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Horner's syndrome is caused by a lesion along the sympathetic pathway that controls the iris and sweat glands. This pathway runs from the brainstem and spinal cord through the neck. Lesions can be central in the brain/spinal cord, preganglionic in the neck, or postganglionic in the eye area. Signs include ptosis, miosis, anisocoria that worsens in dim light, and reduced sweating on the affected side of the face. The location of the lesion determines whether sweating is affected. Central lesions may be due to brainstem issues while preganglionic can arise from lung tumors or neck injuries. Testing distinguishes between lesion locations and rules out other causes of
Horner's syndrome is caused by a lesion along the sympathetic pathway that controls the iris and sweat glands. This pathway runs from the brainstem and spinal cord through the neck. Lesions can be central in the brain/spinal cord, preganglionic in the neck, or postganglionic in the eye area. Signs include ptosis, miosis, anisocoria that worsens in dim light, and reduced sweating on the affected side of the face. The location of the lesion determines whether sweating is affected. Central lesions may be due to brainstem issues while preganglionic can arise from lung tumors or neck injuries. Testing distinguishes between lesion locations and rules out other causes of
Horner's syndrome is caused by a lesion along the sympathetic pathway that controls the iris and sweat glands. This pathway runs from the brainstem and spinal cord through the neck. Lesions can be central in the brain/spinal cord, preganglionic in the neck, or postganglionic in the eye area. Signs include ptosis, miosis, anisocoria that worsens in dim light, and reduced sweating on the affected side of the face. The location of the lesion determines whether sweating is affected. Central lesions may be due to brainstem issues while preganglionic can arise from lung tumors or neck injuries. Testing distinguishes between lesion locations and rules out other causes of
brain stem disease (tumours. vascular. demyelination) syringomyelia lateral medullary (Wallenberg) syndrome spinal cord tumours 1. Preganglionic (second-order neurone) Pancoast tumour carotid and aortic aneurysms and dissection neck lesions (glands. trauma. postsurgical) J. Postganglionic (third~order neurone) duster headaches (migrainous neuralgia) internal carotid artery dissection nasopharyngeal tumours otitis media cavernous sinus mass
Mild ptosis (usually 1-2 mm) as a result of weakness of
Miillermuscle (Fig. 18.67). Slight elevation of the inferior eyelid as a result of weakness of the inferior tarsal muscle. Miosis resnlting from the unopposed acUon of the sphincter pupillae. with resultant anisocoria which is accentnated in dim light. since the Horner pupil will not dUate. like its fellow. i\ormal reactions to light and near
Reduced ipsilateral sweating, but only if thc lesion is
below the superior cervical ganglion because the fibres ~upplying the skin of the face run along the cxternal carotid artery. Hypochromic heterochromia (irides of different colourHorner is lighter) may be seen if the lesion is congenital or long-standing. The pupil is slow to dilate. Less important signs include hyperactive accommodation. ocular hypotony and conjunctival hyperaemia
Horner's syndrome is caused by a lesion of the sympathetic pathway either (1) in
its central portion, which extends from the posterior hypothalamus through the brainstem to the upper spinal cord (C8T2); or (2) in its preganglionic portion, which exits the spinal cord and synapses in the superior cervical (stellate) ganglion; or (3) in its postganglionic portion, from the superior cervical ganglion via the carotid plexus and the ophthalmic division of the trigeminal nerve, by which it enters the orbit. The sympathetic fibers then follow the nasociliary branch of the ophthalmic division of the trigeminal nerve and the long ciliary nerves to the iris and innervate Mller's muscle and the iris dilator. Iris dilator muscle paresis causes miosis, which is more evident in dim light. Melanocyte maturation in the iris of a neonate depends on sympathetic innervation; thus, less pigmented (bluer) irides occur if a congenital sympathetic lesion is present. Paresis of Mller's muscle produces ptosis. Unilateral miosis, ptosis, and absence of sweating on the ipsilateral face and neck make up the complete syndrome. Sweating on the face is normal in postganglionic lesions because postganglionic fibers to the face for sweating follow the external rather than the internal carotid artery. Central Horner's syndrome may be due to brainstem infarction, particularly lateral medullary infarction (Wallenberg's syndrome), syringomyelia, or cervical cord tumor. Preganglionic Horner's syndrome may be due to cervical rib, cervical vertebral fractures, apical pulmonary lesionsparticularly bronchogenic carcinoma (Pancoast's syndrome)or brachial plexus injuries. Postganglionic Horner's syndrome may be due to carotid artery dissection, skull base tumors, or cluster headache. The localization of central and preganglionic Horner's syndrome is often apparent from the associated clinical features. Sudden-onset isolated painful Horner's syndrome, particularly with a recent history of neck trauma or associated with pain in the neck or jaw, necessitates urgent investigation for carotid dissection, which may lead to thrombotic or embolic stroke. Horner's syndrome associated with chronic facial pain, particularly if associated with fifth, sixth, third, fourth, or second cranial nerve palsy, requires investigation for skullbase tumor.
Pharmacologic testing with topical cocaine in the conjunctival sac differentiates
Horner's syndrome, in which the pupil does not dilate, from physiologic anisocoria. Topical apraclonidine, which causes dilation of the affected but not the normal pupil, can also be used. Testing with hydroxyamphetamine drops differentiates central and preganglionic from postganglionic lesions, but they are difficult to obtain.
Figure 24.15. Appearance of Horner syndrome in four patients. A, Congenital
right Horner syndrome. Note associated heterochromia iridis and minimal ptosis. B, Left Horner syndrome after neck trauma. C, Left Horner syndrome associated with apical lung (Pancoast) tumor. D, Left Horner syndrome in a patient with Raeder's paratrigeminal neuralgia.