17/02/2015

Question 1

How is breast cancer definitively diagnosed histologically?

Answer 1

Need a core biopsy to make a definitive histological diagnosis, FNA is no longer enough, even if it gives a c5 result (cytology 5 - malignant)

Question 2

How do you examine for Horners syndrome?

Answer 2

Constricted pupil on the affected side:
Shine a torch in the eye to make the pupil constrict.
Remove the torch and watch the pupil dilate.
Do the same on the other side and compare the response.
The affected pupil lags behind the other in dilation as it lacks sympathetic tone.

Ipsilateral dry skin on the face due to loss of sweating:
Take both index fingers and place then together in the middle of the forehead. Then run them laterally over the forehead to just lateral to the eyebrows.
On the affected side there may be more friction as the skin is drier because there is no sweating on that side.
A lesion in the common carotid artery area causes loss of sweating that involves the entire side of the face.
Lesions distal to the carotid bifurcation produce lack of sweating on the medial aspect of the forehead and the side of the nose.

Question 3

What are the Central (first-order) nerve causes of horners syndrome? (7)

Answer 3

Cerebrovascular accidents.
Multiple sclerosis.
Pituitary or basal skull tumours.
Basal meningitis (eg syphilis).
Neck trauma (eg cervical vertebral dislocation or dissection of the vertebral artery).	
Syringomyelia.
Arnold-Chiari malformation.

Question 4

What are the Preganglionic (second-order) nerve causes of horners syndrome? (7)

Answer 4

Apical lung tumours (eg Pancoast’s tumour).
Lymphadenopathy (lymphoma, leukaemia, tuberculosis, mediastinal tumours).
Lower brachial plexus trauma or cervical rib.
Aneurysms of the aorta, subclavian or common carotid arteries.
Trauma or surgical injury (neck or chest).
Neuroblastoma.
Mandibular dental abscess.

Question 5

What are the Postganglionic (third-order) nerve causes of horners syndrome? (5)

Answer 5

Cluster headaches or migraine.
Herpes zoster infection.
Internal carotid artery dissection.
Raeder's syndrome (paratrigeminal syndrome).
Carotid-cavernous fistula.

Question 6

What is the pathophysiology of Horners syndrome?
What are the triad of symptoms in Horners syndrome?
What other symptoms might there be depending on the location of the lesion?

Answer 6

This is a rare condition that results from disruption of the sympathetic nerves supplying the eye. There is the triad of:

Partial ptosis (upper eyelid drooping).
Miosis (pupillary constriction).
Hemifacial anhidrosis (absence of sweating).

Facial flushing (if preganglionic lesion).
Orbital pain/headache (if postganglionic lesion).

Question 7

A 55 year old patient has acute onset Horners syndrome of the left eye, with headache affecting the same eye. How do you manage this?

Answer 7

This patient with an acute isolated painful Horner syndrome is considered to have a left internal carotid artery dissection until proven otherwise. He needs to be evaluated emergently in neurology with noninvasive vascular imaging. If a dissection is confirmed, he will need to be admitted and treated to prevent a cerebral infarction.