The physical findings of ipsilateral ptosis and miosis are characteristic of Horner's syndrome ( Fig 230-20, Plate 19). Interruption of the sympathetic nerve impulses controlling the Mueller muscle in the upper eyelid and the iris dilators cause these classic findings. Interruption can occur anywhere along the pathway from the brain stem to the sympathetic plexus surrounding the carotid artery (Fig 230-21). It is very important to determine whether this syndrome is acute or chronic. Patients with chronic disease can be evaluated on an outpatient basis, but all cases of acute disease require a full emergent evaluation. Workup includes a chest x-ray, CT of the brain and cervical region, and a carotid angiogram if a carotid dissection is suspected (acute Horner's syndrome with neck pain).
FIG. 230-20. (Plate,19). Horner's syndrome. Note ptosis and miosis of the right eye. This patient sustained an acute right carotid artery dissection after being hit in the neck with a football.
FIG. 230-21. Sympathetic nerve pathway of the eye. An interruption anywhere along this pathway can cause Horner's syndrome.
Causes of Horner's syndrome include, in adults, CVA, tumors, internal carotid dissection, herpes zoster, and trauma. In children, the causes include neuroblastoma, lymphoma, and metastasis.
1. Determine whether the condition is chronic or acute.
2. Chronic: outpatient workup by personal physician.
3. Acute: Evaluate for CVA, tumor, or carotid dissection.*
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