Paediatric Tolosa-Hunt syndrome: the need for treatment guidelines and renewed criteria

Tolosa-Hunt syndrome in children and adolescents: A systematic review

OBJECTIVE

This systematic review aims to consolidate and analyze the existing evidence on Tolosa-Hunt syndrome (THS) in the pediatric population, focusing on clinical features, diagnostic challenges, treatment outcomes, and prognosis.

BACKGROUND

Tolosa-Hunt syndrome is a rare headache disorder caused by idiopathic inflammation of the cavernous sinus, orbital apex, or orbit, resulting in neuro-ophthalmological manifestations. It is uniquely characterized by cranial nerve palsies and often responds well to steroids.

METHODS

A comprehensive literature search was conducted using three databases along with the gray literature. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the review protocol was registered on International Prospective Register of Systematic Reviews (PROSPERO identifier: CRD42024576802). The review included case reports and case series published in multiple languages that documented pediatric or adolescent cases of THS. We excluded any cases that were irrelevant, had insufficient details, were unsure of the diagnosis, or were later re-diagnosed with another condition. Data on clinical presentations, imaging findings, treatment modalities, and outcomes were extracted and analyzed using Microsoft Excel 2021.

RESULTS

The initial literature search provided 325 articles of which 55 articles discussing 61 unique pediatric patients were included. The median (interquartile range [IQR]) age was 11 (8-15) years, with a female predominance (70% [43/61]). Common symptoms included unilateral headache (48% [29/61]), retro-orbital pain (56% [34/61]), and cranial nerve palsies, predominantly involving the oculomotor nerve (66% [40/61]). The median (IQR) duration of symptoms was 14.5 (5-35) days. Imaging often revealed contrast enhancement on magnetic resonance imaging with cavernous sinus/orbital apex lesions. Steroid therapy was the mainstay of treatment, with 91% (52/57) of patients receiving corticosteroids. High-dose steroids ranged from 500-1000 mg/day, with some cases requiring combined therapy (typically intravenous methylprednisolone followed by oral prednisolone) and subsequent tapering. A few patients (5% [3/61]) experienced spontaneous improvement without steroids. Recurrence was noted in 33% (20/61) of patients, often necessitating prolonged or repeated corticosteroid therapy, and some cases required additional immunosuppressive therapies (infliximab/adalimumab) for management. The median (IQR) time to symptom resolution was 14 (4.5-38.5) days, while the median (IQR) duration of follow-up was 730 (195-1095) days.

CONCLUSION

Tolosa-Hunt syndrome in children presents significant diagnostic and management challenges due to the complexity of symptoms and the rarity of the condition. Accurate diagnosis and prompt steroid therapy are crucial after ruling out other causes, although recurrence remains a considerable risk. The present systematic review relies heavily on case reports and case series and is therefore at high risk of publication bias. Further research is needed to establish standardized treatment protocols and improve long-term outcomes in this population.

Tolosa-Hunt Syndrome: A Review of Diagnostic Criteria and Unresolved Issues

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.

Ophthalmoplegia and cranial nerve deficits in an adolescent with headache

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.

Tolosa-Hunt Syndrome in Childhood and Adolescence: A Literature Review in the Last 10 Years

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.

Evaluation and Management of Tolosa-Hunt Syndrome in Children: A Clinical Update

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.

Validation of ICHD-3 beta diagnostic criteria for 13.7 Tolosa-Hunt syndrome: Analysis of 77 cases of painful ophthalmoplegia

BACKGROUND

Three editions of International Classification of Headache Disorders (ICHD) diagnostic criteria for Tolosa-Hunt syndrome (THS) have been published in 1988, 2004 and 2013, in ICHD-3 beta, there have been considerable changes [corrected]. The validity of these new diagnostic criteria remains to be established.

METHODS

We retrospectively identified 77 patients with non-traumatic painful ophthalmoplegia (PO) admitted between 2003 and 2013. We reviewed patients' age at onset and gender, time courses between onset of pain and development of cranial nerve palsy, the cranial nerves involved, imaging findings, therapeutic efficacy of steroid treatment and recurrence of attacks.

RESULTS

THS was the most frequent type of PO (46/77). In THS patients, the third cranial nerve was most commonly involved (76.3%). The median time interval between pain and cranial nerve palsy was two days, although in five patients (10.9%) the interval ranged from 16 to 30 days. Definitely abnormal MRI findings were found in 24 patients (52.2%).

CONCLUSIONS

It is essential to rule out other causes of PO in diagnosing THS, with MRI playing a crucial role in differential diagnosis. It may be helpful to understand and master the entity of THS for researchers and clinicians to adjust the gradation and ranking of the diagnostic criteria.

Tolosa-Hunt syndrome preceded by facial palsy in a child

We report on a previously healthy 11-year-old boy with unilateral periorbital mild headache and facial nerve palsy, followed during the next 5 months by recurrent unilateral headaches and subsequent extrinsic paresis of the third cranial nerve and paresis of the sixth cranial nerve, each of which improved with steroids. Cranial magnetic resonance imaging revealed increased thickening of the left cavernous sinus and adjacent structures, with marked gadolinium enhancement. Eight months after the initial signs, he developed left retro-orbital headache that lasted 16 days and was relieved 24 hours after resuming steroid treatment. Recurrent multiple cranial neuropathies, neuroimaging findings, and long-lasting headache that responded to steroids indicated Tolosa-Hunt syndrome, further confirmed by extensive investigation and a long follow-up to exclude other causes. This patient illustrates the complexity of disorders with multiple cranial nerve palsies, and adds to the sparse literature on Tolosa-Hunt syndrome in children, describing the first pediatric case preceded by facial palsy.