Iatrogenic Horner's syndrome

Iatrogenic Patrick

Homer’s

G. Gallagher*

Recent reports appear to indicate that the incidence of iatrogenic Horn&s Syndrome is increasing, perhaps due to an increased frequency of surgical procedures. anesthetic techniques, and vascular access methods applied to the cervical region. A case

H

ORNER’S SYNDROME consists of homolateral miosis, ptosis, facial anhydrosis, and apparent enophthalmos. It is caused by functional disruption of the three-neuron pathway that supplies the sympathetic fibers to the eye. A number of recent reports appear to indicate that the incidence of iatrogenic Horner’s syndrome is increasing, perhaps due to an increased frequency of surgical procedures, anesthetic techniques, and vascular access methods applied to the cervical region.lM4 The purpose of this report is to describe a case of iatrogenic Horner’s syndrome due to a malpositioned thoracostomy tube, and to review iatrogenic causes of this condition. CASE

REPORT

A 5-year-old girl with spinal muscle atrophy underwent posterior spinal fusion because of worsening scoliosis. A right-sided thoracostomy tube was placed at the time of operation. The patient’s postoperative course was complicated by recurrent right-sided pneumothorax, hyponatremia, and seizures. On the 10th postoperative day, the thoracostomy tube was replaced because of recurrent pneumothorax. The same day, right eyelid ptosis, right facial anhydrosis, and anisocoria were noted; the right pupil was 3 mm and the left 7 mm. Both pupils were round and reactive to light. There were no other new findings in her neurologic examination. The tip of the thoracostomy tube was noted to be at the apex of the right lung at the Tl-T2 interspace (Fig 1). The thoracostomy tube was immediately repositioned. The patient’s symptoms of Horner’s syndrome gradually resolved over the next 2 weeks.

From the Children’s Hospital Medical Center; and the Division of Critical Care, Department of Pediatrics. University ofcincinnati College of Medicine, Cincinnati, OH. Received May 14. 1990; accepted June 13,199O. *Present address: Department of Pediatrics. Yale Vniversity School of Medicine, New Haven, CT 06510. Address correspondence and reprint requests to George Benring III, MD, ChildrenS Hospital Medical Center, Elland and Bethesda Aves, Cincinnati, OH 45229. o 1990 by W.B. Saunders Company. 0a83-9441/90/0504-0004$5.00/0

238

and

Syndrome

George

Benzing

Ill

of Horner’s syndrome, due to a malpositioned costomy tube, is described and iatrogenic Horner’s syndrome are discussed. 0 1990 by W.B. Saunders Company.

thoracauses of

DISCUSSION

The pathophysiology of Horner’s syndrome involves the circuitous path of the three-neuron chain that supplies the sympathetic fibers to the eye and tarsal muscle.s,6 The first-order preganglionic neuron arises from the posterolateral hypothalamus, descends through the brainstem and cervical cord, and terminates between C-7 and T- 1 in the ciliospinal center of Budge. This is the origin of the second-order preganglionic neuron which exits the spinal cord through the first and second thoracic nerve roots and enters the sympathetic chain. The fibers ascend over the pulmonary apex, loop around the subclavian artery in the ansa subclavia, then ascend through the middle cervical ganglion to the superior cervical ganglion near the bifurication of the carotid artery. The third-order postganglionic neuron arises here and ascends to supply the sympathetic innervation of the head and neck, including the pupillary dilator muscle and Muller’s muscle of the eyelid. Horner’s syndrome is usually caused by damage to the first-order neuron by stroke or tumor; iatrogenic Horner’s syndrome is unusual. In 100 consecutive hospitalized adult patients with acquired Horner’s syndrome, surgical trauma was the etiology in seven cases, half of which were due to carotid artery catheterization.’ Review of 450 cases of Horner’s syndrome found 45 cases (10%) to be iatrogenic, primarily due to neck surgery and carotid arteriography.’ Giles and Henderson classified patients with surgicallyacquired Horner’s syndrome as primary or secondary, according to whether a Horner’s syndrome might reasonably be expected as a result of the surgery.6 Reported causes of iatrogenic Horner’s syndrome are listed in Table 1. The most frequently reported causes appear to be attempts at neck vessel catheterization and nerve block anesthesia. Unfortunately, compilation of case reports does not allow an accurate quantitaJournal

of Critical

Care, Vol5,

No 4 (December),

1990:

pp 238-240

IATROGENIC

HORNER’S

SYNDROME

thoracostomy tube A malpositioned Fig Il. interspace of the with its tip at the Tl-T2 pulml cna rya apex is noted on chest radiograph.

Table

Surgical Upper

1. Reported Horner’s

latrogenic Syndrome

Causes

of

-

procedures dorsal

and lower

cervical

sympsthectomy

Chordotomy Cervical laminectomy Thyroidectomy Tonsillectomy Coronary artery bypass grafting Vascular occlusion of sympathetic

ganglia

Anesthesia-related Positioning trauma Brachial plexus block Stellate ganglion block Epidural anesthesia Intraoral anesthesia Lumbar sympathetic

block

lntrapleural anesthesia Vascular catheter-related Internal jugular vein catheterization, catheter placement Carotid artery catheterization Migration of central venous Other

catheter

Neck manipulation Therapeutic pneumothorax Thoracostomy tube malposition Data compiled

from

references

1-22.

including

Swan-Ganz

tive analysis of causes of iatrogenic Horner’s syndrome. Horner’s syndrome, in association with thoracostomy tubes, has been reported in only a few patients.**19-** In all reports, there has been malposition of the thoracostomy tube. Fleishman et al postulated that placement of the tube tip near the first and second thoracic ganglia damages the second-order neuron.* They noted that only a thin connective tissue layer, the endothoracic fascia, separates the cervical pleura from the sympathetic chain in the pulmonary apex. There is no specific treatment for Horner’s syndrome. In iatrogenic cases, removal of the offending agent, if possible, is recommended. Gradual recovery occurs in most patients, although in a few patients, iatrogenic Horner’s syndrome has been permanent.*‘*** Increased recognition and accurate reporting will aid in determining the true incidence and natural history of this condition and, hopefully, prevent its occurrence. ACKNOWLEDGMENT We would like manuscript review.

to thank

Lester

W.

Martin,

MD,

for

240

GALLAGHER

AND

BENZING

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