. [PMID: 32362975 PMCID: PMC7188369 DOI: 10.14740/jocmr4123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/11/2020] [Indexed: 11/11/2022] Open
Abstract
Tolosa-Hunt syndrome is a rare condition involving the orbital and retro-orbital space. The typical symptoms are orbital pain, swelling, headache, palsies of the cranial nerves, and sensory loss in the distribution of the trigeminal nerve. Tolosa-Hunt syndrome relapses and remits with episodes separated by months to years. It is a diagnosis of exclusion after ruling out other causes of painful ophthalmoplegia and is treated with high-dose steroids. We present a case of a 43-year-old woman with a history of recurrent headaches and vision disturbances for the past 4 years presenting with worsening left-eye pain that radiated to the back of her head, swelling around the left eye, double vision, and a unilateral left-sided headache. Visual acuity was decreased in the left eye compared to the right and the patient reported left-eye pain when at extreme medial and lateral gaze. Erythrocyte sedimentation rate (ESR) was found to be elevated with all other laboratory testing within normal limits. Computed tomography (CT) scan of the orbits was unremarkable. Ophthalmology excluded other differential diagnoses and she was treated with intravenous methylprednisolone with significant improvement of symptoms. The triad of one or more episodes of unilateral orbital pain, paresis of one or more of the cranial nerves, and granulomas by magnetic resonance imaging (MRI) or biopsy is 95-100% sensitive at diagnosing the syndrome; however, our patient did not present with the "classic" triad. Initial treatment of Tolosa-Hunt is with high-dose steroids which as in our case lead to rapid and significant improvement of symptoms.
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Affiliation(s)
- Steven Douedi
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Mark Awad
- St. George University School of Medicine, St George, Grenada
| | - Daniel Shenouda
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Prinze Mack
- Department of Ophthalmology, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Michael P Carson
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
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Msigwa SS, Li Y, Cheng X. Tolosa Hunt Syndrome: Current Diagnostic Challenges and Treatment. ACTA ACUST UNITED AC 2020. [DOI: 10.4236/ym.2020.42014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Dholoo F, Shabana A, Paschali M, Mandal AKJ, Missouris CG. Gone in the blink of an eye - A Tolosa-Hunt syndrome variant. J Clin Neurosci 2019; 72:458-460. [PMID: 31879056 DOI: 10.1016/j.jocn.2019.12.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/16/2019] [Indexed: 11/17/2022]
Abstract
Tolosa-Hunt syndrome is a rare disorder characterized by severe peri-orbital headache and ophthalmoplegia resulting from pseudotumour in the cavernous sinus compressing structures within it, namely cranial nerves III, IV, and VI and the superior divisions of cranial nerve V. We report the case of a 47 year old female who presented with painless left unilateral ptosis and complete external ophthalmoplegia. Magnetic Resonance Imaging (MRI) identified an enhancing heterogeneous mass filling the left cavernous sinus, following the course of the oculomotor nerve. After 2 weeks symptoms and signs resolved and there was a parallel resolution of the MRI findings, without the administration of corticosteroids. As far as we are aware this is one of the first reports of Tolosa-Hunt syndrome variant, with painless neurological involvement confined solely to the oculomotor nerve, and with complete resolution without pharmacological intervention.
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Affiliation(s)
- Farzan Dholoo
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Internal Medicine, Berkshire, UK.
| | - Amanda Shabana
- Frimley Park Hospital, Frimley Health NHS Foundation Trust, Internal Medicine, Berkshire, UK.
| | - Myrella Paschali
- Brigham and Women's Hospital, Harvard Medical School, Anesthesiology, Perioperative & Pain Medicine, Boston, MA 02467, USA.
| | - Amit K J Mandal
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Internal Medicine, Berkshire, UK.
| | - Constantinos G Missouris
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Internal Medicine, Berkshire, UK; University of Cyprus Medical School, Cardiology, Nicosia, Cyprus.
