|Year : 2016 | Volume
| Issue : 3 | Page : 88-89
Horner's syndrome: A rare complication of thyroid cancer surgery
Sonmez Ocak1, Huseyin Alakus2, Mehmet Esat Duymus2, Mustafa Kaya2, Kursat Karadayi2, Elif Colak1
1 Department of General Surgery, Samsun Training and Research Hospital, Samsun, Turkey
2 Department of Surgical Oncology, Cumhuriyet University Hospital, Sivas, Turkey
|Date of Submission||19-Jan-2016|
|Date of Acceptance||27-Feb-2016|
|Date of Web Publication||30-Sep-2016|
Department of General Surgery, Samsun Training and Research Hospital, Baris Bulvari, No. 199, Ilyaskoy, Samsun
Source of Support: None, Conflict of Interest: None
Horner's syndrome (HS) is a disorder of oculosympathetic pathway. Signs of this syndrome are ipsilateral ptosis, pupillary miosis, and anhidrosis. Cerebrovascular diseases, malignant tumors and iatrogenic injuries after neck and thoracic surgical procedures are the most common reasons. It is a rare complication of thyroid cancer surgery. In this case report, a patient with HS after total thyroidectomy and central neck dissection due to medullary thyroid carcinoma with multiple endocrine neoplasia type 2A had presented.
Keywords: Central neck dissection, Horner′s syndrome, multiple endocrine neoplasia type 2A, thyroidectomy
|How to cite this article:|
Ocak S, Alakus H, Duymus ME, Kaya M, Karadayi K, Colak E. Horner's syndrome: A rare complication of thyroid cancer surgery. Transl Surg 2016;1:88-9
|How to cite this URL:|
Ocak S, Alakus H, Duymus ME, Kaya M, Karadayi K, Colak E. Horner's syndrome: A rare complication of thyroid cancer surgery. Transl Surg [serial online] 2016 [cited 2019 Mar 22];1:88-9. Available from: http://www.translsurg.com/text.asp?2016/1/3/88/191505
| Introduction|| |
Horner's syndrome (HS) is a clinical entity which consists of ipsilateral ptosis, pupillary miosis, and facial anhidrosis due to interruption of the oculosympathetic pathway.  It was first described in 1869 by a Swiss ophthalmologist, Horner.  It can be congenital or acquired. The most common causes of acquired HS are cerebrovascular diseases, mediastinal and neck tumors, neck trauma and iatrogenic injury after neck and thoracic surgery.  Iatrogenic HS was described in the several case reports after thoracic and neck surgery or invasive surgical procedures in these areas. It can also be seen after thyroid surgery as a rare complication.  Here, we present a patient suffering HS after total thyroidectomy and central neck dissection (CND) due to thyroid medullary cancer with multiple endocrine neoplasia type 2A (MEN-2A).
| Case Report|| |
A 29-year-old female patient with MEN-2A was admitted to the Department of Surgical Oncology of Cumhuriyet University Hospital. Genetic analysis revealed an RET-oncogene mutation. Her mother had died of metastatic medullary thyroid carcinoma. Thyroid ultrasonography demonstrated 4 mm nodules in the left lobe of the thyroid gland and multiple lymph nodes in the central neck compartment. In laboratory studies, serum calcitonin and carcinoembryonic antigen (CEA) levels were high (serum calcitonin: 33.1 pg/mL, CEA: 3.6 ng/mL). Serum parathormone, calcium, metanephrine and urine vanillylmandelic acid, and metanephrine levels were normal, so pheochromocytoma and hyperplasia of the parathyroid glands were ruled out. A total thyroidectomy with bilaterally CND was done. Postoperatively, she complained of inability to retract left upper eyelid. Ophthalmic examination revealed right miosis, ptosis, and anhidrosis consistent with HS. Hematoma, seroma, and infection were ruled out as the possible causes of HS. No other pathology which could lead to HS was found in other clinical examinations. Thus, HS was attributed to damage to the cervical sympathetic chain. The patient was discharged on the second postoperative day. By 2 months after surgery, the patient's signs of HS had resolved without any treatment.
| Discussion|| |
HS can be produced by a lesion anywhere along the sympathetic pathway that supplies the head, eye, and neck. Causes range from benign to serious, requiring a systematic approach to diagnostic evaluation.  HS presents with miosis and ptosis of the affected eye. Furthermore, ipsilateral anhidrosis can be seen. In some cases, this classic triad is not present. , Interruption of the oculosympathetic pathway results in paralysis of the pupillary dilator muscle and the affected eye has a smaller pupil. Because of the paresis of Mueller's muscle, an upper eyelid retractor, ptosis of the upper lid occurs. In patients with HS, the vasomotor and sudomotor innervations to the face are interrupted, resulting in unilateral anhidrosis. 
