Horner Syndrome

Diseases, , ,

Synonyms:

a.k.a. occulosympathetic defect

Diagnosis:

This is a clinical diagnosis plus pharmacological tests on occasion

Clinical features:

Miosis, partial ptosis, anhydrosis, illusion of enophthalmos, red eye

Pharmacological test:

Cocaine eye drops 2% in both eyes, failure to dilate diagnoses Horner’s syndrome.
Dilation on adding amfetamine (Paradrine 1% (hydroxyamphetamine, most common) or Pholedrine 5% (n-methyl derivative of hydroxyamphetamine) to the affected eye localises it to 1st or 2nd order neuron (post ganglionic nerve is intact).

Investigations to consider:

CTA head and neck, or MRA Head and neck: to rule out carotid dissection
CXR: lung tumor
CT thorax: lung tumor, neuroblastoma, metastatic breast cancer
MRI brain and MRA cervical spine: central causes
Ultrasound thyroid & carotid: thyroid tumors

Causes of Horner’s syndrome:

Central (1st neuron)

  • Brainstem infarction
  • Cerebral hemorrhage/infarction
  • Multiple sclerosis
  • Intracranial tumour
  • Transverse myelopathy
  • Syrinx

Preganglionic (2nd neuron)

  • Thoracic & neck tumour:
    • Pulmonary apex
    • Thyroid mass
    • Cervical rib
  • Mediastinum disease
  • Trauma
  • Surgery: Endarterectomy

Postganglionic (3rd neuron)

  • Intrancranial tumour
  • Cavernous sinus
  • Cartoid artery aneurysms & dissection
  • Trauma & surgery
  • Headache e.g. Cluster headache
  • Idiopathic

 

Causes ptosis:

Neurogenic ptosis:

  • Horner’s syndrome
  • Oculomotor nerve palsy (unilateral or bilateral)

Myogenic ptosis:

  • Myasthenia gravis (bilateral, but may be asymmetric)
  • Lambert Eaton myasthenic syndrome (bilateral)
  • Chronic progressive external ophthalmoplegia ‘mitochondrial DNA mutations’ (bilateral)
  • Oculopharyngeal muscular dystrophy (bilateral)
  • Myotonic dystrophy (bilateral)
  • Other myopathies (bilateral)

Mechanical ptosis:

  • Saging tissue in elderly
  • Infection etc.
  • Aponeurotic ptosis: stretching or dehiscence of the tendon