Question 379

Question Answered step-by-step Figure 5: Two 20-French chest tubes were placed in an anterior andposterior positionFigure 6: Miosis and ptosis of the right eyeWhat is the most likely cause of this case of Horner syndrome?Pneumonia with empyemaChest tube placementPigtail catheter placementThoracotomyAnswerThe most likely cause of Horner syndrome in this case is, the high placement of the chest tubes (Figure 5). The tip of the chest tube in the apex of the lung could possibly damage the sympathetic ganglion located in this area. The sympathetic ganglion in the thorax is only separated from the parietal pleura by the endothoracic fascia, which is a thin membranous layer. A French scientist first described Horner syndrome in animal experiments as early as 1727. François Pourfour du Petit found that cutting intercostal nerves in the necks of dogs would cause ocular and facial changes on the ipsilateral side. Edward Sellick Hare, a British physician, described similar changes in a man with a neck tumor in 1838. Claude Bernard more thoroughly described the symptoms in 1852. Three American physicians, one of whom had been influenced by Bernard, described the syndrome in a man shot through the neck in 1864. However, the Swiss ophthalmologist, Johann Friedrich Horner, described the classic symptoms of miosis, ptosis and anhidrosis in a 40-year-old woman in 1869 (Whonamedit.com). Classic Horner syndrome consists of the triad of miosis, ptosis and anhidrosis due to interruption of the sympathetic innervation of the eye. First order sympathetic nerve fibers originate in the posterolateral hypothalamus and descend uncrossed through the midbrain and pons to terminate in the intermediolateral cell column of the spinal cord at the level of T8-C1. Second order preganglionic pupillomotor fibers exit the spinal cord at T1 which places them in close proximity to the lung apex. They ascend and synapse in the superior cervical ganglion located near the bifurcation of the carotid artery. Postganglionic pupillomotor fibers leave the ganglion and ascend with the internal carotid artery. Vasomotor and sudomotor branches are given off immediately after leaving the ganglion, and these fibers travel along the external carotid artery to supply the vessels and sweat glands of the face. The pupillomotor fibers enter the cavernous sinus, join with the fibers of the abducens nerve and enter the orbit with the fibers of the ophthalmic branch of the trigeminal nerve. They innervate the Muller muscle and pupilatory dilator via the long ciliary nerves (Bardos E, emedicine.com). Horner syndrome is more commonly found in adults with tumors compressing this area. Other causes include surgery or other injury to this structure. Tube thoracostomy is a surprisingly rare cause of Horner syndrome. After reviewing the literature on Horner syndrome as a complication of chest tube placement, only two pediatric case reports can be found. Turkish physicians describe the case of a 3-year-old girl who developed Horner syndrome after repair of a diaphragmatic hernia. She had almost total improvement of symptoms one month after her operation. Regarding the other choices listed, pneumonia with empyema was reported in one paper as a cause of Horner syndrome. The paper described a 3-month-old baby girl who developed Horner syndrome as a complication of pneumonia with empyema. No mechanism was proposed to explain this finding. She also had a chest tube placed for treatment of the pneumonia, but the authors did not address this as a potential cause of the findings. She was discharged home without resolution of her symptomWhonamedit? – The dictionary of medical eponyms Health Science Science Nursing NURSING 328 Share QuestionEmailCopy link Comments (0)

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