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Horner’s syndrome in a patient presenting with a spontaneous pneumothorax
  1. C Thakar,
  2. I Hunt,
  3. V Anikin
  1. Harefield Hospital, Middlesex, UK
  1. Mr I Hunt, Department of Thoracic Surgery, Harefield Hospital, Middlesex UB9 6JH, UK; ianjhunt{at}gmail.com

Abstract

Spontaneous pneumothoraces are a common thoracic problem presenting to an Accident and Emergency (A&E) department. The symptoms and signs are well described and a chest x-ray examination is usually diagnostic. However the neurological signs, specifically a Horner’s syndrome on the ipsilateral side, are not widely recognised. This case illustrates the association and emphasises that when assessing a patient with a suspected spontaneous pneumothorax, an ipsilateral Horner’s syndrome supports the clinical diagnosis. Further, its presence makes a tensioning pneumothorax, or as in this case a pneumothorax with significant collapse and apical adhesions, more likely. No previous case reporting the association has had the opportunity for thorascopic assessment and demonstration of likely cause.

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The association between an ipsilateral Horner’s syndrome and a spontaneous pneumothorax has been reported in a small number of cases since first being described in 1965.1 Disruption of the sympathetic innervations to the eye along the course of the sympathetic chain from the hypothalamus manifests in the characteristic features of homolateral miosis, ptosis of the upper eyelid, enopthalmos and varying degrees of facial flushing.2 The syndrome has been recognised as being secondary to many causes such as tumours, trauma and vascular injury.3 The mechanism associated with spontaneous pneumothoraces resulting typically in a partial Horner’s syndrome remains speculative. Tensioning with compression of the anatomical structures at the thoracic inlet or apical adhesions has been postulated.1 4

No available previously published report describes a case of ipsilateral Horner’s syndrome and spontaneous pneumothorax undergoing subsequent thorascopic assessment and visualisation of possible mechanism. As spontaneous pneumothorax presents to the A&E department most commonly, awareness of its association with an ipsilateral Horner’s syndrome provides an additional clinical clue both to the diagnosis and its potential severity.

CASE REPORT

A previously fit and well 39-year-old woman presented to her local emergency department with pleuritic chest pain, breathlessness and her second spontaneous right-sided pneumothorax confirmed radiologically. There was no evidence of tensioning and she remained cardiovascularly stable. After needle aspiration in the department and check chest x-ray examination she was discharged from the A&E department. Two days later she re-presented with acute breathlessness. Clinical observations were normal and chest x-ray examination confirmed a completely collapsed right lung. Further needle aspiration in the A&E department resulted in the lung only partially re-expanding. No neurological observation or eye signs were recorded at this time.

She was admitted overnight without further interventions and transferred to the regional thoracic centre the next day. She remained relatively comfortable throughout. On admission to the thoracic surgical unit a repeat chest x-ray examination demonstrated a completely collapsed right lung but no evidence of tensioning (fig 1A). Clinically, she was noted to have a right-sided miosis and partial ptosis (fig 1B). She underwent right-sided video-assisted thorascopic surgical (VATS) apical lung bullectomy and talc pleurodesis. A single ruptured string of adhesions extending from the thoracic inlet was noted medial to the course of the sympathetic chain. But no haematoma, swelling or other anatomical abnormality was found in the area of the stellate ganglion. Chronic bullae were also noted at the base of the adhesions at the apex of the lung (typical pattern). The procedure was completed without incident via a two-port VATS apical lung bullectomy, and her recovery was essentially unremarkable. The right-sided Horner’s syndrome had resolved in the recovery room, with a chest x-ray examination immediately after surgery showing a well-expanded lung.

Figure 1 (A) Complete right-sided pneumothorax; (B) right-sided Horner’s syndrome.

DISCUSSION

Although different causes of Horner’s syndrome are described, its association with spontaneous pneumothoraces appears to be under-reported and not widely recognised. To our knowledge this is the first report in which thorascopic assessment of a likely mechanism was performed following presentation. The probable cause in this case is traction caused by apical adhesions and a completely collapsed lung disrupting the sympathetic chain as it traverses the thoracic inlet. There was no evidence of tensioning, but this remains an additional mechanism leading to disruption of the sympathetic chain. In all cases cited, once the pneumothorax was relieved the Horner’s syndrome resolved. It is important medicolegally to recognise the presence of a Horner’s syndrome before an operation, as it is a rare but recognised complication of surgical pleurodesis.

In conclusion, the presence of unequal pupils in a patient presenting to the A&E department with a suspected spontaneous pneumothorax may represent an ipsilateral Horner’s syndrome. Further, this association, albeit rare, may reflect the severity of lung collapse and even the presence of a tensioning pneumothorax. Its identification may aid clinical diagnosis and appropriate further management in the emergency room.

REFERENCES

Footnotes

  • Competing interests: None.

  • Informed consent obtained for publication.