Horner's Syndrome and Pancoast Tumours

Question 1

What is Horner’s syndrome?

Answer 1

A triad of three unilateral symptoms: ptosis, anhidrosis and miosis

Question 2

What is ptosis?

Answer 2

Drooping of the upper eyelid

Question 3

What is anhidrosis?

Answer 3

absence of sweating

Question 4

What is miosis?

Answer 4

Constricted pupil

Question 5

In Horner’s syndrome there may also be enophthalmos. What is enophthalmos?

Answer 5

Posterior displacement of the eye

Question 6

Describe the sympathetic nervous supply to the eye

Answer 6

Originates in the hypothalamus and descends via the brainstem to terminate in the ciliospinal centre (C8-T1)
A preganglionic fibre then exits then T1 root and travels close to the lung apex through the sympathetic chain and stellate ganglion to terminate in the superior cervical ganglion
the post ganglionic neuron then forms a plexus around the internal carotid artery and ascends into the cavernous sinus where it enters the orbit via the ophthalmic division of the trigeminal nerve

Question 7

What structures in the eye does the ophthalmic division of the trigeminal nerve innervate?

Answer 7

Iris dilatory muscles

Smooth muscle fibres of the upper and lower lid

Question 8

How do the nerve fibres which provide sympathetic innervation to the eye, affect the sweat glands?

Answer 8

These fibres follow the external carotid artery to supply the sweat glands of the ipsilateral side of the face

Question 9

Horner’s syndrome can result from a lesion at any point in the neuronal pathway of the sympathetic innervation to the eye. T/F?

Answer 9

true

Question 10

What is a Pancoast tumour?

Answer 10

A tumour which exists on the superior sulcus of the lung and has destructive lesions of the thoracic outlet

Question 11

What are the most common tumour types of Pancoast tumours?

Answer 11

Squamous cell carcinomas or adenocarcinomas

Question 12

Why is the location of a Pancoast tumour significant?

Answer 12

Because the local inflammatory effects of the tumour puts pressure on the surrounding nerves and blood vessels (i.e. stellate ganglion, brachial plexus, superior vena cava)

Question 13

If a Pancoast tumour invades the brachial plexus, what symptoms will occur?

Answer 13

Shoulder pain
Weakness
Paraesthesia

Question 14

Pancoast tumours can result in Horner’s syndrome. Why is this?

Answer 14

Horner’s syndrome can result from compression of the T1 sympathetic nerve root which can occur with Pancoast tumours

Question 15

How can Pancoast tumours result in erythema, oedema and a decrease venous return resulting in dyspnoea?

Answer 15

By compressing the superior vena cava if the Pancoast tumour is located in the right lung

Question 16

What imaging techniques are used to diagnose Pancoast tumours?

Answer 16

CT

CXR

Question 17

How are Pancoast tumours treated?

Answer 17

This depends on the types of tumour involved and its effect on surrounding structures
surgery is used to remove the tumour
Often chemotherapy or radiotherapy is required pre-surgery to shrink the tumour

Question 18

From which nerve roots does the brachial plexus arise?

Answer 18

C5-T1

Question 19

Which spinal nerves combine to form the superior trunk of the brachial plexus?

Answer 19

C5/6

Question 20

Which spinal nerves combine to form the inferior trunk of the brachial plexus?

Answer 20

C8/T1

Question 21

Which spinal nerve(s) form the middle trunk of the brachial plexus?

Answer 21

C7

Question 22

Which cord of the brachial plexus do the anterior branches of the superior and middle trunks form?

Answer 22

Lateral cord

Question 23

The three posterior branches of the superior, middle and inferior trunks of the brachial plexus form which cord?

Answer 23

Posterior cord

Question 24

Which branch of the brachial plexus forms the medial cord?

Answer 24

Anterior branch of the inferior trunk

Question 25

A branch from the lateral cord and medial cord combine to form which terminal nerve branch of the brachial plexus?

Answer 25

Median nerve

Question 26

From which cord of the brachial plexus do the axillary and radial nerves form?

Answer 26

Posterior cord

Question 27

From which cord of the brachial plexus does the musculatocutaneous nerve form?

Answer 27

Lateral cord

Question 28

From which cord of the brachial plexus does the ulnar nerve form?

Answer 28

Medial cord

Question 29

From which cord of the brachial plexus do the medial pectoral, medial cutaneous nerve of the arm and medial cutaneous nerve of the forearm arise?

Answer 29

Medial cord

Question 30

From which cord of the brachial plexus do the upper sub scapular, thoracodrosal and lower sub scapular nerve arise?

Answer 30

Posterior cord

Question 31

From which cord of the brachial plexus does the lateral pectoral nerve arise?

Answer 31

Lateral cord

Question 32

From which trunk of the brachial plexus do the supra scapular and subclavius nerve arise?

Answer 32

Superior trunk

Question 33

From which nerve roots does the dorsal scapular nerve arise?

Answer 33

C5/6/7

Question 34

Why are biopsies particularly useful in the diagnosis of Pancoast tumours?

Answer 34

To determine the cell type of the cancer involved

Question 35

What diagnostic tests can be used to check for metastasis of Pancoast Tumours?

Answer 35

CT or mRU of the brain

Mediastinoscopy (determine spread to the mediastinum)

Question 36

What factors worsen the prognosis of a Pancoast tumour?

Answer 36

Presence of Horner syndrome
mediastinal lymph involvement
Incomplete surgical removal of the tumour