|Year : 2021 | Volume
| Issue : 12 | Page : 1852-1854
Horner syndrome—A rare complication after thyroidectomy for benign thyroid swelling
MH Janjua, S Iftikhar, MZ Sarwar, MS Farooq, SA Naqi
Department of Surgery, East Surgical Ward, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
|Date of Submission||06-Jul-2020|
|Date of Acceptance||19-Mar-2021|
|Date of Web Publication||09-Dec-2021|
Dr. M H Janjua
Senior Registrar-East Surgical Ward, Mayo Hospital, Lahore
Source of Support: None, Conflict of Interest: None
| 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 Aug 14];24:1852-4. Available from: https://www.njcponline.com/text.asp?2021/24/12/1852/332079
| Introduction|| |
Horner syndrome includes miosis, ipsilateral ptosis, facial anhidrosis, and vascular dilatation of lateral part of the face. It occurs due to the disruption of oculo-sympathetic pathway which is a three-neuron chain anywhere along its route. In general, cervical spine surgery through an anterior approach and carotid end-arterectomy are the surgical procedures which can result in Horner syndrome, but Horner syndrome occurring after thyroidectomy is a rare entity., 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|| |
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 2: Three months post operatively (improved ptosis but miosis appreciated)|
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| Discussion|| |
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. 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.,
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., 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. 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. 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 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. and Seneviratne et al. 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. 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.,, 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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]