Horner syndrome

Horner's Syndrome Following Thyroid Surgery

Horner's syndrome (HS) is a rare complication of thyroidectomy caused by damage to the oculosympathetic nerves. This article reports the case of a 29-year-old woman referred to the clinic with a newly diagnosed papillary thyroid carcinoma (PTC). Ultrasound studies were concerning for multiple thyroid nodules and an enlarged lymph node, confirmed by a computed tomography (CT) scan. Cytology results of fine needle aspiration (FNA) diagnostic for PTC showed tumors in the thyroid tissue and lymph node. The patient underwent a thyroidectomy and woke up with right-sided ptosis and miosis. Clinical follow-up revealed subjective ipsilateral anhidrosis. She also developed a low parathyroid hormone level and dysphonia, albeit they resolved after months. The patient still exhibits HS eight months after surgery. This paper reviews the literature and attempts to establish the most probable causal factor while providing implications for surgical teams to minimize HS occurrence in future thyroid surgeries.

Horner Syndrome subsequent to ultrasound-guided cervical lymph node fine-needle aspiration - A case report and literature review

Horner Syndrome (HS) is characterized by symptoms of ipsilateral miosis, ptosis, enophthalmos, and facial anhidrosis, which is caused by the damaged oculosympathetic pathway. HS is rarely reported as postoperative complications of fine-needle aspiration (FNA). We report a case of HS triggered by Ultrasound-guided FNA during thyroid cancer management and conducted the literature review. A 31-year-old male with differentiated thyroid cancer underwent total thyroidectomy and regional lymph node dissection as well as radioactive iodine ablation, presented with persistently elevated tumor marker of thyroglobulin and suspicious left level IV and V cervical lymph nodes by neck ultrasound. Ultrasound-guided left cervical lymph nodes FNA for cellular diagnosis was performed, and typical manifestations of HS appeared immediately after the procedure. Subsequent ultrasound evaluation of the same area demonstrated a subtle strip of the hypo-echogenic area in the superior pole of the suspected level IV structure, suggesting sympathetic ganglia with the visible originating nerve fiber on the superior pole. All of the patient's symptoms of HS were resolved 2 months after the incidence. Cervical sympathetic ganglia can be similar in size, shape, and ultrasound characteristics to a malignant lymph node. Thorough ultrasound examination by directly comparing the potential ganglia with a typical malignant lymph node, and paying attention to any potential root fibers on the target is key to avoiding ganglia injury before the neck invasive procedures.

Ipsilateral Facial Hyperhidrosis in a Patient With Squamous Cell Carcinoma of the Lung

While anhidrosis in Horner's Syndrome is a well-documented result of apical lung malignancies impinging on the sympathetic pathway traveling through the upper lobe of the lung, its opposite effect, hyperhidrosis, is a seldom reported consequence. Hyperhidrosis occurs as a result of irritation of the sympathetic nervous system near the superior cervical ganglion. In this report, we examine a patient with known Stage IIIB squamous cell carcinoma of the lung presenting with right hemifacial hyperhidrosis, dyspnea, and right upper extremity swelling. Computed tomography angiography (CTA) of the chest re-demonstrated the intrathoracic neoplasm encroaching on his mediastinum. During admission, the patient had his first cycle with carboplatin and paclitaxel. His hyperhidrosis, as well as dyspnea and swelling improved post-treatment, and the patient was stable for discharge to follow up outpatient with oncology and radiation oncology to continue further treatment. As hemifacial hyperhidrosis is rarely reported, it becomes important to recognize this as a likely indicator of mediastinal invasion from malignancy.

The evaluation of patient demographics, etiologies and apraclonidine test results in adult Horner's syndrome

PURPOSE

We aimed to demonstrate the patient demographics, etiologies and apraclonidine test results in adult Horner's syndrome.

METHODS

This retrospective study was performed by the analysis of medical data of patients who were given 0.5% apraclonidine test. Patients' past medical history, demographic data, etiologies, accompanying neurological findings and pharmacological test results were assessed.

