Horner's Syndrome???

• By dizzybee
• Posted January 21, 2009 at 7:41 pm
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This is directly from www.emedicine.medscape.com

Background:
Horner syndrome (Horner’s syndrome) refers to a constellation of signs produced when sympathetic innervation to the eye is interrupted. Lesions at any point along the sympathetic pathway may result in Horner syndrome. Signs found in all patients, regardless of the level of interruption include mild-to-moderate ptosis owing to denervation of the sympathetically controlled Müller muscle, slight elevation of the lower lid (upside-down ptosis) due to denervation of the lower lid muscle analogous to the Müller muscle in the upper lid, and miosis and dilation lag, where pupillary dilation after psychosensory stimuli is slower in the affected pupil than the unaffected pupil.

Depending on the level of the lesion, impaired flushing and sweating may be found ipsilaterally. Anhydrosis affects the ipsilateral side of the body with central, first-order neuron lesions. Lesions affecting second-order neurons may cause anhydrosis of the ipsilateral face. With postganglionic lesions occurring after vasomotor and sudomotor fibers have branched off the sympathetic chain, anhydrosis is either absent or limited to an area above the ipsilateral brow. The pupils react normally to light and accommodation.

Iris heterochromia (with the affected eye being hypopigmented) is seen in congenital Horner syndrome or Horner syndrome that occurs in children younger than 2 years. Iris heterochromia also may occur in long-standing Horner syndrome.

Pathophysiology
First-order central sympathetic fibers arise from the posterolateral hypothalamus, descend uncrossed through the mid brain and pons, and terminate in the intermediolateral cell column of the spinal cord at the level of C8-T2 (ciliospinal center of Budge). Second-order preganglionic pupillomotor fibers exit the spinal cord at the level of T1, and enter the cervical sympathetic chain, where they are in close proximity to the pulmonary apex and the subclavian artery.

The fibers ascend through the sympathetic chain and synapse in the superior cervical ganglion at the level of the bifurcation of the common carotid artery (C3-C4). Postganglionic pupillomotor fibers exit the superior cervical ganglion and ascend along the internal carotid artery. Shortly after the postganglionic fibers leave the superior cervical ganglion vasomotor and the sudomotor fibers branch off, they travel along the external carotid artery to innervate the blood vessels and sweat glands of the face. The pupillomotor fibers ascending along the internal carotid artery enter the cavernous sinus. Then, the fibers leave the carotid plexus briefly to join the abducens nerve (cranial nerve VI) in the cavernous sinus and enter the orbit through the superior orbital fissure along with the ophthalmic branch of the trigeminal nerve (V1) via the long ciliary nerves. Then, the long ciliary nerves innervate the iris dilator and the Müller muscle.

Mortality/Morbidity
Depends on specific etiology

Clinical
History
Obtaining a careful history is very helpful in the localization of lesions causing Horner syndrome.

First-order neuron lesions may be associated with signs and symptoms such as hemisensory loss, dysarthria, dysphagia, ataxia, vertigo, and nystagmus.
Second-order neuron lesions may be preceded by trauma and may be accompanied by facial, neck, axillary, shoulder or arm pain, cough, hemoptysis, history of thoracic or neck surgery, history of chest tube or central venous catheter placement, or neck swelling.
Symptoms associated with third-order neuron lesions include diplopia from sixth nerve palsy, numbness in the distribution of the first or second division of the trigeminal nerve, and pain.
The presence, absence, and/or location of anhydrosis is an important localizing sign that may be elicited from the history.
Although Horner syndrome is commonly an incidental finding related to a benign cause, it occasionally may be a manifestation of a serious and life-threatening disorder. Careful direction of the history to rule out such life-threatening disorders is of the utmost importance (see Causes).

