Horner’s Syndrome and Lymphocele Following Thyroid Surgery

Abstract

Horner’s syndrome (HS), caused by lesions of the 3-neuron oculosympathetic nerve pathway (ONP), includes the triad: blepharoptosis, miosis and anhidrosis (ipsilateral with ONP damage). Thyroid–related HS represents an unusual entity underling thyroid nodules/goiter/cancer–HS (T-HS), and post-thyroidectomy HS (Tx-HS). We aim to overview Tx-HS. This is a narrative review. We revised PubMed published, full-length, English papers from inception to November 2022. Additionally, we introduced data on post-thyroidectomy lymphocele/chylous leakage (Tx-L), and introduced a new pediatric case with both Tx-HS and Tx-L. Tx-HS: the level of statistical evidence varies from isolated case reports, studies analyzing the large panel of post-thyroidectomy complications reporting HS among the rarest side effects (as opposite to hypocalcemia), or different series of patients with HS due to various disorders, including T-HS/Tx-HS. Tx-HS is related to benign or malignant thyroid conditions, regardless the type of surgery. A pre-operatory rate of T-HS of 0.14%; a post-operatory rate of Tx-HS between 0.03% and 5% (mostly, 0.2%) are identified; a possible higher risk on endoscopic rather than open procedure is described. Incomplete HS forms, and pediatric onset are identified, too; the earliest identification is after 2 h since intervention. A progressive remission is expected in most cases within the first 2–6 months to one year. The management is mostly conservative; some used glucocorticoids and neurotrophic agents. One major pitfall is an additional contributor factor like a local compression due to post-operatory collections (hematoma, cysts, fistula, Tx-L) and their correction improves the outcome. The prognostic probably depends on the severity of cervical sympathetic chain (CSC) lesions: indirect, mild injury due to local compressive masses, intra-operatory damage of CSC like ischemia and stretching of CSC by the retractor associate HS recovery, while CSC section is irreversible. Other iatrogenic contributors to HS are: intra-operatory manipulation of parathyroid glands, thyroid microwave/radiofrequency ablation, and high-intensity focused ultrasound, and percutaneous ethanol injection into thyroid nodules. Tx-L, rarely reported (mostly <0.5%, except for a ratio of 8.3% in one study), correlates with extended surgery, especially lateral/central neck dissection, and the presence of congenitally—aberrant lymphatic duct; it is, also, described after endoscopic procedures and chest-breast approach; it starts within days after surgery. Typically low-fat diet (even fasting and parental nutrition) and tube drainage are useful (as part of conservative management); some used octreotide, local sealing solutions like hypertonic glucose, Viscum album extract, n-Butyl-2-cyanoacrylate. Re-intervention is required in severe cases due to the risk of lymphorrhoea and chylothorax. Early identification of Tx-HS and Tx-L improves the outcome. Some iatrogenic complications are inevitable and a multifactorial model of prediction is still required, also taking into consideration standardized operatory procedures, skillful intra-operatory manipulation, and close post-operatory follow-up of the patients, especially during modern era when thyroid surgery registered a massive progress allowing an early discharge of the patients.

Diagnosis and treatment of HS after endoscopic thyroid surgery: case report and brief literature review

“…It is important to note that the closure of the carotid artery sheath with an ultrasonic knife for separating the thyroid gland from the surrounding lymphoid and adipose tissue may result in temporary or permanent nerve damage due to heat conduction ( 15 ). In addition, there are other factors that can potentially cause Horner’s syndrome, including but not limited to thyroid neoplasms or huge goiter compression ( 3 ), arteritis ( 16 ), central nervous system infection ( 3 ), peridural obstetric anesthesia ( 17 , 18 ), and occasionally lung transplantation.…”

“…The prominent clinical features include ptosis (drooping eyelid), miosis, and the rare but characteristic symptom of ipsilateral anhidrosis. HS is commonly secondary to compression caused by thyroid masses ( 2 ) or iatrogenic injury to the cervical sympathetic nerve pathway during cervical or thoracic surgery ( 3 ). More than 20 cases of post-thyroidectomy HS have been reported, with endoscopy-related HS being particularly notable ( 4 ).…”

Cardiac Tamponade Revealing an “APECED Syndrome”, an Unsual Manifestation in a 7-Year-Old Moroccan Girl: A Case Report

“…Oral calcium and levothrox was prescribed in our case. The treatment of pericardial effusion after pericardiocentesis was based on aspirine and colcichine for four weeks according to the management guidelines of the European Society of Cardiology (ESC 2015) [25] with a good clinical outcome without the occurrence of residual pericarditis in a year [26].…”