Journal of Neuro-Ophthalmology, September 1983, Volume 3, Issue 3

Iatrogenic Horner's syndrome secondary to chest tube thoracostomy.

We report a 22-year-old male who underwent a left thoracostomy and left lower lobectomy for a shotgun wound of the left anterior chest. During surgery, two chest tubes were placed in the left hemithorax at the level of the first and second intervertebral spaces. On the 10th postoperative day, the patient developed a left-sided miosis and ptosis. The diagnosis of a left preganglionic Horner's syndrome was confirmed by pharmacologic testing. The Horner's syndrome was unchanged 3 months after discharge. We conclude that the chest tubes damaged the preganglionic sympathetic fibers of the left orbit resulting in this patient's Horner's syndrome.

f. Clin. Neuro-ophthalmol. 3: 205-210, 1983. Iatrogenic Horner's Syndrome Secondary to Chest Tu.be Thoracostomy* JOHN A. FLEISHMAN, M.D. JOHN D. BULLOCK, M.D., M.s., F.A.C.S. JILL S. ROSSET, M.D. ROY W. BECK, M.D. Abstract We report a 22-year-old male who underwent a left thoracostomy and left lower lobectomy for a shotgun wound of the left anterior chest. During surgery, two chest tubes were placed in the left hemithorax at the level of the first and second intervertebral spaces. On the lOth postoperative day, the patient developed a left-sided miosis and ptosis. The diagnosis of a left preganglionic Horner's syndrome was confirmed by pharmacologic testing. The Horner's syndrome was unchanged 3 months after discharge. We conclude that the chest tubes damaged the preganglionic sym­pathetic fibers of the left orbit resulting in this pa­tient's Horner's syndrome. The sympathetic fibers to the eye follow a cir­cuitous pathway from the hypothalamus to the orbit, and the variety of lesions that can interrupt this pathway are myriad. Such lesions are mani­fested in the classic Horner's syndrome. Iatrogenic Horner's syndrome is a common clinical event and has been attributed to many procedures including lower cervical and upper dorsal sympathectomy, I. ~ stellate ganglion block,'} cordotomy,4 tumor exci­sion, 4 thyroidectomy,-" and phrenicotomy.!i Tran­sient Horner's syndrome has been observed fol­lowing percutaneous catheterization of the carotid artery6 and internal jugular vein7 during angiogra­phy, caudal anesthesia,H obstetric extradural block,~ and interscalene brachial plexus block. 10 We report a case of Horner's syndrome secondary to place­ment of chest tubes high within the pleural space. A review of the literature failed to reveal a similar case in an adult. From the Departments of Ophthalmology (JAF,RWB) and Pa­thology (jSR). University of Michigan, Ann Arbor, Michig,ln; and Wright State University (JOB), Dayton, Ohio. • Presented at the Annual Ohio State Medical Association Meeting, May 27, 1982, Dayton, Ohio. September 1983 Case Report A 22-year-old white male, who had previously been in excellent health, was admitted to the hos­pital after sustaining a shotgun injury to the left anterior chest wall. In the emergency room, the patient was noted to be in severe shock. He was bleeding profusely from two wounds: 1) an en­trance wound 2 cm in diameter located 3 cm medial to the left nipple, and 2) an exit wound 3 cm in diameter located in the left anterior axillary line 15 cm below the axilla (Fig. 1). A chest x-ray revealed a large pneumohemothorax and multiple rib frac­tures on the left side. The patient was transfused with whole blood and taken to the operating room where he underwent a left thoracostomy, left lower lobectomy, and extensive debridement of his wounds. During surgery, two semirigid chest tubest were inserted in the left hemithorax. In the immediate postoperative period, it was noted that both pupils were round and equal. The direct and consensual light reflexes were normal. Postoperatively, the patient required multiple transfusions for stabilization of vital signs. A chest x-ray revealed a left hemothorax, multiple pellets in the lower left chest wall, and two chest tubes with the distal ends placed in the thorax at the level of the first and second intervertebral spaces (Fig. 2). On the 10th day, it was noted that the right pupil was larger than the left (Fig. 3a). Examination revealed both pupils to be round; the right pupil was 8 mm and the left pupil was 5 mm in diameter. The right and left palpebral fissures measured 11 mm and 8 mm, respectively. Direct and consensual light reflexes were normal in both eyes. There was no evidence of ocular trauma. The conjunctivae, extraocular muscle function, visual acuity, visual fields, and funduscopic exam were normal in both eyes. The remainder of the neurological exam was unremarkable. A cocaine test was performed. I I t Argyle thoracic catheter (No. 32 Fr). 