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CASE REPORT
Year : 2021  |  Volume : 24  |  Issue : 12  |  Page : 1852-1854

Horner syndrome—A rare complication after thyroidectomy for benign thyroid swelling


Department of Surgery, East Surgical Ward, Mayo Hospital, King Edward Medical University, Lahore, Pakistan

Date of Submission06-Jul-2020
Date of Acceptance19-Mar-2021
Date of Web Publication09-Dec-2021

Correspondence Address:
Dr. M H Janjua
Senior Registrar-East Surgical Ward, Mayo Hospital, Lahore
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_419_20

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   Abstract 


Horner syndrome occurring after thyroidectomy is a rare entity and most of the reported cases have happened after surgeries on malignant thyroid swellings. In the present report, we describe a 27-year-old female who developed ptosis, miosis, enophthalmos, and anhidrosis on the second post-operative day after thyroidectomy for benign goiter. Post-operative ultrasound, computed tomography of neck, nerve conduction study, and electromyography of brachial plexus were unremarkable. Patient was kept on conservative management. She was given short course of Prednisolone orally for 2 weeks and was discharged on 150 mcg thyroxine. She had significant improvement in ptosis, miosis, and enophthalmos after six months. Horner syndrome is a rare but an important complication after thyroidectomy which may lead to cosmetic disfigurement. Surgeons should be well aware of this possibility and its presentation for timely recognition and management postoperatively. Early intervention should be done for any reversible cause, i.e., hematoma and oral steroids should be initiated as early as possible.

Keywords: Disfigurement, Horner syndrome, steroids, thyroidectomy


How to cite this article:
Janjua M H, Iftikhar S, Sarwar M Z, Farooq M S, Naqi S A. Horner syndrome—A rare complication after thyroidectomy for benign thyroid swelling. Niger J Clin Pract 2021;24:1852-4

How to cite this URL:
Janjua M H, Iftikhar S, Sarwar M Z, Farooq M S, Naqi S A. Horner syndrome—A rare complication after thyroidectomy for benign thyroid swelling. Niger J Clin Pract [serial online] 2021 [cited 2022 Sep 27];24:1852-4. Available from: https://www.njcponline.com/text.asp?2021/24/12/1852/332079




   Introduction Top


Horner syndrome includes miosis, ipsilateral ptosis, facial anhidrosis, and vascular dilatation of lateral part of the face.[1] It occurs due to the disruption of oculo-sympathetic pathway which is a three-neuron chain anywhere along its route.[2] In general, cervical spine surgery through an anterior approach and carotid end-arterectomy are the surgical procedures which can result in Horner syndrome,[3] but Horner syndrome occurring after thyroidectomy is a rare entity.[4],[5] However, most of the reported cases happened after surgeries on malignant thyroid swellings. Here we present a unique case of Horner syndrome that developed after total thyroidectomy for the benign disease.


   Case Report Top


A 27-year-old female presented to the surgical outpatient department with a swelling in front of neck for the last 5 years which was progressively increasing in size. There was no history of radiation to the neck or family history of such disease. Past medical and surgical history was unremarkable. On examination there was a moderate sized multi-nodular swelling in front of neck which moved with deglutition and had no retrosternal extension or associated cervical lymphadenopathy. She was clinically euthyroid. Neck ultrasound showed it to be a multi-nodular goiter and thyroid function tests confirmed euthyroid status. She underwent total thyroidectomy after necessary preparation. Recurrent laryngeal nerves and parathyroid glands were identified and preserved on both sides. She had no hoarseness of voice or any signs of hypo-calcemia after surgery.

On second post-operative day, she developed drooping of left eyelid. On examination, she had ptosis, miosis, enophthalmos, and anhidrosis on left side of the face [Figure 1]. Her ocular movements and visual acuity were normal. Postoperative neck ultrasound showed no hematoma. Computerized tomography (CT) of the neck and chest was unremarkable as well. Nerve conduction studies and electromyography of the brachial plexus was normal. Histopathology revealed right lobe 9 × 5 × 5 cm, isthmus 2 × 1 × 1 cm, and left lobe 8 × 5 × 4 cm in measurements and microscopic evaluation turned out to be benign adenomatoid nodules with no evidence of malignancy. She was prescribed short course of Prednisolone (1 mg/kg) orally for 2 weeks and patient showed mild improvement in ptosis. She was discharged on 150 mcg thyroxine for maintenance of euthyroid state. After 3 months, the ptosis and enophthalmos significantly improved but miosis was still there [Figure 2]. After 6 months, there was significant improvement in ptosis, miosis, and enophthalmos [Figure 3].
Figure 1: Second post operative day (ptosis and miosis)

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Figure 2: Three months post operatively (improved ptosis but miosis appreciated)

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Figure 3: Six months post operatively (improved miosis as well)

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   Discussion Top


In 1853, Bernard first described Horner syndrome but it follows the name of Johann Friedrich Horner, a swiss ophthalmologist, who presented a case of 40-year-old woman having unilateral ptosis, miosis, and facial anhidrosis.[6] Horner syndrome may develop as a complication of neck and thoracic surgery, e.g., chest tube thoracostomy, tonsillectomy, coronary artery bypass grafting, central venous cannulation, epidural analgesia, and carotid endarterectomy. All of these are well-described iatrogenic causes of Horner's syndrome while non-iatrogenic causes are infection, trauma, vascular anomalies, and tumors which include sympathetic paraganglioma, neuroblastoma, schwannoma, and Ewing sarcoma.[7],[8]

