Horner syndrome results from a lesion anywhere along the sympathetic pathways from the brainstem to the spinal cord; then from the spinal cord to the sympathetic chain of the thorax; then to the cervical sympathetic system including the stellate ganglion and superior cervical ganglion giving off fibers around the carotid arteries. If we picture this neuroanatomy, we can recall most of the causes of Horner syndrome.
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Hoarseness |
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TABLE 39. Hoarseness |
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· Brainstem: Wallenberg syndrome (posterior inferior cerebellar artery thrombosis)
· Spinal cord: Syringomyelia spinal cord tumors, neurosyphilis
· Thorax: Carcinoma of the lung or esophagus, Hodgkin lymphoma, aortic aneurysm, mediastinitis
· Cervical sympathetics: Laryngeal carcinoma, thyroid carcinoma, cervical rib, brachial plexus neuralgia or trauma
· Carotid artery chain: Migraine, cluster headaches, carotid thrombosis
Approach to the Diagnosis
A history of headaches would suggest migraine or cluster headaches as the cause. The finding of long tract signs (pyramidal tract, e.g.) would suggest a brainstem or cord lesion. Hemiplegia would point to a carotid artery thrombosis. A mass in the neck suggests a Pancoast tumor or thyroid carcinoma. Pain in the neck or upper extremities without a mass should suggest a brachial plexus neuralgia, scalenus anticus syndrome, or Pancoast tumor. X-rays of the chest and cervical spine are indicated in all cases without other neurologic signs. When there are other neurologic signs, an MRI of the brain or spinal cord must be done. A neurologist should be consulted.
Other Useful Tests
1. VDRL (neurosyphilis)
2. Carotid duplex scan (carotid artery thrombosis)
3. CT scan of the mediastinum (mediastinal tumor)
4. SSEP (brachial plexus neuralgia)
5. Histamine test (cluster headaches)
6. Aortography (aortic aneurysm)
7. Mediastinoscopy (mediastinal tumor)
