Isolated Horner syndrome as a rare initial presentation of nasopharyngeal carcinoma: a case report

Abstract

BackgroundHorner syndrome refers to a set of clinical presentations resulting from disruption of sympathetic innervation to the eye and adnexa. Classically, the clinical triad consists of ipsilateral blepharoptosis, pupillary miosis, and facial anhidrosis. Ocular sympathetic denervation may signify life-threatening causes. Timely investigation and accurate diagnosis are essential in patients with oculosympathetic denervation.Case presentationA 33-year-old Asian man with a heavy smoking habit presented with a 3-week history of left ptosis and no other complaints. His visual acuity was 20/20 bilaterally. An ophthalmic examination was significant for mild ptosis of his left eyelid and anisocoria (smaller left pupil), which was greater in the dark. Both pupils reacted to light briskly without an afferent pupillary defect. Anhidrosis was found on the medial side of the left forehead. A 10% cocaine test was positive. At his first visit, neurologic examination was unremarkable. Comprehensive radiological investigations were scheduled for a left-sided isolated Horner syndrome. Two weeks after his first visit, he experienced a left-sided headache along with ipsilateral Horner syndrome. Neurologic examination revealed hypoesthesia in the left cranial nerve V1–3 territories. Emergent computed tomography angiography was suspected for petrous part of the left internal carotid artery (ICA) dissection. Magnetic resonance imaging demonstrated an enhancing infiltrative lesion with its epicenter at the left sphenoid bone. The lesion encased the left ICA and invaded the left Meckel cave. Rhinoscopy with incisional biopsy revealed squamous cell nasopharyngeal carcinoma.ConclusionThis case involved an unusual initial presentation of nasopharyngeal carcinoma: isolated Horner syndrome with clinical progression to adjacent structures. Infiltration involving the Meckel cave and ICA at the foramen lacerum can present as postganglionic Horner syndrome associated with trigeminal pain and hypoesthesia. These clinical findings may mimic carotid artery dissection on computed tomography angiography. Detailed magnetic resonance imaging with careful attention to the skull base should be performed.

Rochen-Duvigneaud syndrome with nasopharyngeal carcinoma

“…6 A case of 3 rd cranial nerve palsy as the presenting neurophthalmic feature of NPC has been reported by Beckmann et al 9 A study by Padungkiatsagul et al has reported isolated Horner's syndrome as the initial presentation of NPC. 12 But our patient did not have any miosis or anhidrosis. Studies by Agarwal et al Popovska et al have reported cranial nerve palsies due to cavernous sinus involvement in nasopharyngeal malignancies.…”

Ophthalmic manifestations of nasopharyngeal carcinoma (NPC): a systematic review of reported cases with and without prior history of nasopharyngeal carcinoma

“…All papers that were gathered were either case series or case reports. A total of 20 articles were gathered, which included 57 patients (1,3,(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26) . These were analyzed in the first part of our study.…”