Physical
Important aspects of the physical examination include the following:
Measurement of pupillary diameter in dim and bright light and their reactivity to light and accommodation
Examination of the upper lids for ptosis
Examination of the lower lids for upside-down ptosis (eg, position of the lower lid with respect to the inferior limbus)
Extraocular movements
Biomicroscopic examination of the pupillary margin and iris structure and color
Confrontational visual field testing and testing of facial sensation
Observation for the presence of nystagmus, facial swelling, lymphadenopathy, or vesicular eruptions
Causes
First-order neuron lesions
Arnold-Chiari malformation
Basal meningitis (eg, syphilis)
Basal skull tumors
Cerebral vascular accident (CVA)/Wallenberg syndrome (lateral medullary syndrome)
Demyelinating disease (eg, multiple sclerosis)
Intrapontine hemorrhage
Neck trauma (eg, traumatic dislocation of cervical vertebrae, traumatic dissection of the vertebral artery)
Pituitary tumor
Syringomyelia
Second-order neuron lesions
Pancoast tumor (tumor in the apex of the lung - most commonly squamous cell carcinoma)
Birth trauma with injury to lower brachial plexus
Cervical rib
Aneurysm/dissection of aorta
Subclavian or common carotid artery
Central venous catheterization
Trauma/surgical injury (eg, radical neck dissection, thyroidectomy, carotid angiography, coronary artery bypass graft)
Chest tubes
Lymphadenopathy (eg, Hodgkin disease, leukemia, tuberculosis, mediastinal tumors)
Mandibular tooth abscess
Lesions of the middle ear (eg, acute otitis media)
Neuroblastoma
Third-order neuron lesions
Internal carotid artery dissection (associated with sudden ipsilateral face and/or neck pain)
Raeder syndrome (paratrigeminal syndrome) - Oculosympathetic paresis and ipsilateral facial pain with variable involvement of the trigeminal and oculomotor nerves
Carotid cavernous fistula
Cluster/migraine headaches
Herpes zoster

Drugs (may cause symptoms similar to Horner syndrome and may affect any region)
Acetophenazine
Alseroxylon
Bupivacaine
Butaperazine
Carphenazine
Chloroprocaine
Chlorpromazine
Deserpidine
Diacetylmorphine
Diethazine
Ethopropazine
Etidocaine
Fluphenazine
Guanethidine
Influenza virus vaccine
Levodopa
Lidocaine
Mepivacaine
Mesoridazine
Methdilazine
Methotrimeprazine
Oral contraceptives
Perazine
Prilocaine
Procaine
Prochlorperazine
Promazine
Promethazine
Propoxycaine
Reserpine
Thioproperazine
Thioridazine
Trifluoperazine

As you can see, a WIDE array of things can cause it, including medications......i also search 'diseases' using the www.diseasesdatabase.com it has just about anything and everything you could imagine, and it is reliable information (not wikipedia)......

don't be scared, if its a tumor, they'll take the little bugger out of there. Good Luck tomorrow!!!!

• Reply

• By snuffle
• Posted January 21, 2009 at 8:11 pm
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Dizzybee,
Thank you so much for the comprehensive overview. I read the e-med entry, and I didn't get nearly as much info from it as you did. I understand better now, (but am still apprehensive)
I read your posts as often as they appear, and I think you're amazing. Your willingness to give your time to help the rest of us keep informed is wonderfuly selfless. Thanks again. I did not know about the disease database. Going there now.
Cheryl

• Reply

• By dizzybee
• Posted January 21, 2009 at 8:20 pm
• Report post

No, not at all selfless -- just glad to be able to help. Been on disability since 2002.....i am so glad to have found this site. It really HELPS me, i get tired or cleaning house (and i like to clean) or sitting around feeling sorry for myself; so this gives me a chance to help someone else, just to help point them in the right direction is sometimes enough. Knowledge is power!!

Don't be to apprehensive, i know that stuff is complicated and hard to read and scary....just muddle through it and think happy thoughts, you may not have nearly half of the stuff that is there and maybe just a different version of it....Good luck.

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