Tolosa Hunt Syndrome
NORD is very grateful to Roman Shinder, MD, Assistant Professor of Ophthalmology, Ophthalmic Plastic & Reconstructive Surgery, SUNY Downstate Medical Center; Director Oculoplastics, Kings County Hospital Center and Renelle Pointdujour, MD, Department of Ophthalmology, SUNY Downstate Medical Center, for assistance in the preparation of this report.
Synonyms of Tolosa Hunt Syndrome
- ophthalmoplegia, painful
- ophthalmoplegia, recurrent
- ophthalmoplegia syndrome
- No subdivisions found.
Tolosa-Hunt syndrome is a rare disorder characterized by severe periorbital headaches, along with decreased and painful eye movements (ophthalmoplegia). Symptoms usually affect only one eye (unilateral). In most cases, affected individuals experience intense sharp pain and decreased eye movements. Symptoms often will subside without intervention (spontaneous remission) and may recur without a distinct pattern (randomly). Affected individuals may exhibit signs of paralysis (palsy) of certain cranial nerves such as drooping of the upper eyelid (ptosis), double vision (diplopia), large pupil, and facial numbness. The affected eye often abnormally protrudes (proptosis). The exact cause of Tolosa-Hunt syndrome is not known, but the disorder is thought to be associated with inflammation of specific areas behind the eye (cavernous sinus and superior orbital fissure).
Many individuals with Tolosa-Hunt syndrome experience the sudden onset of severe periorbital headache, followed by painful and decreased eye movements (ophthalmoplegia). In some cases of severe ophthalmoplegia, the eye itself is unable to move or look in various directions (frozen globe).
The major symptoms of Tolosa-Hunt syndrome include chronic periorbital headache, double vision, paralysis (palsy) of certain cranial nerves, and chronic fatigue. Affected individuals may also exhibit protrusion of the eye (proptosis), drooping of the upper eyelid (ptosis) and diminished vision. In most cases, symptoms associated with Tolosa-Hunt syndrome affect only one side (unilateral). Symptoms will usually subside without intervention (spontaneous remission) and may recur without a distinct pattern (randomly).
While the exact cause of Tolosa-Hunt syndrome is unknown, one theory is an abnormal autoimmune response linked with an inflammation in a specific area behind the eye (cavernous sinus and superior orbital fissure). In some cases, inflammation may be due to a clumping of a certain type of cell (granulomatous inflammation). Autoimmune disorders are caused when the body's natural defenses against "foreign" or invading organisms (e.g., antibodies) begin to attack healthy tissue for unknown reasons. Other possible causes may include generalized inflammation and constricted or inflamed cranial blood vessels.
Tolosa-Hunt syndrome is a rare neuro-immunological disorder that occurs in males and females in equal numbers. The average age of onset is 41 years, but there have been cases reported among people younger than age 30. In rare cases, children under the age of 10 have been diagnosed with Tolosa-Hunt syndrome.
Symptoms of the following disorders can be similar to those of Tolosa-Hunt syndrome. Comparisons may be useful for differential diagnosis:
Orbital cellulitis is characterized by inflammation of the tissues within the cavity which holds the eyeball. Symptoms include extreme pain, impaired eye movement, swelling, fever and a general feeling of discomfort. Possible complications may include impaired vision, vein abnormalities and spread of the inflammation to the entire orbit, brain or the membranes surrounding the brain.
Cavernous sinus thrombosis is an ophthalmologic disorder usually caused by infection and clotting in veins behind the eyeball. It can be a complication of Orbital Cellulitis or infections of facial skin. Swelling and protrusion of both eyes, fever, headache, poor eye movements, droopy eyelids, facial numbness, and an overly sick appearing patient are symptoms of this deadly disorder. Prompt treatment with antibiotics and blood thinners and rest is recommended.
Migraine headaches usually involve one side of the head like the Tolosa-Hunt syndrome. Individuals who suffer from these intense headaches may have a genetic predisposition to them. Often associated with these painful attacks are irritability, nausea, vomiting, constipation or diarrhea, and sensitivity to light. Medical researchers believe constriction of the cranial arteries may precede migraine headaches in some cases. Poor eye movements are not characteristic of migraine headaches and should alert physicians to the possibility of Tolosa-Hunt syndrome.
