What is the diagnosis and treatment for Horner's (Horner) Syndrome?

From the Guidelines

Horner's Syndrome is a neurological condition that requires prompt medical attention to address the underlying cause, which may be a life-threatening condition such as a stroke or tumor. The syndrome is characterized by a triad of symptoms: pupil constriction (miosis), drooping of the upper eyelid (ptosis), and decreased sweating (anhidrosis) on the affected side of the face. It occurs due to damage to the sympathetic nerve pathway that runs from the brain to the eye and face. Some key points to consider in the diagnosis and management of Horner's Syndrome include:

• A complete ophthalmic examination with emphasis on the sensorimotor evaluation, complete three-step test, and consideration of the additional upright-supine test 1
• Careful checking for other neuro-ophthalmic signs and symptoms looking for Horner’s syndrome, cranial nerve palsy, internuclear ophthalmoplegia (INO), nystagmus, and hearing loss 1
• The primary diagnostician should refer the patient for evaluation by indicated neurology or otolaryngology specialists 1
• Treatment focuses on addressing the underlying cause rather than the symptoms themselves, and patients should seek prompt medical attention when these symptoms appear, as some causes (like stroke or tumors) require urgent intervention 1
• Understanding the anatomical pathway of sympathetic nerves helps explain why damage at different points can produce this specific constellation of symptoms. In terms of specific causes, carotid and vertebral artery dissection can result in ischemic stroke or transient ischemic attack, often associated with neck pain or headaches, and occasional Horner syndrome in cases of carotid dissections 1. Given the potential for serious underlying conditions, it is essential to prioritize prompt medical evaluation and treatment to minimize morbidity, mortality, and improve quality of life.

From the Research

Definition and Symptoms of Horner's Syndrome

• Horner's syndrome is a condition that results from an interruption of the oculosympathetic pathway, leading to a slightly droopy upper lid and a smaller pupil on the affected side 2.
• Patients may also experience a deficiency of sweating over the brow or face on the affected side, although this is less common 2.
• The condition does not usually cause vision problems or other significant symptoms, but it can be a warning sign of serious and potentially life-threatening processes 2.

Causes of Horner's Syndrome

• The causes of Horner's syndrome can be varied, including chest and neck tumors, stroke, and surgical procedures in the neck and chest 3.
• Carotid dissection is a common cause of Horner's syndrome, and it is important to diagnose dissection as anticoagulation can prevent carotid thrombosis and embolism 4.
• Internal carotid artery occlusion is a relatively rare cause of Horner's syndrome, but it can occur due to atherosclerosis 5.
• The prevalence of causes of Horner's syndrome depends on the accrual method, with procedures in the neck, chest, skull base, and paraspinal region accounting for most of the identified causes in some studies 3.

Diagnosis and Evaluation of Horner's Syndrome

• The diagnosis of Horner's syndrome can be difficult, as patients rarely present with the classic triad of ptosis, miosis, and anhydrosis 6.
• A combined clinical, pharmacological, and imaging algorithm can be used to diagnose and evaluate Horner's syndrome, including the use of apraclonidine and hydroxyamphetamine 6.
• Modern imaging modalities, such as magnetic resonance imaging and angiography, can be used to investigate the cause of Horner's syndrome, particularly in cases where carotid dissection is suspected 4.
• A clinical review of Horner's syndrome can help identify the signs, confirm the diagnosis, and evaluate the many causes of the condition 2.