Horner Syndrome Secondary to Thyroid Surgery

Horner syndrome immediately after deep dissection of upper thyroid pole: a case report and review of the literature

Objectives

Horner syndrome (HS) is a rare complication of thyroid surgery. However, the relationship between the occurrence of HS and thyroid upper pole injury is still not completely clear, and there are only few reports.

Case presentation

A 24-year-old female underwent endoscopic thyroidectomy for thyroid papillary carcinoma. The intraoperative examination found that the upper pole of the thyroid was bleeding. During hemostasis, the ultrasonic knife consciously peeled too deep and stopped. The patient developed HS immediately after operation. We analyzed the association between deep dissection of the upper thyroid pole and an increase in the HS incidence rate through literature searches and anatomical relationships.

Conclusions

Our case report discussed the potential relationship between the degree of thyroid upper pole dissection and the occurrence of HS in routine thyroid surgery, and provided a warning for the degree of thyroid upper pole dissection in the clinic to avoid HS.

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 after thyroid-related surgery: a review

BACKGROUND

Horner syndrome (HS) is caused by damage to the cervical sympathetic nerve. HS is a rare complication after thyroidectomy. The main manifestations of HS include miosis and ptosis of the eyelids, which seriously affect esthetics and quality of life. At present, there is a lack of research on HS after thyroidectomy, and its etiology is not completely clear. This review aimed to evaluate how to reduce the incidence of HS and promote the recovery from HS as well as to provide a reference for the protection of cervical sympathetic nerves during surgery.

RESULTS

HS caused by thyroid surgery is not particularly common, but it is still worthy of our attention. After searching with "Horner Syndrome," "Thyroid" as keywords, a total of 22 related cases were screened in PubMed. The results showed that open surgery, endoscopy, microwave ablation, and other surgical methods may have HS after operation. In addition, the statistics of 1213 thyroid surgeries in our hospital showed that the incidence of HS after endoscopic surgery (0.39%) was slightly higher than that after open surgery (0.29%). Further, this review analyzed potential causes of HS after thyroidectomy, so as to provide a theoretical basis for reducing its incidence.

CONCLUSION

Preventing HS during thyroidectomy is a difficult problem. The close and highly variable anatomical relationship between the thyroid and cervical sympathetic nerves increases the risk of sympathetic nerve damage during thyroidectomy. Surgery and the use of energy equipment are also closely related to the occurrence of HS.

OUP accepted manuscript

Complications of percutaneous ethanol injection (PEI) for thyroid cyst are rare. Almost all complications reported have been transient, including Horner’s syndrome. We provide herein the first description of persistent blepharoptosis subsequent to PEI, necessitating surgical correction. A 54-year-old woman presented to our hospital with left blepharoptosis that had occurred the day after PEI for a thyroid cyst. She showed 2 mm of blepharoptosis and 1 mm of miosis in the left eye compared to the right eye. Magnetic resonance imaging of the brain demonstrated no abnormalities, and computed tomography detected no lesions in the neck or chest other than the already known cyst. Instillation of phenylephrine eye drops allowed elevation of the left upper eyelid. Considering these findings, we diagnosed the blepharoptosis as part of Horner’s syndrome. The ptosis was corrected by levator aponeurosis advancement. No recurrence has been observed as of 9 months postoperatively.

Imaging of Horner syndrome in pediatrics: association with neuroblastoma

Neuroblastoma is the most common neoplasm associated with pediatric Horner syndrome. The laboratory and imaging evaluation of isolated pediatric Horner syndrome is controversial. We review the literature published in the last several decades and present the rationale for the imaging work-up in this patient cohort.

Case report and literature review: Horner syndrome subsequent to endoscopic thyroid surgery

Background

Horner syndrome (HS), mainly characterized by symptoms including ptosis, miosis, and anhidrosis on the affected face, is a condition that is well documented but rarely reported as a postoperative complication of thyroidectomy, particularly in endoscopic thyroid surgery (ETS). We hereby report a case of HS due to ETS with a brief literature review on this topic.

Case presentation

A 31-year-old female was admitted to our hospital with an unexpected physical examination finding of two thyroid nodules that were hypoechoic, had an irregular shape, and exhibited calcification. Subsequently, the results of a fine-needle aspiration (FNA) biopsy from the thyroid nodules and BRAF^V600E mutation further confirmed the malignancy of these nodules. Thus, total thyroidectomy combined with central lymph node dissection (CLND) by ETS via the bilateral axillo-breast approach was performed on this patient. Histology confirmed the diagnosis of papillary thyroid microcarcinoma (PTMC) concurrent with Hashimoto’s thyroiditis (HT). However, this patient developed HS with ptosis in her left eye on postoperative day 3. All symptoms gradually resolved before the 3-month follow-up.

Conclusion

HS subsequent to ETS is a rare complication. Thus, standardized and appropriate operative procedures, as well as subtle manipulation, are essential in preventing and reducing the occurrence of HS. In addition, the early diagnosis and management of this rare complication are also important for a favorable outcome.