Horner syndrome following thyroid surgery is an extremely rare complication with an incidence of less than 0.2% to 0.3%. Till date, there are less than 30 reported cases of Horner syndrome after thyroid surgery.[2],[9] Most of these surgeries are for malignant thyroid swelling combined with lymph node dissection. In addition, minimally invasive techniques for thyroid surgery have also been reported as a cause of Horner syndrome.[10] Four theories have been reported in the literature regarding the etiology of Horner syndrome. First is the over stretching of cervical sympathetic chain due to lateral retraction while elevating the thyroid tissue from its bed. Second is the ischemic injury caused when the inferior thyroid artery is ligated away from the gland which disrupts the blood supply to the cervical sympathetic chain. Third theory suggests disruption of recurrent laryngeal nerve's communication with the cervical sympathetic chain during the dissection. Last one says there may be post-operative hematoma which may cause compression of the cervical sympathetic chain leading to Horner syndrome.[9] However, the exact cause still remains unknown.

Horner syndrome typically presents with ptosis and miosis which may or may not be associated with lack of sweating on the same side of forehead or face. In most of the cases it is incomplete with lack of vasomotor signs[10] but in our case, patient did complain of absence of sweating on the forehead. Timing of the onset of symptoms may be related to the mechanism of injury. Late onset of syndrome may be related to ischemic injury as reported by Neki et al.[9] and Seneviratne et al.[10] Both of these cases showed late onset, i.e., 6 days after surgery and both showed no significant recovery which probably denotes possible ischemic injury. Diagnosis of Horner syndrome is mainly clinical and investigations are done to ascertain the cause or to exclude one. As our patient was fine pre-operatively and developed these signs and symptoms on the second post-operative day so ultrasound and CT scan was done to exclude other causes. Management is mainly directed toward rectification of the underlying reversible cause of this syndrome and prevention of irreversible causes. Huang L et al.[3] reported two cases of Horner syndrome after thyroidectomy which were managed by oral steroids. Both of them showed clinical improvement after 8 days of steroid administration which indicates that post-operative steroids may have a role in resolution of signs and symptoms of Horner syndrome. Prognosis of Horner syndrome is variable, some cases show complete recovery but it may take up to two years, some show incomplete recovery while others may show no recovery at all.[2],[3],[4] In our case, most probable cause appears to be over stretching of cervical sympathetic chain as supported by early onset of syndrome, no post-operative hematoma, normal electro-diagnostic studies, and significant improvement after the steroids. From the above discussion, it is evident that most of the etiologies are secondary to per-operative period so one should be well aware of them and avoid vigorous lateral retraction to prevent over-stretching of the cervical sympathetic chain. Inferior thyroid artery should be ligated close to the gland and meticulous hemostasis should be practiced to prevent post-operative hematoma.

Thus, Horner syndrome is a rare but a significant complication after the thyroid surgery which may lead to cosmetic disfigurement. Head and neck surgeons should be well aware of this possibility and its signs and symptoms for prevention and timely recognition. Early intervention should be done for any reversible causes, i.e., hematoma and oral steroids should be initiated as early as possible.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Cozzaglio L, Coladonato M, Doci R, Travaglini P, Vizzotto L, Osio M, et al. Horner's syndrome as a complication of thyroidectomy: Report of a case. Surg Today 2008;38:1114-6.  Back to cited text no. 1
    
2.
Giannaccare G, Gizzi C, Fresina M. Horner syndrome following thyroid surgery: The clinical and pharmacological presentations. J Ophthalmic Vis Res 2016;11:442-4.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Huang L, Tang XQ, Su L. Horner's syndrome after thyroidectomy: Two cases report. Open J Prevent Med 2018;8:325-9.  Back to cited text no. 3
    
4.
Demiral, M, Binay C, Simsek, E, Ilhan, H. Horner syndrome secondary to thyroid surgery. Case Rep Endocrinol 2017;3:1-3.  Back to cited text no. 4
    
5.
Cho SH, Kim SH, Lee JH, Joo WI, Chough CK, Park HK, et al. Brain Metastases of papillary thyroid carcinoma with Horner's syndrome. Brain Tumor Res Treat 2014;2:132-7.  Back to cited text no. 5
    
6.
Martin TJ. Horner syndrome: A clinical review. ACS Chem Neurosci 2018;9:177-86.  Back to cited text no. 6
    
7.
Challapalli A, Howell L , Farrier M, Kelsey A, Birch J, Eden T. Cervical paraganglioma—a case report and review of all cases reported to the Manchester children's tumour registry 1954–2004. Pediatr Blood Cancer 2007;48:112-6.  Back to cited text no. 7
    
8.
Bhagat S, Varshney S, Bist SS, Gupta N. Pediatric cervical sympathetic chain schwannoma with horner syndrome: A rare case presentation. Ear Nose Throat J 2014;93:1-3.  Back to cited text no. 8
    
9.
Neki N, Shergill G, Singh A, Kaur A, Nizami S, Sidhu P. Post thyroidectomy Horner's syndrome-expect the unexpected! Bangladesh J Med Sci 2017;16:600-1.  Back to cited text no. 9
    
10.
Seneviratne SA, Kumara DS, Drahaman AM. Horner's syndrome: An unusual complication of thyroidectomy: A case report. J Med Case Rep 2016;10:300.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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