Tolosa Hunt Syndrome is a rare disease often characterized by painful ophthalmoplegia, and severe periorbital headaches which are usually unilateral in presentation, along with features of cranial nerve paralysis such as ptosis, diplopia, facial hypoaesthesia etc. Onset can be seen any age. Although it tagged as a benign condition, but permanent neurologic deficits may occur. Treatment may include use of glucocorticoids or other immunosuppressive therapies according to the standard protocol. A female patient 32 years of age visited National Institute of Homoeopathy OPD presented with complaints of severe left sided headache throbbing in nature since four to five months associated with nausea. The attacks of headache being with very short duration with rising and falling suddenly. She had very plethoric, congestive red facies and complained of dimness of vision of the left eye and of general debility. MRI brain and orbit with IV contrast showed a brilliantly enhancing plaque-like mass lesion measuring 37*18*12mm noted within left orbital apex compressing the orbital contents with extensions also to cavernous sinus and middle cranial fossa compressing adjacent temporal lobe. A detailed case taking was done and based on the totality of symptoms and collaborating with the portrait of disease Belladonna 10M one dose was given followed by rubrum for 1 month. Her paroxysms of headache had considerably decreased with no redness of the face on her first visit. Patient was better with almost no paroxysms of headache for almost five months after first dose then the symptoms reappeared and another dose of Belladonna 10M was repeated on fourthvisit. MRI Brain done almost a year later after commencement of homoeopathic treatment showed the reduction of the lesion upto 17.4mm*11.7*13.7mm seen in the left orbital apex inseparable from lateral rectus and compressing existing optic nerve the lesion extended to the meningeal lining over antero-inferior temporal lobe and parasellar region.MRI result showed significant reduction in the size of the lesion with symptomatic improvement under the homoeopathic treatment with no use of steroids or any other immunosuppressive therapies whatsoever.
Keywords: Tolosa hunt syndrome, Headache, Ophthalmoplegia, Congestive red face, Belladonna, Homoeopathy
Tolosa-Hunt syndrome (THS) is a rare disorder characterized by severe periorbital or hemicranial pain, associate with painful and restricted eye movements. The exact cause is not known, but the disorder is thought to be associated with non-specific inflammation in the region of the cavernous sinus and/or superior orbital fissure. It usually unilateral but either side can be affected. Symptoms often will subside without intervention (spontaneous remission) and may recur without a distinct pattern. 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).1,2
There are no clinical characteristics that distinguish THS from other pathologic processes in the orbitocavernous area. Although computed tomography (CT) and magnetic resonance imaging (MRI) are the ideal neuroimaging techniques used in diagnosis of THS, but MRI studies of the cavernous sinus and orbital apex demonstrate a high sensitivity than CT for the detection and monitoring of inflammatory mass lesions in THS.3,4 MRI also helps in the differential diagnosis of the THS from conditions such as meningioma, lymphoma, and sarcoidosis. So, MRI should be the initial screening study in patients presenting symptoms of THS.4,5
Systemic corticosteroid therapy has been the mainstay of the treatment of THS. Corticosteroids markedly reduce the periorbital pain but spontaneous remissions may occur. Some individuals may need immunosuppression in combination with other medications, either to avoid side effects of prolonged steroid therapy or for long-term suppression of the disease process.1,2
A female patient 32 years of age visited National Institute of Homoeopathy OPD on 24th January 2020. She presented with complaints of severe headache (left sided) throbbing in nature since four to five months associated with nausea. Headache very severe since last five days, in left temporal and left supra orbital region. The attacks of headache she complained of had a nature of being very short duration attacking suddenly and rising and falling suddenly. Headache aggravation from noise, lying down and amelioration from hard pressure or from massage. She had very plethoric facies and she complained of dimness of vision of the left eye and of general debility. This was accompanied by a very markedly red face. She also had nausea without vomiting or with no relief from vomiting and congestive redness of face. No significant past history and family history was found.