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Rodriguez-Homs LG, Goerlitz-Jessen M, Das SU. A 17-Year-Old Girl With Unilateral Headache and Double Vision. J Investig Med High Impact Case Rep 2019; 7:2324709619838309. [PMID: 31010318 PMCID: PMC6480981 DOI: 10.1177/2324709619838309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Tolosa-Hunt syndrome is characterized by a painful ophthalmoplegia secondary to a granulomatous inflammation in or adjacent to the cavernous sinus. Magnetic resonance imaging will show enhancement of the cavernous sinus and/or the orbital apex. Although this syndrome is extremely rare in children, it should be a diagnostic consideration in patients presenting with painful ophthalmoplegia with variable involvement of cranial nerves II to VI. The differential diagnosis for unilateral cavernous sinus lesion is broad, including vascular lesions (cavernous sinus thrombosis), inflammatory processes (sarcoidosis, autoimmune), neoplastic processes (schwannoma, lymphoma), as well as infectious etiologies. We describe a pediatric patient presenting with neurological symptoms from a unilateral cavernous sinus magnetic resonance imaging abnormality and the thorough diagnostic approach to arrive at the diagnosis of Tolosa-Hunt syndrome.
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Affiliation(s)
| | | | - Samrat U Das
- 1 Duke University School of Medicine, Durham, NC, USA
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Świątkowska-Stodulska R, Stodulski D, Babińska A, Piskunowicz M, Sworczak K. Bilateral Tolosa-Hunt syndrome mimicking pituitary adenoma. Endocrine 2017; 58:582-586. [PMID: 29032531 PMCID: PMC5693964 DOI: 10.1007/s12020-017-1422-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 09/04/2017] [Indexed: 12/11/2022]
Abstract
The authors report a rare case of bilateral Tolosa-Hunt syndrome, which occurred in a 80-year-old female and remitted spontaneously. Inflammatory lesions were found not only in typical locations, i.e. superior orbital fissures and cavernous sinuses, but also in the pituitary; these imitated gland's macroadenoma in imaging studies.
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Affiliation(s)
| | - Dominik Stodulski
- Department of Otolaryngology, Medical University of Gdańsk, Gdańsk, Poland
| | - Anna Babińska
- Department of Endocrinology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
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AKPINAR ÇK, ÖZBENLİ T, DOĞRU H, İNCESU L. Tolosa-Hunt Syndrome - Cranial Neuroimaging Findings. Noro Psikiyatr Ars 2017; 54:251-254. [PMID: 29033638 PMCID: PMC5630104 DOI: 10.5152/npa.2016.13791] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/02/2016] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION The etiology of Tolosa-Hunt Syndrome (THS) is still unknown. The initial standard magnetic resonance imaging (MRI) may not be sufficient for diagnosis, so dynamic contrast-enhanced MRI may be necessary to demonstrate the presence of lesions. METHODS Seven patients diagnosed with THS according to the International Headache Society criteria (beta version) were included into the study. Patients were assessed in terms of type, age, symptoms and findings, accompanying disease, localization of the determined lesion, response to treatment, and clinical progress. The "Tolosa-Hunt protocol" was applied in all patients, and the cavernous sinuses, orbital apices, and orbits were evaluated. The parameters used for the patients were as follows: Turbospin echo T1 and T2 weighted sequences on the axial plane, turbospin echo fat-saturated T2 weighted sequence on the coronal plane, turbospin echo T2 weighted sequence on the sagittal plane, spin echo fat-saturated T1 sequences repeated on the axial and coronal planes followed by intravenous administration of gadolinium. In all sequences the slice thickness was 3 mm. RESULTS Four of seven cases diagnosed with THS were males, and the average age of the patients was 45.7±18.1 years (range 25-69 years). A follow-up MRI in patient 5 after three months showed decreased signal intensity and enhancement of the affected cavernous sinus. CONCLUSION Conventional MRI may be insufficient to show the granulomatous inflammation, and an MRI method referred to as the Tolosa-Hunt protocol should be applied to those who are thought to have THS.
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Affiliation(s)
| | - Taner ÖZBENLİ
- Department of Neurology, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Hakan DOĞRU
- Department of Neurology, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Lütfi İNCESU
- Department of Radiology, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
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Litwin CE, Leung ASO. Tolosa-Hunt syndrome presenting during pregnancy following progesterone administration. Int J Gynaecol Obstet 2017; 137:340-341. [PMID: 28295285 DOI: 10.1002/ijgo.12145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 11/29/2016] [Accepted: 03/07/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Charles E Litwin
- Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada
| | - Annie S O Leung
- Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada
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Murtaza G, Konowitz N, Lu H, Faqah A, Kuruvilla A. An Interesting Case of Tolosa-Hunt Syndrome in a Young Male. J Investig Med High Impact Case Rep 2017; 5:2324709616689478. [PMID: 28210639 PMCID: PMC5298529 DOI: 10.1177/2324709616689478] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/11/2016] [Accepted: 12/26/2016] [Indexed: 11/24/2022] Open
Abstract
Tolosa-Hunt syndrome is a rare disease with a limited number of cases reported in the literature. It typically presents with orbital pain associated with palsy of the third, fourth, or sixth cranial nerve. We present an interesting case of Tolosa-Hunt syndrome in a young male who responded well to high-dose steroids and in a few days had significant improvement in his retro-orbital pain and ocular movements.
