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Show PHOTO ESSAY Reversible Chest Tube Horner Syndrome Michael Levy, MD, PhD and David Newman-Toker, MD, PhD Abstract: A 54-year-old woman who underwent chest tube placement after a lung biopsy was found on the first postoperative day to have ipsilateral ptosis and miosis, suggesting a Horner syndrome. A chest CT scan showed that the tip of the chest tube was apposed to the stellate ganglion. Repositioning of the chest tube later on the first postoperative day led to complete reversal of the Horner syndrome within 24 hours. We propose that the Horner syndrome arose as a result of pressure on the stellate ganglion, which interrupted neural conduction but did not sever the sympathetic pathway (‘‘neurapraxia''). Whether prompt repositioning of the chest tube was critical in reversing the Horner syndrome is uncertain. (J Neuro-Ophthalmol 2008;28:212-213) A 54-year-old woman was noted to have asymmetric pupils after a left upper lung wedge resection for dia-gnostic biopsy of a lung mass that was followed by routine FIG. 1. A. Line drawing illustrating the normal three-dimensional anatomy of the posterior thorax and stellate ganglion from an oblique, anterolateral vantage point. (Drawn by Timothy H. Phelps, MS, Department of Art as Applied to Medicine, The Johns Hopkins University School of Medicine.) Postcontrast sagittal (B), coronal (C), and axial (D) chest CTs of our patient show the position of the chest tube in relation to nearby structures, including the stellate ganglion. FR, first rib; SA, subclavian artery; VA, vertebral artery; VB, vertebral body. Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland. Address correspondence to David Newman-Toker, MD, PhD, Department of Neurology, Johns Hopkins Hospital Pathology Building 2-210, 600 N. Wolfe St., Baltimore, MD 21287; E-mail: toker@jhu.edu 212 J Neuro-Ophthalmol, Vol. 28, No. 3, 2008 placement of a thoracostomy tube. Our bedside examination on the first postoperative day confirmed left upper lid ptosis and left miosis. There were no deficits of ocular motility or obvious asymmetry of facial sweating. A left Horner syndrome was diagnosed and a chest CT with contrast was recommended to determine the precise etiology. As seen on the CT image, the chest tube was in direct apposition to the stellate ganglion posterior to the subclavian artery (Fig. 1). Although the stellate (cervico-thoracic) ganglion can only be visualized surgically or by MRI (1), its regional location can be confidently assigned using three-dimensional CT reconstructions of the upper chest. Repositioning of the chest tube later on that first postoperative day led to complete reversal of the Horner syndrome within 24 hours, with no residual ptosis, miosis, or pupillary dilatation lag. The incidence of Horner syndrome after chest tube placement is less than 1% (2), but chest tubes account for nearly half of all cases of iatrogenic Horner syndrome in patients undergoing thoracic surgical procedures (2). As expected, most cases associated with tube placement are noted within 12-72 hours of the procedure (2,3), but others have been reported to occur up to 2 weeks later (3). Urgent repositioning of chest tubes is associated with rapid reversal of or gradual recovery from Horner syndrome in the majority of reported cases (2,4,5). The presumed mechanism of injury in such early-onset and rapidly reversible cases is compressive neurapraxia, or interruption of neural conduction without structural damage to the pathway (4). Only a thin layer of endothoracic fascia separates the apical lung pleura from the stellate ganglion (6), and direct pressure from the tube tip is believed to be responsible for the Horner syndrome. However, cases of Horner syndrome with apparently delayed onset are not infrequent and require some explanation beyond direct compression alone. Although some delays in diagnosis may simply reflect the clinical subtlety of the sign rather than the underlying pathogenesis, truly delayed onset can sometimes result from chest tube migration, such as when the patient is mobilized from bed (5). Whether tube migration accounts for most cases with delayed onset is unclear. Other explanations to account for delayed symptoms have been proposed, including inflammation, fibrosis, and local hematoma formation (3). Whether these mechanisms might also help explain cases of patients with incomplete recovery, or rare cases occurring after removal of the tube (3) remains speculative. Routine chest radiography does not permit direct visualization of the anatomic relationship between a chest tube and sympathetic chain or stellate ganglion. However, in the appropriate clinical context, an apical and medial location of the chest tube tip is highly suggestive of a ‘‘chest tube Horner syndrome'' (3,5). A chest CT with contrast offers the possibility of high-resolution anatomic lesion localization, as well as the opportunity to diagnose dangerous alternative causes not uniformly identified on chest radiographs such as vascular dissection or pseudoa-neurysm formation. Acknowledgment We thank Timothy Phelps of the Department of Art as Applied to Medicine for his work in drawing Figure 1A and Dr. Stephen Yang of the Division of Thoracic Surgery for critically reviewing the manuscript and artwork. REFERENCES 1. Hogan QH, Erickson SJ. MR imaging of the stellate ganglion: normal appearance. AJR Am J Roentgenol 1992;158:655-9. 2. Kaya SO, Liman ST, Bir LS, et al. Horner's syndrome as a complication in thoracic surgical practice. Eur J Cardiothorac Surg 2003;24: 1025-8. 3. Zagrodnik DF 2nd, Kline AL. Horner's syndrome: a delayed com-plication after thoracostomy tube removal. Curr Surg 2002;59: 96-8. 4. Bell RL, Atweh N, Ivy ME, et al. Traumatic and iatrogenic Horner syndrome: case reports and review of the literature. J Trauma 2001;51: 400-4. 5. Shen SY, Liang BC. Horner's syndrome following chest drain migration in the treatment of pneumothorax. Eye 2003;17:785-88. 6. Fleishman JA, Bullock JD, Rosset JS, et al. Iatrogenic Horner's syndrome secondary to chest tube thoracostomy. J Clin Neuro-ophthalmol 1983;3:205-10. 213 Chest Tube Horner Syndrome J Neuro-Ophthalmol, Vol. 28, No. 3, 2008 |
