54. Horner's Syndrome

History: In September of 1975 J. Lawton Smith talks about the nine cardinal features of the Horner syndrome or oculosympathetic palsy. Anatomy: Oculosympathetics originating from hypothalamus as the first order neuron going to spinal cord levels C7 to T2 synapse in ciliospinal center of budge, post ganglionic 2nd order neurons further synapse in superior cervical ganglion and post ganglionic third order neurons pass through carotid canal to the orbit. Pathology: Oculosympathetic palsy or interruption of the sympathetics at the level of first, second or third order neurons. Disease/Diagnosis: 1. Horner syndrome 2. Vidian neuralgia 3. Otogenic Horner syndrome. Clinical: 1. Increased amplitude of accommodation 2. Positive 10% cocaine test (he goes into details about how to conduct a cocaine test). 3. Extent of ptosis can be subtle in Horner syndrome compared to a third cranial nerve palsy. 4. Transient ocular hypotony 5. Iris heterochromia seen in congenital Horner syndrome. 6. Late change in the viscosity of tears 7. Elevation of the lower eyelids with apparent narrowing of the palpebral fissure. Neuroimaging: Chest x-ray to rule out pancoast tumor affecting second order neurons.