PBL - Weak Hand And Drooping Eyelid

Question 1

Where would pain be felt if a Pancoast tumour encases the C8 nerve root, and what would happen to the muscles in that area?

Answer 1

Medial two digits of the hand would be painful

The intrinsic muscles of the hand would atrophy

Question 2

Describe the pain that would be felt if a tumour interferes with the T1 nerve root?

Answer 2

Pain which radiates down the medial aspect of the arm and forearm, stopping at the wrist

Question 3

If there is a disruption to the sympathetic nerves of the eye, what symptoms occur?

Answer 3

Ptosis 
Miosis 
Hemi-facial anhidrosis 
Loss of head and neck sympathetic tone 
Enophthalmos

Question 4

Describe the sympathetic pathway to the eye.

Answer 4

First order neuronal fibres
Second order neuronal fibres (pre ganglionic)
Third order neuronal fibres (postganglaionic)

Question 5

Describe when first-order neuronal fibres arise and end in sympathetic innervation of the eye

Answer 5

Arise from poster-lateral hypothalamus

Descend through brainstem until termination at C8-T2

Question 6

Describe when second-order neuronal fibres arise and end in sympathetic innervation of the eye

Answer 6

Exit through T1 root, travelling close to lung apex through sympathetic chain and cervical-thoracic ganglion
Terminate in superior cervical ganglion

Question 7

Describe when third-order neuronal fibres arise and end in sympathetic innervation of the eye

Answer 7

Exit ganglion forming plexus around carotid internal. Ascending into cavernous sinus
Runs to eye via CN4and CN51

Question 8

What does the sympathetic innervation of the eye supply do?

Answer 8

Supplies iris dilator muscles

Supplies smooth muscle of upper and lower lid

Question 9

Which fibres of the face cause sweating and tone to occur?

Answer 9

Vasomotor and sweat gland fibres

- form plexus around external carotid artery

Question 10

Which order of neuronal fibres are affected by a pancoast tumour to cause horners syndrome?

Answer 10

Second order neuronal fibres

- called a second order neuronal lesion

Question 11

Are pancoast tumours the only thing that can cause horners syndrome?

Answer 11

No - if any of the orders of neuronal fibres are affected in any way, the syndrome can appear

Question 12

Why does enopthalmos occur?

Answer 12

Loss of sympathetic supply to the eye causes narrowing of the palpebral fissure, causing the ILLUSION of enopthalmos

Question 13

How can upper limb swelling and discolouration be caused by a pancoast tumour?

Answer 13

Tumour growth in the lung apex can completely or partially compress the subclavian vein

Question 14

What problems in the upper limb can be caused by a pancoast tumour - and why?

Answer 14

Upper limb swelling and discolouration 
Loss of vascular tone (loss of sympathetic innervation)
Oedema (failure of venous drainage)
Tenderness
Erythema
Warmth

Question 15

Which anatomical structures allow the formation of three compartments within the thoracic inlet?

Answer 15

Insertion of the anterior and middle scalene muscle on the posterior scalene muscle (on second rib)

Question 16

What is found within the anterior compartment of the thoracic inlet?

Answer 16

Subclavian and internal jugular veins

Question 17

What is found within the middle compartment of the thoracic inlet?

Answer 17

Subclavian artery and some of its branches

Question 18

What is found within the posterior compartment of the thoracic inlet?

Answer 18

Brachial plexus branches, sympathetic trunk and cervical-thoracic ganglion

Question 19

What is a Pancoast tumour characterised by?

Answer 19

Malignant neoplasm of the superior sulcus of the lung with destructive lesions of the thoracic inlet and involvement of the brachial plexus and cervical sympathetic nerves

Question 20

What are the common clinical features of a Pancoast tumour?

Answer 20

Severe shoulder pain - radiating toward axilla and scapula 
Atrophy of hand and arm muscles 
Horner's syndrome 
Compression of blood vessels 
Oedema

Question 21

What type of cancer are Pancoast tumours normally?

Answer 21

Squamous cell carcinomas

Adenocarcinomas

Question 22

What is a main difference between a Pancoast tumour and classic lung cancers?

Answer 22

No breathlessness or coughing up blood

Question 23

How would a Pancoast tumour be diagnosed?

Answer 23

Biopsy
CT
MRI
PET

Question 24

How is a Pancoast tumour managed?

Answer 24

Assessment and appropriate staging
Surgical resection of the chest wall and lower brachial plexus and en bloc lung resection
- 30% 5yr survival

Question 25

Give some examples of problems at the level of first order neuronal fibres that can lead to horner’s syndrome

Answer 25

Basal meningitis 
Base of skull tumour
Demyelination disease
Intrapontine heamorrhage 
Neck trauma

Question 26

Give some examples of problems at the level of second order neuronal fibres that can lead to horner’s syndrome

Answer 26

Pancoast tumour 
Birth trauma to lower brachial plexus
Aortic dissection 
Central venous catheterisation 
Trauma 
Middle ear lesions

Question 27

Give some examples of problems at the level of third order neuronal fibres that can lead to horner’s syndrome

Answer 27

Internal carotid artery dissection
Migraine 
Carotid thrombosis 
Herpes zoster
Idiopathic