Iatrogenic causes of the syndrome include neck and thoracic surgery, tube thoracostomy, carotid endarterectomy, lymph node fine needle aspiration, and central venous catheterization. ,,
It is a rare complication of cervical and thyroid surgery. ,,,,, The surgical procedures which most often trigger it are carotid endarterectomy and cervical spine surgery via an anterior approach. , Postoperative hematomas, ischemia-induced nerve damage and excessive stretching of the cervical sympathetic chain by the retractor are leading possible causes.  Cervical lymph node dissection is a very rare cause of HS. , The cervical sympathetic trunk (CST) can pass within the posterior wall of the carotid sheath. Hence, compression of the carotid sheath by the retractor is a possible cause of CST injury during thyroidectomy.  Anatomical variations which leave a patient susceptible to damage to the sympathetic chain, postoperative hematoma compressing the sympathetic chain, and ischemic damage to the sympathetic chain are suspected theories to explain this phenomenon.  The inferior thyroid artery may cross the intermediate ganglion anteriorly or posteriorly. If the middle ganglion and inferior thyroid artery are too close together, the middle ganglion can be injured during the ligation of the inferior thyroid artery. This may be another reason for postoperative HS after thyroidectomy. However, HS after thyroid surgery remains a very rare complication. Cozzaglio et al.  described one case (0.2%) of postsurgical HS in a series of 495 thyroidectomies. Ban et al. reported that HS was a rare complication (0.03%) after robotic thyroidectomy for thyroid carcinoma.
HS can be seen after lateral cervical neck dissection (LCND). In a study, a total of 45 LCNDs (5 bilateral) were performed in 40 patients, 35 with differentiated thyroid cancer and 5 with medullary carcinoma. HS was seen in 2 patients (4.4%).  However, HS after total thyroidectomy and CND due to medullary thyroid carcinoma with MEN-2A was not found in the literature. To the best of our knowledge, this case will be the first reported case.
In iatrogenic HS, spontaneous resolution of the ptosis follows sympathetic regeneration with re-establishment of the original sympathetic pathways. , In our patient, HS was relieved without any treatment after 2 months of surgery. The prompt and complete recovery of this patient may be due to cervical sympathetic chain damaged by retractor stretching, as suggested Cozzaglio et al. 
In conclusion, this syndrome is a rare complication of thyroid and neck surgery. Careful dissection and hemostasis, gentle traction on retractors, and good knowledge of cervical sympathetic chain are mandatory to prevent iatrogenic HS. Surgeons should be aware of the possibility of this syndrome after thyroid cancer surgery and know that spontaneous resolution is high without any treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Davagnanam I, Fraser CL, Miszkiel K, Daniel CS, Plant GT. Adult Horner′s syndrome: A combined clinical, pharmacological, and imaging algorithm. Eye (Lond)
Horner JF. On a form of ptosis. Klin Monatsbl Augenheilkd
Maloney WF, Younge BR, Moyer NJ. Evaluation of the causes and accuracy of pharmacologic localization in Horner′s syndrome. Am J Ophthalmol
Cozzaglio L, Coladonato M, Doci R, Travaglini P, Vizzotto L, Osio M, Gennari L. Horner′s syndrome as a complication of thyroidectomy: Report of a case. Surg Today
Nielsen PJ. Upside down ptosis in patients with Horner′s syndrome. Acta Ophthalmol (Copenh)
Martin TJ. Horner′s syndrome, Pseudo-Horner′s syndrome, and simple anisocoria. Curr Neurol Neurosci Rep
Perry C, James D, Wixon C, Mills J, Ericksen C. Horner′s syndrome after carotid endarterectomy - A case report. Vasc Surg
Civelek E, Karasu A, Cansever T, Hepgul K, Kiris T, Sabanci A, Canbolat A. Surgical anatomy of the cervical sympathetic trunk during anterolateral approach to cervical spine. Eur Spine J
Meng LW, Huang LM, Chen W. Horner′s syndrome after central neck dissection in thyroid cancer: Two cases report. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi
Solomon P, Irish J, Gullane P. Horner′s syndrome following a thyroidectomy. J Otolaryngol
Welch K, McHenry CR. Selective lateral compartment neck dissection for thyroid cancer. J Surg Res
González-Aguado R, Morales-Angulo C, Obeso-Agüera S, Longarela-Herrero Y, García-Zornoza R, Acle Cervera L. Horner′s syndrome after neck surgery. Acta Otorrinolaringol Esp
Ban EJ, Yoo JY, Kim WW, Son HY, Park S, Lee SH, Lee CR, Kang SW, Jeong JJ, Nam KH, Chung WY, Park CS. Surgical complications after robotic thyroidectomy for thyroid carcinoma: A single center experience with 3,000 patients. Surg Endosc
Nowak £R, Duda K, Mizianty M, Wilczek M, Bieda T. Horner syndrome after unsuccessful venous port implantation by cannulation of the right internal jugular vein. Anaesthesiol Intensive Ther