RESULTS

Forty patients (21 females and 19 males) with a mean age of 50.3 ± 11.6 years were evaluated. Apraclonidine 0.5% test was positive in 37 patients (92.5%). An etiology could be identified in 20 patients (central [9 patients, 45%], preganglionic [9 patients, 45%] and postganglionic [2 patients, 10%]). Neurological findings accompanying Horner's syndrome were present in 8 patients.

CONCLUSION

Despite detailed investigations, in a significant number of patients with Horner's syndrome an underlying cause may not be detected. Among the identifiable lesions, central and preganglionic involvements are still the first leading causes of Horner's syndrome. In addition, apraclonidine test may not be positive in all patients and a negative response does not exclude Horner's syndrome.

Horner syndrome: tribute to Professor Horner on his 190th birthday

This paper reviews some aspects of the life and work of Professor Johann Friedrich Horner, on the occasion of the 190th anniversary of his birthday and 152 years after the publication of "Über eine Form von Ptosis". It also shows the importance of the historical description of ptosis, myosis and anhidrosis associating those symptoms with sympathetic cervical damage. He pharmacologically confirmed the impairment of sympathetic innervation to the eye and preserved parasympathetic function.

A Case of Spinal Epidural Abscess Presenting with Horner Syndrome

A spinal epidural abscess (SEA) is an uncommon disease, but it is associated with significant morbidity. SEA can be promoted by multiple risk factors. Moreover, the diagnosis of SEA usually requires the presence of a classic triad of back pain, fever, and neurological deficit, hence, the difficulty in making the diagnosis if presented otherwise. Horner syndrome (HS) is an uncommon presentation in association with SEA. Even though nonsurgical versus surgical management of SEA is still controversial, the literature review indicates a preference for surgical decompression as a treatment for SEA presenting with neurological compromise, followed by long-term antimicrobial therapy. The rapidity of making the diagnosis and the initiation of appropriate treatment determine the outcome.

We present a case of a 23-year-old male with no past medical history. The patient arrived at the Hamad General Hospital emergency department (ED) with severe upper back pain radiating to his left shoulder, which progressed to numbness and weakness of the left upper limb and spastic paraplegia. A left HS was revealed in a further neurological examination. However, the diagnosis of a spinal epidural abscess (SEA) was made after a left posterolateral epidural abscess extending from C5/6-T2/3 with associated cord compression and edema was revealed on an MRI scan. The patient then underwent a left C7, T1 hemilaminectomy and received antibiotics followed by admission to the rehabilitation unit. Staph. aureus was reported in culture microbiology results. Unfortunately, motor power recovery after the surgery was not significant.

Although it is difficult to diagnose SEA, it is crucial to suspect it in the presence of a neurological deficit regardless of the presence or absence of predisposing factors. Nevertheless, HS is not a relatively common finding in association with SEA. In this case report, we have a young patient with SEA who presented with left HS, upper back pain, and progressive neurological deficit in the absence of identifiable risk factors.

Postoperative Horner's syndrome following excision of incidental cervical ganglioneuroma during hemithyroidectomy and parathyroid gland exploration

This 49-year-old woman was referred to ear, nose and throat (ENT) with primary hyperparathyroidism. Imaging studies failed to localise the adenoma so she required four-gland parathyroid exploration. She also required diagnostic left hemithyroidectomy as she had a U3 nodule with multiple insufficient fine needle aspirations (FNAs). Intraoperatively, the left thyroidectomy proceeded uneventfully. No convincing left inferior parathyroid gland was identified however palpation revealed a 1 cm mass just medial to carotid artery. This was excised as probable ectopic parathyroid gland. She was discharged two days later. Thirteen days postoperatively she attended Eye Casualty with a left-sided Horner's syndrome. A CT angio of aortic arch was normal. She was reviewed at ENT outpatients. Histopathology report of the expected ectopic parathyroid gland returned as benign ganglioneuroma, likely arising from her left sympathetic chain. Horner's syndrome is a common side effect from excision of ganglioneuromas, but an incredibly rare side effect from thyroid or parathyroid surgery.

