Question 10

Outline the diagnostic features of Horner’s Syndrome and list the likely causes in patients in Intensive Care.

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College Answer

Horner’s Syndrome is due to damage to the cervical sympathetic pathway, and exhibits a smaller pupil [miosis: due to reduced pupilo-dilation], a variable degree of ptosis and anhydrosis [impaired sweating over variable area] ± bloodshot eye [loss of vasoconstrictor].   The presence of enophthalmos is controversial.   Likely causes include common lesions along the path of the sympathetic pathway: including from brainstem (CVA) and cervical cord lesions (including trauma and local anaesthetic eg. epidural), through T1 root lesions (malignant disease eg. Pancoast syndrome; traction injuries to arm or aneurysms of aortic arch or subclavian artery), along the chain in the neck (malignancy, neck surgery, carotid artery dissection).   Transient Horner’s can occur with cluster headaches and with migraine. Many cases have no demonstrable cause.


Features of Horner's Syndrome:

  • Ptosis
  • Miosis
  • Anhidrosis of the forehead
  • Enophthalmos
Localisation of Lesions in Horner's Syndrome

Causes of Horner's

Associated clinical findings:

Cluster headache
  • Transient Horners; comes and goes
  • Severe headache, with rhinorrhoea and excessive tear production
Cortical stroke (hemispheric)
  • weakness, sensory deficit, homonymous hemianopia, diplopia, or ataxia
  • No sensory or motor level (instead, hemiplegia)
Brainstem stroke (lateral medullary syndrome)
  • Contralateral pain and temperature sensory loss
  • Ipsilateral facial sensory loss
  • Ipsilateral nystagmus
  • Dysphagia
  • Ipsilateral V, IX and X cranial nerve lesions
Cavernous sinus pathology
  • An associated sixth nerve palsy
  • Everything in the cavernous sinus may have been taken out (that being upper facial branches of the 5th nerve, the 4th nerve and the 3rd nerve)
  • Dysphagia
  • Nystagmus
  • Pharyngeal and palatal weakness
  • Asymmetric weakness and atrophy of the tongue
  • Sensory loss involving primarily pain and temperature senses in the distribution of the trigeminal nerve
  • Bilateral signs!
  • Dissociated sensory loss: lost pain and temperature sensation, but preserved light touch, vibration and proprioception
  • Cape-like distribution of pain
  • Hand weakness
  • Bowel and bladder incontinence, sexual dysfunction
Spinal injury or infarction
  • Weakness, sensory deficit; with a distinct sensory or motor level
  • No diplopia or hemianopia
Malignancy in the apex of the lung
  • Wasting of small muscles of hand and clubbing
  • Cervical and axillary lymph nodes
Thyroid cancer
  • Suprasternal mass, goitre
  • Thyroid bruit
  • Cervical and supra/infraclavicular lymph nodes
  • Signs of retrosternal goitre, eg. stridor
Neck trauma or surgery
  • Various scars, signs of head / neck surgery/trauma (it wouldn't be subtle)
Lower trunk brachial plexus injuries
  • Motor deficit isolated to the affected arm
  • Weakness in all median and ulnar innervated hand muscles
  • Weakness in radial innervated distal forearm and wrist muscles.
  • Sensory loss in the medial aspect of the arm, forearm and hand
Carotid aneurysm or dissection
  • Sudden onset of the syndrome
  • Pain of the neck or face
  • A carotid bruit which is unilateral