The diagnosis of Tolosa-Hunt syndrome has been codified by the International Headache Society. The following criteria must be met for a definitive diagnosis of this disorder: Eye pain on one side of the head that persists for at least eight weeks if untreated; associated irritation or damage to the third, fourth, or sixth cranial nerves; relief of pain within 48 hours upon the administration of steroids; and specialized testing that rules out other conditions such as neoplasm, infection or aneurysm.
The diagnosis of Tolosa-Hunt syndrome is suspected based upon the presence of characteristic physical features (e.g., pain, headache, ophthalmoplegia). The diagnosis may be confirmed by a thorough clinical evaluation, detailed patient history, and a variety of specialized radiologic tests including computed tomography (CT) scan, and magnetic resonance imaging (MRI). These examinations may reveal characteristic enlargement or inflammation of the areas behind the eye (cavernous sinus and superior orbital fissure).
In most cases, the pain associated with Tolosa-Hunt syndrome subsides with short-term use of steroid drugs. Pain is usually reduced in untreated cases within fifteen to twenty days. With steroid treatment, pain typically briskly subsides within twenty-four to seventy-two hours - and this brisk steroid response aids in the diagnosis. Affected individuals may be vulnerable to recurrent future attacks.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
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For information about clinical trials sponsored by private sources, contact:
Researchers have been studying various additional treatment options for individuals who do not respond to, or develop resistance to, corticosteroid treatment. Radiation therapy has demonstrated long-term improvement in several subjects. Immunosuppressive drugs such as methotrexate are being studied as a potential treatment for individuals with Tolosa-Hunt syndrome. Some researchers have advocated the use of acupuncture. More research is necessary to determine the long-term safety and effectiveness of these potential treatments for individuals with Tolosa-Hunt syndrome.
Contacts for additional information about Tolosa-Hunt syndrome:
Roman Shinder, MD
Assistant Professor of Ophthalmology
Ophthalmic Plastic & Reconstructive Surgery
SUNY Downstate Medical Center
Kings County Hospital Center
451 Clarkson Ave, E Bldg, 8th Fl, Suite C
Brooklyn, NY 11203
Renelle Pointdujour, MD
SUNY Downstate Medical Center
Department of Ophthalmology
450 Clarkson Ave, Box 58
Brooklyn, NY 11203
Organizations related to Tolosa Hunt Syndrome
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Kanski JJ, ed. Clinical Ophthalmology. 4th ed. Oxford, UK: Butterworth-Heinemann; 1999.
Adams RD, Victor M, Ropper AA, eds. Principles of Neurology. 6th ed. New York, NY: McGraw-Hill Companies; 1997.
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Haque TL, Miki Y, Kashii S, et al. Dynamic MR imaging in Tolosa-Hunt syndrome. Eur J Radiol. 2004;51:209-17.
Mandrioli J, Frank G, Sola P, et al. Tolosa-Hunt syndrome due to actinomycosis of the cavernous sinus: the infectious hypothesis revisited. Headache. 2004;44:806-11.
Gladstone JP, Dodick DW. Painful ophthalmoplegia: overview with a focus on Tolosa-Hunt syndrome. Curr Pain Heachache Rep. 2004;8:321-29.
Yeung MC, Kwong KL, Wong YC, et al. Paediatric Tolosa-Hunt syndrome. J Paediatr Child Health. 2004;40:410-13.
Chmielewska B, Leszek Kaminski M. Progression of preexisting trigem-inalgia to Tolosa-Hunt-like syndrome. The importance of neuroimaging for early differential diagnosis. Neurol Sci. 2003;24:281-85.
Nepp J, Jandrasits K, Schauersberger J, et al. Is acupuncture a useful tool for pain-treatment in ophthalmology? Acupunct Electrother Res. 2002;27:171-82.
Sugano H, Iisuka Y, Arai H, et al. Progression of Tolosa-Hunt syndrome to a cavernous dural arteriovenous fistula: a case report. Headache. 2003;43:122-26.
Taylor DC, Mankowski K. Tolosa-Hunt Syndrome. Emedicine. http://emedicine.medscape.com/article/1146714-overview. Updated April 29, 2010. Accessed March 19, 2012.
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Report last updated: 2012/03/20 00:00:00 GMT+0
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