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Affiliation(s)
| | - Nicholas Konowitz
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Hannah Lu
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Anadil Faqah
- UIC/Advocate Christ Medical Center, Oak Lawn, IL, USA
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Ceylan ME, Evrensel A, Noyan CO, Dönmez A. Tolosa-Hunt syndrome and comorbidity of obsessive compulsive disorder and aortic aneurysm. BMJ Case Rep 2016; 2016:bcr-2016-216727. [PMID: 27872048 DOI: 10.1136/bcr-2016-216727] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Alper Evrensel
- Department of Psychiatry, Üsküdar University, Istanbul, Turkey
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Pérez CA, Evangelista M. Evaluation and Management of Tolosa-Hunt Syndrome in Children: A Clinical Update. Pediatr Neurol 2016; 62:18-26. [PMID: 27473647 DOI: 10.1016/j.pediatrneurol.2016.06.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 06/12/2016] [Accepted: 06/18/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Tolosa-Hunt syndrome is a painful ophthalmoplegia caused by an inflammatory process of unknown etiology in the region of the cavernous sinus, orbital apex, or superior orbital fissure. This disease is rare in the pediatric population. The objective of this study was to provide a clinical framework for the evaluation and treatment of children with this disorder. A systematic approach to the diagnosis of painful ophthalmoplegia in children is proposed. METHODS We present a 15-year-old girl whose clinical presentation and neuroradiological findings support a diagnosis of Tolosa-Hunt syndrome as defined by the 2013 International Classification of Headache Disorders (Third Edition, ICHD-3 beta) diagnostic criteria. An exhaustive systematic literature search based on these criteria yielded 15 additional cases of Tolosa-Hunt syndrome in children. Clinical, demographic, and radiological features were retrospectively analyzed. The results and statistical analyses are reported. RESULTS A total of 16 individuals were included in the final analysis. This review summarizes the current knowledge and recommendations for the diagnosis and management of pediatric Tolosa-Hunt syndrome. It highlights demographic, clinical, and radiological features of this disease in children and underscores areas of the literature where evidence is still lacking. CONCLUSIONS Overall, Tolosa-Hunt syndrome seems to follow a similar course in children compared to adults. The diagnostic approach and treatment require specific considerations. New observations and possible features of pediatric Tolosa-Hunt syndrome are discussed. Further research is needed to optimize clinical detection and medical management of this disease.
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Affiliation(s)
- Carlos A Pérez
- Division of Child and Adolescent Neurology, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas.
| | - Monaliza Evangelista
- Division of Community and General Pediatrics, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
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A Rare Case of Tolosa-Hunt-Like Syndrome in a Poorly Controlled Diabetes Mellitus. Case Rep Med 2016; 2016:9763621. [PMID: 27087813 PMCID: PMC4818810 DOI: 10.1155/2016/9763621] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/07/2016] [Indexed: 01/03/2023] Open
Abstract
We report a case of a 50-year-old female with diabetes mellitus who presented with progressive second, third, fifth, sixth, and eighth cranial nerve palsy. Diagnostic investigation revealed hyperglycemic state, and brain imaging showed a right cavernous sinus enhancement suggestive of and consistent with Tolosa-Hunt syndrome. The patient was started on steroids with tight glycemic control for eight weeks; subsequently, the cranial nerve palsies resolved as well as documented resolution of the right cavernous sinus enhancement.
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Affiliation(s)
- Jonathan Zurawski
- Medstar Washington Hospital Center Department of Medicine, Washington, DC 20010, USA.