205 Iatrogenic Horner's Syndrome \ Figure 1. Diagram illustrating entrance and exit wounds sus­tained by patient. Instillation of a 5% cocaine solution into both eyes resulted in dilation of the right pupil from 8 mm to 10 mm; the left pupil remained 5 mm. The patient continued to recover from his wounds and on the 17th day the chest tubes were removed. A paredrine test was performed.12 Instil­lation of a 1% paredrine solution into both eyes resulted in dilation of the right pupil from 6 mm to 9 mm; the left pupil dilated from 4 mm to 8 mm (Fig. 3b). The patient was discharged on the 24th day. A follow-up examination 3 months later dem­onstrated the left-sided Homer's syndrome to be unchanged. He had otherwise recovered from his injuries. Discussion Giles and Henderson4 analyzed 216 cases of Homer's syndrome at the University of Michigan Hospital and attributed 18.5% to surgical proce­dures. Of 450 cases of Homer's syndrome reviewed at the Mayo Clinic, involvement of the pregan­glionic neuron was demonstrated in 84% of the 45 cases with iatrogenic etiology.13 The patient we described developed a preganglionic Homer's syn­drome that was confirmed by the cocaine and paredrine tests. The Homer's syndrome developed 10 days after placement of two chest tubes, the distal ends of which were lodged in the first and second intervertebral spaces. We believe that the Figure 2. Chest x-ray taken on first postoperative day. The distal ends (large white arrows) of the chest tubes are in the first and second intervertebral spaces. Note left hemothorax and pellets in the left chest wall. Journal of Clinical Neuro-ophthalmology Fleishman, Bullock, Rosset, Beck 101 Figure 3a. External photograph of patient on 16th day of hospitalization. Note the marked miosis and mild ptosis of the left eye. Figure 3b. External photograph of patient taken 4S minutes after instillation of a 1% paredrine solution into both eyes. Eighth cervical anterior ramus Vll+--F-----------jl- Superior cervical ganglion I-t--+-+------,f-- Middle cervical ganglion .u;~~~~~;:)~~-t--Inferior ) cervical ganglion Ansa subclavia Figure 4. Diagram illustrating the pathway of the ocular sympathetic fIbers. location of the tubes lying near the first and second thoracic ganglia resulted in damage to the second order preganglionic sympathetic fibers of the left orbit. The course of the ocular sympathetic fibers is illustrated in Figure 4. This is a three-neuron path- September 1983 way containing two preganglionic neurons and one postganglionic neuron. The first-order pregan­glionic (central) neuron has its origin in the pos­terolateral aspect of the hypothalamus. Its fibers descend without decussation through the tegmen­tum of the midbrain and pons, through the lateral 207 Iatrogenic Horner's Syndrome . . • " '. ..' ," 'r .. ' ENDOTHORActC FASCIA IPARIET.AL PLEURA STELLAT GANGtlON lbl Figures Sa and sb. Histologic section of human stellate ganglion with over­lying endothoracic fascia and parietal pleura. (X47. Luxo!') medulla and into the spinal cord. In the ciliospinal center of Budge, located between the seventh cer­vical and second thoracic cord levels, a synapse is made with the second-order preganglionic neuron. The axons of the second-order preganglionic neu­rons exit the cord in the eighth cervical, and first and second thoracic nerves. In the classically de­scribed pathway the fibers then gain entrance to the sympathetic chain via the white rami commu­nicantes. (However, Palumbo has recently pro­vided evidence that the fibers circumvent the rami communicantes and enter the sympathetic chain via a sepilfate "paravertebral pathway.'o\4) Regard­less of the mode of entrance, once inside the sym-pathetic chain the fibers course through the first thoracic and inferior cervical ganglia, which are often fused to form the stellate ganglion. The fibers then loop around the subclavian artery in the ansa subclavia prior to continuing their ascent through the middle cervical ganglion to the superior cervical ganglion near the carotid bifurcation. It is here that a synapse is made with the postganglionic neuron. The intimate anatomic relationship that exists between the cervical pleura and the sympathetic chain containing the ocular sympathetic fibers is emphasized in Figures Sa and sb. Only a thin, loose connective tissue layer, the endothoracic fas­cia, separates these structures. It is for this reason Journal of Clinical Neuro-ophthalmology Fleishman, Bullock, Rosset, Beck Eighth cer~1cal.