Generalities: Mental and physical generals
Patients built was normal, thermal reaction was ambithermal, appetite was slightly reduced, she had marked desire for spicy food and aversion for milk and sour food, thirst was moderate, perspiration was moderate, tongue was coated white with clean tip and imprints of teeth at the edges and her sleep was adequate.
Patient has Desires for company, weeps easily, irritable and she was very anxious about her disease.
Physical examination: general & systemic
The patient was alert conscious and cooperative during every visit with normal speech. No motor deficits were noted with muscle strength 5/5 bilaterally and intact sensation bilaterally.
Diagnostic assessment
The case was provisionally diagnosed as Tolosa-Hunt syndrome; Her investigations revealed: MRI brain and orbit with IV contrast showed a brilliantly enhancing plaque-like mass lesion measuring 37*18*12mm noted within left orbital apex compressing the orbital contents with extensions also to cavernous sinus and middle cranial fossa compressing adjacent temporal lobe; So final diagnosis of this case was Tolosa-Hunt syndrome Figure 1.
The totality of symptoms
The totality of this case was formed after analysis and evaluation characteristic mental generals, physical generals and particular symptoms which mentioned as follows:
- 1. Desires company
- 2. Weeps easily
- 3. Irritability
- 4. Anxious about disease
- 5. Acuteness of all senses
- 6. Desire spicy food++
- 7. Aversion milk and sour food
- 8. Tongue coated white with clean tip and imprints of teeth at the edges.
- 9. Severe throbbing headache in the left temporal and left supra orbital region
- 10. Headache was aggravated by noise and lying down
- 11. Headache was ameliorated by hard pressure
- 12. Nausea without vomiting or with no relief from vomiting
- 13. Congestive redness of face
Repertorial result
Considering the above symptomatology, Synthesis Repertory was selected for repertorisation and was done using RADAR software 10.0. After repertorisation, the top medicines were Lycopodium, Phosphorus, Belladonna and Nux Vomica. Repertorisation result is shown in Figure 2.
Final selection of remedy
On the basis of totality and repertorisation along with the help of Homoeopathic Materia medica the final remedy selected was Belladonna.
First Prescription (24/01/2020): Belladonna 10M, 1 dose in Sac lac, early morning in empty followed by Nihilinum 30, 1-2 globule each day for 30days.
Follow up and outcomes
Follow‑up of the patient was assessed regularly as required. Date‑wise detailed follow‑ups with result in investigations are summarised in Table 1.
In this case, the response of individualized homoeopathic treatment was assessed through Modified Naranjo Criteria for Homoeopathy (MONARCH) Inventory.6 The total score of MONARCH inventory for this case was 11 out of 13, which suggest a “definite” causal attribution between the medicine and its outcome Table 2.
A detailed case taking was done and based on the totality of symptoms and collaborating with the portrait of disease Belladonna 10M one dose was given followed by rubrum for one month. The patient was asked to report a month later.
There was no redness of the face as seen on her first visit and her paroxysms of headache had considerably decreased. Patient was better with almost no paroxysms of headache for almost five months after first dose of Belladonna 10M, so she was on placebo during that said period. Then the symptoms reappeared and another dose of Belladonna 10M was repeated on her fourth visit. After that her headache was decrease and further no reappearance of her presenting complaints was noticed. Along with a general well-being of the patient was also observed.
MRI brain was done almost a year later after commencement of homoepathic treatment which showed the reduction of the lesion from 37*18*12mm to 17.4mm*11.7*13.7mm seen in the left orbital apex inseparable from lateral rectus and compressing existing optic nerve. The lesion extended to the meningeal lining over anteroinferior temporal lobe and parasellar region.
In this case, the response of individualized homoeopathic treatment was assessed through MONARCH Inventory which suggest a “definite” causal attribution between the medicine and its outcome.
Apart from the steroidal intervention, which is the general road taken in management of majority of rare diseases, a more conscious homoeopathic intervention guided by a proper case taking could make a lot of difference even in cases of rare diseases like the one already presented here. Researches if conducted following standard protocols inclusive of homoeopathic drugs could open a new arena of studying the changes brought in terms of improvement in diseases lesser known or less dealt with.
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Author declares that there is no conflict of interest.
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