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Sugie K, Morikawa M, Taoka T, Hirano M, Ueno S. Serial neuroimaging in tolosa-hunt syndrome with acute bilateral complete ophthalmoplegia. J Neuroimaging 2011; 21:79-82. [PMID: 19453827 DOI: 10.1111/j.1552-6569.2009.00381.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Tolosa-Hunt syndrome (THS) is a very rare, relapsing, and remitting painful ophthalmoplegia caused by nonspecific granulomatous inflammation in the cavernous sinus. To our knowledge, bilateral complete, simultaneous palsies of all 3 cranial nerves associated with extraocular movement have not been reported. We describe the first such patient with bilateral THS that responded quickly to corticosteroid therapy. A 54-year-old man presented with a periorbital and frontal headache with acute bilateral severe blepharoptosis and fixed eyes, which dramatically responded to corticosteroid therapy. He had diabetes mellitus type II. Brain MRI showed granulomatous inflammation in both cavernous sinuses and thickening of the surrounding dura mater of the cranial base, suggesting the coexistence of focal hypertrophic cranial pachymeningitis. Our experience indicates that steroid therapy with strict control of blood sugar should be considered in patients with THS complicated by diabetes. MRI is a valuable tool for serially monitoring the response of lesions to treatment in THS.
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Affiliation(s)
- Kazuma Sugie
- Department of Neurology, Nara Medical University School of Medicine, Kashihara, Nara, Japan.
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Kang CH, Huang YC, Lui CC, Chang YC, Hung PL. Unusual clinical course in pediatric Tolosa-Hunt syndrome. Pediatr Neurol 2011; 44:471-4. [PMID: 21555061 DOI: 10.1016/j.pediatrneurol.2011.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 12/16/2010] [Accepted: 01/10/2011] [Indexed: 11/18/2022]
Abstract
We report on a 7-year-old immunocompetent boy initially presenting with right-sided frontal cephalalgia, painful ophthalmoplegia, and ptosis for 1 month. Initial cerebrospinal fluid analysis produced normal results. Magnetic resonance imaging revealed an inflammatory pseudotumor of the right cavernous sinus after intravenous gadolinium administration, indicating a rare idiopathic inflammatory disorder of the cavernous sinus, i.e., Tolosa-Hunt syndrome. Ptosis and cephalalgia resolved after steroid treatment, although right-sided ophthalmoplegia remained. Breakthrough headache, associated with signs of meningeal irritation, developed 6 weeks later. Follow-up contrast-enhanced computed tomography revealed no enhancing cavernous soft tissue mass. A further lumbar puncture disclosed central nervous system infection with Staphylococcus saprophyticus. After 6 weeks of vancomycin, the headache resolved completely, and neuroimaging produced normal results. A diagnosis of Tolosa-Hunt syndrome should be rendered cautiously, because the etiology may involve a rare but not "idiopathic" infection. Moreover, if clinical signs are not fully responsive to steroid treatment, the underlying problems should receive careful investigation.
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Affiliation(s)
- Chia-Hao Kang
- Department of Pediatrics, Chang Gung Memorial Hospital- Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
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Tolosa–Hunt syndrome misdiagnosed as sinusitis complication. The Journal of Laryngology & Otology 2008; 122:97-9. [DOI: 10.1017/s0022215106005317] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:Tolosa–Hunt syndrome is a rare condition of painful ophthalmoplegia combined with ipsilateral ocular motor nerve palsies, caused by non-specific granulomatous inflammation in the cavernous sinus, superior orbital fissure or orbit. A case of Tolosa–Hunt syndrome misdiagnosed as sinusitis orbital complication is reported.Case report:A patient suffering from left periorbital pain, upper eyelid oedema and ptosis, and horizontal diplopia, diagnosed as sinusitis orbital complication, was referred to our department. Clinical evaluation revealed only a left VIth nerve paresis. Haematological studies, cerebrospinal fluid tests and computed tomography scanning were negative. A magnetic resonance imaging (MRI) scan showed enhancement of the left cavernous sinus. Corticosteroid therapy was commenced, and within three days all symptoms disappeared. A diagnosis of Tolosa–Hunt syndrome was made. Follow-up MRI studies were normal.Conclusion:Tolosa–Hunt syndrome, although rare, is a nosological entity that otolaryngologists must bear in mind. Magnetic resonance imaging studies are essential in the diagnosis and follow up of these patients, in order to avoid a mistaken Tolosa–Hunt syndrome diagnosis.
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