~_~. an erj'Of J1 mllJs; / First t nOl'i'lcic . ganglion Ii SBccmd thoracic ganglion ~4~~--- Sy pathetic film Ical .Ansa ~ bclavla Endothorraoe ic fascia ~, \ \ Figure 6. Artist's conception of chest tube in the first intervetebral space resulting in trauma to the sympathetic chain. (Adapted from Gray's Anatomy (35th Br. ed.) W. B. Saunders Co., Philadelphia, 1973, p. 1072.) that the ocular sympathetic fibers are so prone to injury in the region of the pulmonary apex. Rosegger and Fritsch 16 have described a Horner's syndrome that developed in a premature infant treated with tube thoracostomy for tension pneu­mothorax. The Horner's syndrome was an inciden­tal finding noted 42 days after removal of the tube. Although the authors attributed the Horner's syn­drome to damage of the preganglionic sympathetic fibers secondary to the chest tube, the temporal relationship between tube placement and onset of the Horner's syndrome was unclear. We can offer two possible mechanisms that could account for this patient's oculosympathetic paresis. It is con­ceivable that the tubes created apical adhesions between the parietal pleura and the endothoracic fascia, thus resulting in traction on the pregan­glionic sympathetic fibers. A similar mechanism of injUry was implicated in two patients who devel­oped Horner's syndrome following spontaneous pneumothorax. 17 . IH In both cases, the Horner's syn­drome occurred abruptly with the onset of pul­monary symptoms and disappeared almost imme­diately with expansion of the lung. The Horner's syndrome in these patients was presumably sec­ondary to traction on the sympathetic fibers due to superior mediastinal displacement. 1H This mecha­nism seems unlikely in the patient described here as the ocular symptoms developed 10 days after treatment of the pneumothorax at which time there was no superior mediastinal displacement. A more tenable explanation is that the tubes directly in­jured the second-order preganglionic sympathetic fibers resulting in the persistent Horner's syn­drome observed in this patient (Fig. 6). September 1983 References 1. Rosner,S.: The physiology of bilateral cervical sym­pathectomy and Horner's syndrome. Vase. Surg. 4: 44-45, 1970. 2. Romano, A, Kurchin, A, Rudich, R., and Adar, R.: Ocular manifestations after upper dorsal sympa­thectomy. Ann. Ophthalmol. 7: 1083-1086, 1979. 3. Winnie, AP., Ramamurthy, 5., Durrani, Z., Radon­jic, R., and Shaker, M.H.: Pharmacologic reversal of Horner's syndrome following stellate ganglion block. Anesthesiology 41: 615-617, 1974. 4. Giles, CL., and Henderson, J. W.: Horner's syn­drome: An analysis of 216 cases. Am. f. Ophthalmol. 46: 289-296, 1q58. 5. Dejong, R.N.: Horner's syndrome: A report of ten cases. Arch. Neurol. Psychiatry 34: 734-743, 1935. 6. Amundsen, P., Dietrichson, P., Enge, I., and Wil­liamson, R.: Cerebral angiography by catheterisa­tion: Complications and side effects. Acta Radiol. (Diagn.) 1: 164-172, 1963. 7. Parikh, R.K.: Horner's syndrome: A complication of percutaneous catheterisation of internal jugular vein. Anaesthesia 27: 327-329, 1972. 8. Kepes, E.R., Martinez, L.R., Pantuck, E., and Stark, D.: Horner's syndrome following caudal anesthesia. N. Y. State f. Med. 72: 946-947, 1972. 9. Hertz, R., Chiovari, C, and Marx, G.: Delayed Hor­ner's syndrome following obstetric extradural block. Anesth. Analg. 59:299-300, 1980. 10. Seltzer, J.L.: Hoarseness and Horner's syndrome after interscalene brachial plexus block. An~sth. An­a/ g. 56: 585-586, 1977. 11. Jaffe, N.5.: Localization of lesions causing Horner's syndrome. Arch. Ophthalmol. 44: 710-727, 1950. 12. Thompson, H.s., and Mensher, J,H.: Adrenergic my­driasis in Horner's syndrome: Hydroxyampheta­mine test for diagnosis of post-ganglionic defects. Am. f. Ophtha/mol. 72: 472-480, 1971. 209 Iatrogenic Horner's Syndrome 13. Maloney, W.F., Younge, B.R., and Moyer, N.J.: Eval­uation of the causes and accuracy of pharmacologic localization in Horner's syndrome. Am. I. Ophthal­mol. 90: 394-402, 1980. 14. Palumbo, L.T.: A new concept of the sympathetic pathways to the eye. Ann. Ophthalmol. 8: 847-954, 1976. 15. Walsh, F.B., and Hoyt, W.F.: Clinical Neuro-Oph­thalmology, Vol. 1, (3rd ed.). Williams & Wilkins Co., Baltimore, 1969, p. 476. 16. Rosegger, H., and Fritsch, G.: Horner's syndrome after treatment of tension pneumothorax with tube thoracostomy in a newborn infant. Eur. I. Pediatr. 133: 67-68, 1980. 17. Sataline, L.R., and Kraus, T.: Horner's syndrome occurring with spontaneous pneumothorax. N Engl. I. Med. 272: 1227-1228, 1965. 18. Osterman, P.O., and Osterman, K.: Reversible Hor­ner's syndrome associated with spontaneous pneu­mothorax. Scand. I. Resp. Dis. 52: 230-231, 1971. Write for reprints to: John D. Bullock, MD., 33 West First Street, Suite 59, IBM Building, Dayton, Ohio 45402. Journal of Clinical Neuro-ophthalmology