Neuroscience · Year 2 · from Neuroscience
Case 1: Horner Syndrome
Patient Presentation
Demographics: 45-year-old male
Chief Complaint: Drooping of right eyelid and decreased sweating on right side of face for 2 weeks
History of Present Illness: A 45-year-old man noticed his wife pointing out that his right eyelid appeared droopy, and his right pupil looked smaller than the left. He had also noticed decreased sweating on the right side of his face during exercise. Over the past month, he has experienced right-sided neck pain and right arm pain radiating to the medial forearm and hand. He has a 30-pack-year smoking history. He denies headache, visual changes, or weakness.
Physical Examination:
- Vital signs: BP 138/82, HR 76, RR 14
- General: Well-appearing male
- HEENT: Right pupil 2 mm, left pupil 4 mm; anisocoria more pronounced in dim lighting; right ptosis (1-2 mm); right-sided facial anhidrosis
- Neurological:
- Cranial nerves: Ptosis and miosis on right; extraocular movements full; remainder normal
- Motor: Normal strength except 4/5 right hand intrinsics
- Sensory: Decreased sensation medial right forearm and 4th-5th digits (C8-T1 distribution)
- Reflexes: Absent right biceps and brachioradialis
Workup:
- Pharmacological testing: Cocaine 4% drops fail to dilate right pupil (confirms Horner syndrome); apraclonidine reverses anisocoria
- Chest X-ray: Apical mass in right upper lobe with rib destruction
- CT chest with contrast: 4.5 cm Pancoast tumor (superior sulcus tumor) invading the right brachial plexus and stellate ganglion
- Biopsy: Non-small cell lung carcinoma
Diagnosis: Right Horner syndrome secondary to Pancoast tumor (superior sulcus tumor)
Treatment:
- Oncology referral for staging and treatment of lung cancer
- Combined chemoradiation followed by surgical resection consideration
- Pain management for brachial plexopathy
- Horner syndrome is permanent due to destruction of sympathetic chain
Clinical Pearl: Horner syndrome results from disruption of the oculosympathetic pathway at any of three levels: first-order (hypothalamus to ciliospinal center at C8-T2), second-order (ciliospinal center through stellate ganglion to superior cervical ganglion), or third-order (along internal carotid to orbit). The classic triad is ptosis (paralysis of Muller's muscle), miosis (unopposed parasympathetic pupillary constriction), and anhidrosis (loss of facial sweating in central or preganglionic lesions). A Pancoast tumor affecting the stellate ganglion causes second-order Horner syndrome, often with ipsilateral brachial plexopathy (C8-T1).