Horner's Syndrome

Question 1

Pathway associated with Horner’s

Answer 1

Sympathetic innervation to the eye
1. Ipsilateral Hypothalamus through the brain stem to T1/T2
2. At T1 it synapses and leaves the Spinal cord and ascends the cervical sympathetic chain the superior cervical ganglion
3. Internal carotid artery to the orbit via the superior orbita fissure to the dilator muscle of the iris

Question 2

Examination findings of horner’s

Answer 2

Miosis
Ptosis
Anhydrosis: upper quarter in 1st, face in 2nd, none in 3rd

Question 3

Causes of 1st order Horner’s

Answer 3

brain stem: stroke, tumour demyelination
spinal cord: syringomyelia, tumour, trauma

Question 4

Causes of 2nd order horner’s

Answer 4

lung apex: pan coast tumour
neck: tumour in cervical nodes, surgery, trauma, common carotid dissection

Question 5

Causes of 3rd order Horner’s

Answer 5

internal carotid dissection
cavernous sinus: thrombus, tumour
Orbit: tumour

Question 6

How would you investigate Horner’s?

Answer 6

Confirm horner’s: cocaine or hydroxyampethamine will exagerate anisocoria in 1st/2nd order horners, in 3rd order pupil will dilate. Apraclondine will cause dilation of affected pupil and other pupil may constrict.
Localise:
1st: MRI brain/spine
2nd: MRI neck, CXR, CT thorax, lymph node biopsy, carotid doppler
3rd: MRI neck, carotid doppler, MRI sinus/orbits

Question 7

How would you manage a patient with Horner’s?

Answer 7

Treat underlying cause
Manage ptosis: surgical correction