Question 25.2

Examine the photograph shown below

This image is not from the college paper, but is reproduced without any permission whatsoever from this blog post by A. Lewis. Hang in there.

a) List three likely anatomical sites of lesions that can result in these eye signs

b) Give two associated clinical features that would help determine the site of the lesion?

[Click here to toggle visibility of the answers]

College Answer

a) List three likely anatomical sites of lesions that can result in these eye signs

Any three anatomical sites of the lesion:
•    Hemispheric lesion (hemispherectomy, massive hemispheric CVA, thalamic CVA)
•    Brainstem lesion (brainstem infarct, multiple sclerosis, brainstem tumour or encephalitis)
•    Central cord lesion (syringomyelia, glioma, ependymoma, traumatic)
•    T1 root lesion (Pancoast tumour, cervical rib, brachial plexus avulsion, aortic or subclavian aneurysm
•    Sympathetic chain (laryngeal, pharyngeal, thyroid or parathyroid surgery, carotid artery lesion, malignancy at base of skull)

b) Give two associated clinical features that would help determine the site of the lesion?

Any two of:
•    distribution of loss of sweating
•    distribution of loss of pain and temperature sensation
•    motor deficit
•    signs of central cord syndrome

•    wasting of small muscles of hand and clubbing
•    cervical LNs
•    Signs of head / neck surgery/trauma
•    Subclavian artery bruit

Discussion

This question is well revised from Table 10-12 of the most recent edition of Talley and O'Connor, which I have fancifully reinterpreted below:

Causes of Horner's Syndrome
Malignancy in the apex of the lung Thyroid cancer Neck trauma or surgery Lower trunk brachial plexus injuries Carotid aneurysm or dissection Cluster headache Brainstem stroke (lateral medullary syndrome) Syringobulbia Syringomyelia

In brief, one could answer the question in the following manner:

a) three likely anatomical sites of lesions:

Cortical hemisphere (eg. stroke or tumour)
Brainstem (eg. stroke or tumour)
Brachial plexus (eg. pancoast tumour)

b) two associated clinical features that would help determine the site:

Contralateral hemiparesis (cortical hemisphere or brainstem infarct)
Brainstem nuclei signs (diplopia, vertigo, ataxia)
Brachial plexus signs (eg. arm pain or weakness, small muscle wasting)

This could be really over-done. For example, in the cranial nerves section, there is a much longer list:

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)
Syringobulbia	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
Syringomyelia	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

References

Clinical Examination of the Critically Ill Patient, 3rd edition by L.I.G. Worthley - which can be ordered from our college here.

Clinical Examination: whatever edition, by Talley and O'Connor. Can be acquired any damn where.

[Submit a comment or correction]

Question 25.2

College Answer

Discussion

Causes of Horner's

Associated clinical findings:

References