Horner syndrome as a complication after thyroid microwave ablation: Case report and brief literature review

RATIONALE

Horner's syndrome (HS) can present as a complication of thyroid surgery, particularly after thyroid microwave ablation (MWA). HS presents clinically with eyelid ptosis, miosis, enophthalmos, anhidrosis, and vascular dilatation, all of which result from a damaged oculosympathetic chain. We aimed to try to avoid such devastating symptoms in future cases by exploring reasons for the destruction of the cervical sympathetic trunk.

PATIENT CONCERNS

HS has previously been reported in the literature as a complication of thyroid surgery. Here, we report the case of a 44-year-old female patient who presented with miosis and eyelid ptosis following thyroid MWA.

DIAGNOSES

This patient was subsequently diagnosed with HS.

INTERVENTIONS

Mecobalamin was administered immediately.

OUTCOMES

After 5 months of follow up, the patient's miosis and ptosis was incompletely relieved.

LESSONS

Although HS is a rare complication of thyroid MWA, surgeons must be aware of the anatomic relationship of the cervical sympathetic trunk and thyroid gland with adjacent structures. Moreover, we hope this case presentation enables surgeons to take measures to minimize the possibility of oculosympathetic damage. Long-term follow up and comprehensive assessments are important for the patient's prognosis.

Horner's syndrome in traumatic first rib fracture without carotid injury; review of anatomy and pathophysiology

Case report of a 51 year old man involved in a motor vehicle accident presenting with multiple thoracic wall injury, including bilateral first rib fractures. He slowly developed a right sided Horner's syndrome due to a right paravertebral haematoma. The initial imaging did not display any carotid injury, however the developing right paravertebral haematoma was not initially reported. We review the anatomy and pathophysiology of this well-known but rare condition to show how first rib fractures should raise suspicion of Horner's syndrome irrespective of the presence or absence of any underlying blunt carotid injury.

Unusual Horner's Syndrome in Recurrent Breast Cancer: Evaluation Using 18F-FDG PET/CT

¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is a widely used imaging modality in the initial diagnosis of cancer, treatment response evaluation and detection of recurrence. Herein, we present the case of a 39-year-old female who presented right ptosis on the follow-up of breast cancer after surgery. Clinicians suspected Horner's syndrome, and the patient underwent FDG PET/CT for the evaluation of recurrence that could cause Horner's syndrome. FDG PET/CT demonstrated a focal hypermetabolic lesion in the right cervicothoracic junction area, corresponding to the preganglionic cervical sympathetic trunk. A subsequent needle biopsy was done, and the lesion was confirmed as metastatic ductal carcinoma. In this case, we could detect the exact location of the recurring lesion that caused Horner's syndrome using FDG PET/CT.

Horner syndrome in glandular fever: a case report

OBJECTIVE

This study aimed to present and discuss the case of a patient with known glandular fever who presented with Horner syndrome.

CASE REPORT

A 35-year-old patient with known glandular fever developed acute unilateral Horner syndrome, a previously undescribed complication of this common illness. Magnetic resonance imaging and magnetic resonance angiography showed that enlarged intra-carotid sheath lymphoid tissue was likely to be the underlying cause of sympathetic nerve disruption. The case is described, the anatomy of the sympathetic chain is discussed and possible alternative pathophysiological mechanisms are reviewed.

CONCLUSION

This is the first report in the worldwide literature of Horner syndrome arising as a result of compression from enlarged lymph nodes in glandular fever.

Horner's syndrome: An unusual presentation of metastatic disease in breast cancer

Horner's syndrome (HS) is caused by an interruption of the cervical sympathetic pathway to the eye and the face. Acquired HS is mainly caused by benign or malignant neoplasms, and in patients with a history of cancer, it is almost always the result of tumor infiltration into the periphery or the central region of the cervical sympathetic chain.We present the case of a 52-year-old patient with long-term disease-free survival (6 years) after a radical mastectomy for breast cancer who presented with cervicobrachialgia and typical HS due to a left lateral-cervical and supraclavicular lymph nodal mass. Treatment of the metastatic disease with taxanes and concurrent trastuzumab resulted in a complete pain resolution, as well as long-term clinical and radiologic remission; however, the neurological cohort of HS remained as the expression of permanent damage to the sympathetic pathway.This report presents a highly rare case of HS as the first and solitary appearance of metastatic disease in a breast cancer patient. This neurologic involvement should always raise suspicion of metastatic infiltration, and the early recognition of the syndrome may prevent permanent nerve injury.

