Horner syndrome following thyroidectomy

Abstract

Dear Editor,Horner syndrome (HS) is due to the disruption of sympa-thetic innervation of the eye anywhere along its three-neuron circuit. The typical clinical feature includes a triadof ipsilateral blepharoptosis, pupillary miosis, and facialanhydrosis. Neoplasm of lung apex (Pancoast tumor),vascular injuries, syringohydromyelia, carotid dissection orfibromuscolar dysplasia, are the most common causes [1].HS has only rarely been reported after thyroidectomy, withonly 28 cases mostly published in surgical journals [2, 3].Herein, we report a 56-year-old man exhibiting HS aftertotal thyroidectomy. Patient came at our observation40 days after surgical intervention for multinodular goiter.Histological examination on specimens from ablate thyroidtissue was negative for neoplasms. Immediately afterawakening from anesthesia, mild myosis, eyelid ptosis andenophthalmos of the right eye were evident. Patient alsoexhibited a bitonal voice. Neurological examination wasotherwise normal. Emiphacial anhydrosis was not noticedby patient. Laryngoscopy examination revealed right vocalcord paralysis. Brain MRI, chest X ray, single fiber EMGand neck CT scan were normal. At 2-month follow-up, aslight improvement of eyelid ptosis was observed.The possible causes of HS following thyroidectomyinclude post-operative hematoma compressing the cervicalsympathetic chain, ischemia-induced neural damagecaused by lateral ligature on inferior thyroid artery trunk,stretching of the cervical sympathetic chain by the retrac-tor, damage to the anastomosis between the cervical sym-pathetic chain and the recurrent laryngeal nerve during itsidentification [2]. Prognosis is usually poor with 70% ofpatients presenting permanent damage or incompleterecovery. Complete remission may occur after long time(up to 15 months). In the reported case, post-operativehematoma or adherences were ruled out by neck CT scan.Since right vocal cord paralysis, probably related to thedeficit of the inferior laryngeal nerve, was also present, weargue that mechanical damage on the anastomosis of therecurrent laryngeal nerve and sympathetic nervous bran-ches around the inferior thyroid artery, might cause HS inour patient.References