Author Communication
Case Report on Horner’s syndrome following Thyroidectomy
Syeda Sidra Gillani, Ahmad
Zeeshan Jamil
Pak J Ophthalmol 2019, Vol. 35, No. 1
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See end of article for authors affiliations …..……………………….. Correspondence to: Syeda Sidra Gillani Optometrist M. Phil, FIACLE DHQ teaching Hospital
Sahiwal/ Sahiwal Medical College (SMC) Email: shahnoor2020@gmail.com …..……………………….. |
We report a case of 37-year-old Pakistani
Punjabi woman who visited the Eye department of DHQ teaching hospital Sahiwal
with complaint of drooping of right upper eyelid following the thyroidectomy.
This is to highlight the importance of proximity of Thyroid gland and
sympathetic trunk. Hence, to make surgeon more vigilant to avoid risk of
injury to sympathetic trunk so that potentially stressing cosmetic
disfigurement can be avoided. Moreover, this would help the surgeon to
undertake measures to lessen the risk of injuring the sympathetic runk while
doing the thyroidectomy. Key words: Horner’s syndrome, miosis,
ptosisthyroidectomy. |
Miosis and ptosis are the two commonest features of Horner’s syndrome.
Moreover, it may or may not be associated with ipsilateral facial anhydrosis and
dilatation of vessels. It is probably the outcome of traumatized ipsilateral
cervical sympathetic chain. Up to now a thorough knowledge of the cause and pathophysiology
is not unknown. Once it is diagnosed, the management is conservative. Horner’s
syndrome is reported to be rarest complication subsequent to thyroidectomy and
a few cases are reported worldwide. We would like to report such a case in Pakistan
where thyroid disorders are abundant and thyroidectomy is a common surgical procedure1,2.
CASE
HISTORY
A
37-year-old Pakistani Punjabi woman visited eye department of DHQ teaching
hospital Sahiwal with complaint of drooping of Right upper eyelid. After taking
complete history it became evident that patient had developed unilateral
partial ptosis as well as miotic pupil following the thyroidectomy which is
done for a benign multinodular goiter. There was no history of facial
anhidrosis reported by the patient.
On examination it was found there was mild
Fig. A: Photographs
of patient showing right ptosis and surgical mark of thyroidectomy.
ptosis in right eye with miosis. Marginal reflex distance was
found to be 2 mm in right eye and 4 mm in left eye. Palpebral fissure height
was measured to be 6 mm in right eye which was 3 mm less than palpebral fissure
height of left eye and normal lid position and retraction. There was no history
of anhydrosis, normal sensation and full extra ocular motility in all cardinal
position of gaze. Moreover, both eyes were centrally placed in the orbit and no
dystropia was noted.
Fig. B: Photographs of patient showing right miosis while patient is
looking in up gaze.
A clinical diagnosis of
Horner’s syndrome was made with phenylephrine 1% which was prepared by diluting
10% phenylephrine and instilled in both eye. It produced dilatation in a
Horner’s syndrome and minimal dilatation in normal pupil because of denervation
hyper-sensitivity. Therefore it became clear that lesion was interrupting the
postganglionic fibers.
DISCUSSION
Horner's Syndrome usually presents with
miosis, eyelid ptosis, enophthalmos and vascular dilatation disorder. Besides,
Facial anhidrosis may or may not be present. In 1853, it was firstly described
by Bernard, and after that Johann Horner reported it in 18694. In spite of the fact that there is huge literature which
describes Horner's Syndrome is result of pressure caused by majority of benign
goiter to cervical sympathetic chain but there may be less than 30 cases of the
reported Horner's Syndrome after thyroidectomy so far.
At the very first in 1865, Kappeler explained
that Horner's Syndrome might occur after thyroid surgery. A first case of
Horner's Syndrome post thyroidectomy was reported by the Kaelin in early 1900’s5. Horner's Syndrome with conventional surgical
procedure of thyroidectomy is quite possible and however the late
reports propose that comparative dangers of harm to sympathetic innervation are
related with minimal invasive surgery also. Then, Harding et al. has lately
described the Horner's Syndrome following minimal invasive parathyroidectomy,
on the other side Meng with his partners have revealed Horner's Syndrome
following video assisted surgery6.
A possible explanation behind Horner's
Syndrome following thyroid surgery are, the sympathetic chain may get stretched
during Lateral retraction or compressed by a hematoma post operatively, ligation
of inferior arterial trunk of thyroid can cause ischemia induced damage to
neural tissue. Besides, communication between sympathetic innervation and laryngeal
nerve may get affected due to its repetitive identification during procedure.
Anatomically, the middle cervical ganglion and sympathetic truck are very close
and relation is quite variable either present in front or behind the inferior
thyroid artery. That’s why middle cervical ganglion and sympathetic truck are profoundly
prone to complications in thyroidectomy. Solomon et al. proposed that blood
supply to the sympathetic trunk originated from the inferior thyroid trunk or
its branches and ligation of these vessels may cause prompt devascularization
and ischemic damage to the sympathetic chain prompting Horner's Syndrome7.
De
Quervain says that sympathetic chain gets stretched when the lateral retraction
of carotid sheath is done to expose the lateral aspects of gland and other close
structures. This stretching is sufficient to cause damage to the chain and
subsequently neuropraxic-type trauma occurs8. In a recently published case series by Harding et al. reports
that the more complicated surgery higher would be the risk of Horner's Syndrome. For instance in malignant thyroid disease which involves level III
lymph node dissection and large goiters with retrosternal extension chances of Horner's Syndrome are relatively higher6.
It
is observed that there is no uniform pattern for onset of Horner's Syndrome subsequently thyroidectomy. Most of the literature confirms that Horner's Syndrome starts at 2nd to 4th postoperative
day which reflects the possibility of various etiologies. But here in this case
we are unable to describe the exact onset of symptoms due to vague medical
history given by the patient and lack of medical record.
Patient here did not show any ipsilateral inability of facial sweating
and cutaneous vascular dilatation as noted in most of such cases. The exact
reason behind is not known so far.
CONCLUSIONS
This case report features
an uncommon however particularly important complication of very common surgery
done by general and endocrine and otorhinolaryngology specialists. In spite of
the fact that it is a rare complication but the specialist should be careful
during the procedure because it can cause a noteworthy cosmetic problem, which
could last long.
Author’s
Affiliation
Syeda Sidra Gillani
BSc(hons)Optometry/M.phil
Optometry
Optometrist
DHQ teaching Hospital
Sahiwal
Dr. Ahmad Zeeshan Jamil
Associate Professor of
Ophthalmology
MBBS, MCPS, FCPS, FRCS,
FCPS (VRO)
Sahiwal medical
college/DHQ teaching Hospital Sahiwal
Author’s Contribution
Syeda Sidra Gillani
Concept of study,
drafting of manuscript.
Dr. Ahmad Zeeshan Jamil
Critical review and
literature search.
REFERENCES
4. Horner
JF. Übereine Form von Ptosis. KlinMonatsbl Augenheilkd. 1869: 7.
8. Quervain
F. Weiteres zur technik der kropfoperation. Langenbecks Arch Surg. 1915: 134.