Minor's Test: Objective Demonstration of Horner's Syndrome

To highlight the Minor's test, which is useful in demonstrating anhidrosis of Horner's syndrome. A 39 year old female presented to us with a slow growing neck swelling which was provisionally diagnosed as a probable case of cervical sympathetic chain (CSC) Schwannoma. Intra operatively, the mass was found arising from the CSC which was sacrificed. Post operatively, Horner's syndrome was expected, but was difficult to demonstrate clinically. On performing the Minor's test, the presence of anhidrosis, and thus Horner's syndrome was confirmed. Minor's test is a simple objective test to demonstrate Horner's syndrome, especially because diagnosis from the eye signs can be difficult.

Same day discharge following inter-scalene block administration for arthroscopic shoulder surgery: implementing a change in practice

Patients who had arthroscopic shoulder surgery with the provision of an inter-scalene nerve block (ISB) at Blackpool Teaching Hospitals, were previously required to remain in hospital overnight. We introduced a new protocol that allowed same day discharge following arthroscopic shoulder surgery under general anaesthesia and ISB. The aim of this study was to review the outcome of this change in practice. Our results indicated that providing a discharge protocol for patients having arthroscopic shoulder surgery with the inclusion of ISB can avoid unnecessary overnight stay and enable significant cost savings, without detriment to patient safety or satisfaction.

Intrathoracic schwannoma with Horner syndrome

Horner syndrome (HS) results from the interruption of the sympathetic pathway to the eye and face, and describes a collection of signs consisting of ipsilateral miosis, partial ptosis, anhidrosis and apparent enophthalmos. It is a clinical observation, and has a plethora of possible causes, ranging from the benign to the malignant. Involvement of the stellate ganglion on the sympathetic chain by malignant tumours of the lung is a well-recognised cause of HS. On the other hand, HS secondary to the excessive growth of a benign intrathoracic neoplasm is a very rare finding, with only a few cases described in the literature. Our patient was found to have such a diagnosis when he presented to medical attention with a 1-month history of cough that was associated with features of HS that he had ignored for the preceding 9 years.

Avoiding injury to the abducens nerve during expanded endonasal endoscopic surgery: anatomic and clinical case studies

BACKGROUND

Understanding the course of the most medially located parasellar cranial nerve, the abducens, becomes critical when performing an expanded endonasal approach.

OBJECTIVE

We report an anatomoclinical study of the abducens nerve and describe relevant surgical nuances to avoid its injury.

METHODS

Ten anatomic specimens were dissected using endoscopes attached to an high-definition camera. A series of anatomic measurements and relationships of the abducens nerve were noted. Illustrative clinical cases are described to translate those findings into practice.

RESULTS

Cisternal, interdural, gulfar, and cavernous segments of the abducens were identified intracranially. The mean distance from the vertebrobasilar junction (VBJ) to the pontomedullary sulcus (PMS) was 4 mm; horizontal distance between both abducens nerves at the PMS was 10 mm, and between both abducens at the interdural segment was 18.5 mm. The upper limit of the lacerum segment of the internal carotid artery was at the same level of the dural entry point of the sixth cranial nerve posteriorly. The sellar floor at the sphenoid sinus marks the level of the gulfar segment in the craniocaudal axis. At the superior orbital fissure, the abducens nerve and V2 were at an average vertical distance of 11.5 mm.

CONCLUSION

Anatomic landmarks to localize the abducens nerve intraoperatively, such as the VBJ for the transclival approach, the lacerum segment of the carotid, and the sellar floor for the medial petrous apex approach, and V2 for Meckel's cave approach, are reliable and complementary to the use of intraoperative electrophysiological monitoring.

