What should be the focus of history in the evaluation of Horner syndrome?

Updated: May 01, 2019
  • Author: Christopher M Bardorf, MD, MS; Chief Editor: Edsel Ing, MD, MPH, FRCSC  more...
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Although Horner syndrome is commonly an incidental finding related to a benign cause, it occasionally may be a manifestation of a serious and life-threatening disorder. Careful direction of the history to rule out such life-threatening disorders is vital.

Given that malignancy is a prominent feature of recently diagnosed preganglionic Horner syndrome, patients may avoid an unnecessary extensive workup for carcinoma if the lesion can be shown to be old or long-standing. To prove that a lesion is long-standing, inspect old photographs of the patient that might show ptosis or anisocoria. If the affected iris is blue and the other is brown, the lesion most likely was present at birth or during the first 2 years of life. (Of course, this color asymmetry will not occur in patients who are genetically blue-eyed.)

It is important to determine whether the patient has recently undergone an interventional procedure that has the potential to cause relevant neurologic damage. Iatrogenic Horner syndrome has been reported as a complication of a variety of chest, neck, and otolaryngologic procedures [13, 14, 15, 16, 17] ; for example, ptosis may rarely complicate injection of botulinum toxin for glabellar lines. [18]

Patients may not be able to open the affected eye completely and may not sweat on that side of the face. The presence, absence, or location of anhidrosis is an important localizing sign.

Patients with preganglionic lesions may have facial flushing. This symptom (ie, harlequin effect) occurs with physical exercise in some patients. Patients with postganglionic lesions may have ipsilateral orbital pain or a migrainelike headache.

Raeder described a combination of orbital pain, miosis, and ptosis and termed it paratrigeminal syndrome. [19] If this set of symptoms is associated with lesions of CNs III-VI on the ipsilateral side, a mass lesion in the middle cranial fossa (ie, type I Raeder paratrigeminal syndrome) should be suspected. A benign form characterized by episodic retrobulbar or orbital pain, with miosis and ptosis but without associated cranial nerve findings, is considered a migraine variant (ie, type II Raeder paratrigeminal syndrome).

Patients with carotid artery dissection may present with ipsilateral head, neck, or facial pain.

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