Horner sdr and Ddx

Question 1

A 60-year-old man comes to the physician because his wife has noticed that his left eye looks smaller than his right. He has had worsening left shoulder and arm pain for 3 months. He has smoked two packs of cigarettes daily for 35 years. Examination shows left-sided ptosis. The pupils are unequal but reactive to light; when measured in dim light, the left pupil is 3 mm and the right pupil is 5 mm. Which of the following is the most likely cause of this patient’s ophthalmologic symptoms?

Answer 1

Compression of the stellate ganglion by a Pancoast tumor can lead to Horner syndrome via injury of preganglionic sympathetic fibers. Superior sulcus tumors can infiltrate neighboring structures and cause additional symptoms, which is known as Pancoast syndrome. This patient’s shoulder and arm pain are likely symptoms of Pancoast syndrome, which also includes atrophy of the arm and hand muscles, and possibly superior vena cava syndrome and hoarseness due to compression of the recurrent laryngeal nerve. The most common cause of Pancoast syndrome is NSCLC, for which this patient is at risk because of his history of smoking.

Question 2

Aneurysm of the posterior cerebral artery (MIDRIASI FISSA, come anche l’erniazione uncale)

Answer 2

Aneurysm of the posterior cerebral artery could compress CN III, which carries parasympathetic fibers to the pupillary sphincter and ciliary muscle, and motor fibers to the levator palpebrae superioris and all extraocular muscles except for the superior oblique muscle and the lateral rectus muscle. Such an aneurysm would result in ptosis, which this patient has, as well as diplopia, a fixed and dilated pupil, and a down-and-out gaze, which are not present here. Rather than mydriasis, this patient has miosis. Furthermore, if such an aneurysm were symptomatic, it would manifest with headache rather than the shoulder and arm pain seen here.

Question 3

Dissecazione aortica

Answer 3

Carotid artery dissection can cause Horner syndrome by compressing the postganglionic sympathetic fibers near the internal carotid artery and damaging them directly or decreasing blood flow to their vasa nervorum. This patient’s smoking history is a risk factor for carotid artery dissection. However, carotid artery dissection most often has an acute onset of symptoms following some types of trauma (e.g., blunt trauma), which is not the case here. Furthermore, in addition to Horner syndrome, carotid artery dissection would manifest with headache and/or neck pain, while this patient has shoulder and arm pain.

Question 4

Trobosi seno cavernoso

Answer 4

Cavernous sinus thrombosis can result in Horner syndrome due to compression of postganglionic sympathetic neurons. However, cavernous sinus thrombosis has additional symptoms that are not present in this case, such as headache, photophobia, proptosis, and other cranial nerve palsies (commonly CN VI). In addition, cavernous sinus thrombosis is most commonly caused by an ascending infection from the face or sinuses, signs of which are not present here. This patient’s arm and shoulder pain would likewise not be explained by cavernous sinus thrombosis.