Evidence for hypohydrosis as clinical clue to diagnosis of Horner's syndrome

A 59-year-old man presented with hypohydrosis in his left upper extremity and left hand, and experienced difficulty in gripping the steering wheel while driving. One year prior to admission, he had felt pain and/or paresthesias in his left anterior chest, left shoulder area and left periaxillar area, which corresponded to involvement of dermatomes in T1-T3. He was diagnosed with Horner's syndrome caused by lung tumour, which was located at the apical posterior wall along with the second to fourth ribs. The tumour interrupted sympathetic neurons at the T1-T4 level. The degree of hypohydrosis was successfully evaluated by the starch-iodine technique, dermal thermography and a skin surface hygrometer. After radiation therapy, hypohydrosis and pain or paresthesias improved partially, and he was discharged uneventfully.

Agenesis of the internal carotid artery associated with ipsilateral Horner syndrome in a child

Agenesis of the internal carotid artery is a rare, usually asymptomatic congenital anomaly. Patients may remain asymptomatic because a network of collaterals develops in response to agenesis of the internal carotid artery, which is usually diagnosed as an incidental finding after magnetic resonance imaging. The collateral circulation is prone to developing aneurysms and subarachnoid hemorrhages. We report on a 16-year-old boy with a 1-year history of chronic daily headache. He manifested left-sided miosis and ptosis, with no evidence of anhidrosis, flushing, or pain. He was diagnosed with agenesis of the internal carotid artery with established collateral circulation. The association of Horner syndrome with agenesis of the internal carotid artery is not well reported. Agenesis of the internal carotid artery should be further evaluated to delineate the underlying mechanism, using computed tomography to examine the integrity of the bony carotid canal. Hypoplasia or agenesis of the carotid canal will confirm the congenital cause of the condition. If the canal is intact, dissection of the internal carotid artery should be considered.

Thoracic outlet syndrome with involvement of the cervical sympathetics because of idiopathic tumoral calcinosis

A 38-yr-old woman reported intermittent pain, paresthesia, and weakness in the right upper limb and sweating on the right side of her face and ipsilateral upper limb during the last 4 yrs. Eventually, she was diagnosed with thoracic outlet syndrome, whereby sympathetic nervous system involvement was thought to ensue because of idiopathic tumoral calcinosis in the neck region. To our best knowledge, this is the first report of such a concomitance.

A rare cause of Horner syndrome

OBJECTIVES

To demonstrate the importance of thorough investigation of patients with Horner syndrome, and to explain the relevant anatomy.

CASE REPORT

A 46-year-old man presented with right-sided Horner syndrome. No other abnormality was found. Magnetic resonance imaging showed calcification of the stylohyoid ligament, with a pseudoarthrosis in the mid-portion of the ligament. This pseudoarthrosis was displacing and compressing the internal carotid artery and the adjacent sympathetic chain, causing Horner syndrome.

CONCLUSION

In this case, magnetic resonance imaging was invaluable in elucidating the cause of the Horner syndrome. This is the first described case of pseudoarthrosis of a calcified stylohyoid ligament causing Horner syndrome.

RESOLUTION OF MYDRIATIC PUPIL AFTER ANGIOPLASTY AND STENTING OF CERVICAL INTERNAL CAROTID ARTERY DISSECTION

OBJECTIVE

A patient with cervical internal carotid artery (ICA) dissection presented with visual loss and a mydriatic pupil that resolved after angioplasty and stenting.

CLINICAL PRESENTATION

A 49-year-old woman presented with a unilateral dilated tonic pupil and transient monocular visual loss and subsequently developed speech disturbance. Angiography revealed a left cervical ICA dissection with significant luminal narrowing. The ophthalmic artery filled retrograde through external carotid artery branches and reconstituted the supraclinoid ICA. Computed tomographic perfusion showed significant hypoperfusion of the left hemisphere. Magnetic resonance imaging showed punctate boundary zone infarcts.

INTERVENTION

The patient experienced pressure-dependent left hemispheric transient ischemic attacks and pressure-dependent ocular findings despite anticoagulation. She underwent uncomplicated left ICA angioplasty and stenting. The flow through the ophthalmic artery became anterograde. The tonic pupil returned to symmetry with the contralateral pupil, and the patient's symptoms resolved completely.

CONCLUSION

Cervical ICA dissection can manifest with a tonic mydriatic pupil. Treatment with angioplasty and stenting of the dissected segment can restore flow and resolve the pupillary abnormality. A pathophysiological mechanism for the mydriasis is proposed.