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Temporary Horner’s Syndrome Following Selective
Neck Dissection
Gerald T. Kangelaris, M.D.*, Frederick C. Roediger, M.D.*,
#
Young S. Oh, M.D. , David W. Eisele, M.D.*
*Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco
#Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente, Anaheim, California
POTENTIAL MECHANISMS
INTRODUCTION
DISCUSSION
RISKS OF NECK DISSECTION
ANATOMY
• Cervical lymphadenectomy for the treatment of head and neck cancer
has evolved over time in an effort to reduce the morbidity associated
with the procedure while maintaining oncological effectiveness.
• Based on predictable patterns of spread and the primary goal of
preserving the spinal accessory nerve, modified radical and selective
neck dissections were introduced and have gained wide acceptance.
• Despite these advances, injury to the numerous motor, sensory and
autonomic nerves that course through the neck can still occur.
• The cervical sympathetic trunk is located posteromedial to the carotid
sheath, anterior to the deep cervical muscles and transverse processes
of the cervical vertebrae, and deep to the prevertebral fascia (Figure 2).
• The cervical sympathetic ganglia are enlarged conglomerates of nervous
tissue that lie alongside the trunk, at which secondary- and third-order
neurons synapse.
• The number of cervical sympathetic ganglia may vary; however, four are
most commonly cited: the superior cervical ganglion, the middle cervical
ganglion, the intermediate ganglion, and the stellate ganglion.
• The cervical sympathetic trunk and its ganglia are not commonly
dissected or encountered during neck dissection because of their
anatomic location. Anatomic variations exist, however, and one study
demonstrated the presence of the sympathetic trunk within the carotid
sheath in 2/12 (17%) cadaveric dissections. (Lyons and Mills, 1998)
HORNER’S SYNDROME
• Horner’s syndrome is the triad of ptosis, miosis, and anhidrosis that
results from injury to the cervical sympathetic chain. This complication
has been reported to occur in less than one percent of neck
dissections.
• We report a case of a patient with an oral tongue carcinoma treated
with partial glossectomy and selective neck dissection (levels I-III) who
developed a temporary Horner’s syndrome, discuss the potential
mechanisms of this complication, and review the relevant literature.
Figure 2. Cervical
Sympathetic Chain
Di
Ca
IJ
CASE PRESENTATION
CSC
PREOPERATIVE HISTORY
CR
• A 29 year-old woman presented with a nine-month history of a
progressively enlarging painful lesion on her right lateral tongue.
• Physical examination revealed a 3 cm ulcerated right lateral tongue
lesion. There was no palpable cervical lymphadenopathy.
• Computed tomography scan showed a 1.5cm depth of invasion in the
right lateral tongue. There were no cervical nodes suspicious for
metastases.
• Biopsy of the tongue lesion revealed well-differentiated squamous cell
carcinoma.
OPERATIVE EVENTS
• The patient underwent a right partial glossectomy and ipsilateral
selective neck dissection (levels I-III) performed in the standard
fashion. Tissue planes and all relevant surgical landmarks were easily
identified.
• The sternocleidomastoid muscle, internal jugular vein, and spinal
accessory nerve were preserved. The cervical rootlets were
preserved. The cervical sympathetic chain was not dissected.
• Final pathology revealed a 3.5 cm well-differentiated squamous cell
carcinoma with 76 cervical lymph nodes negative for carcinoma;
pT2N0M0.
POSTOPERATIVE COURSE
• Right-sided miosis and ptosis were noted at three weeks
postoperatively (Fig. 1A). The remainder of the physical examination
was within normal limits. Vision was unaffected.
• The miosis resolved by two months. Her ptosis steadily improved and
complete resolution was noted six months after surgery (Fig. 1B).
• She remains free of disease three years after treatment.
Figure 1. Temporary Horner’s syndrome
A.
X
B.
A. Patient exhibiting right-sided miosis and ptosis. B. Complete recovery at
six months postoperatively.
XI
Cervical sympathetic chain
(CSC) lying posteromedially
to carotid sheath contents.
The internal jugular vein (IJ),
vagus nerve (X), and carotid
artery (Ca) are retracted
anteromedially. The
accessory nerve (XI), digastric
muscle (Di), and cervical
rootlets (CR) are also shown.
• Mobilization of carotid sheath structures in the course of neck
dissection may expose the cervical sympathetic chain and its ganglia.
This is most likely to occur during removal of level II, III, and IV lymph
nodes when the assisting surgeon applies anteromedial retraction to
the dissected tissues and the operating surgeon dissects along the
deep cervical (prevertebral) fascia to its junction with the carotid
sheath. Forceful retraction itself may injure the cervical sympathetics
or obscure the border of the carotid sheath, leading the surgeon into a
plane of dissection posterior to the carotid artery.
• Traction and compression injuries may directly or indirectly occur
resulting in a Sunderland type I (neurapraxia) or type II (axonotmesis)
injury.
• Thermal or transection injuries may occur in the course of dissection if
the patient displays anatomic variation or if the surgeon dissects in
planes deeper than intended. These injuries may result in permanent
deficits.
• An enlarged superior cervical ganglion may be mistaken for an upper
jugular chain lymph node resulting in a transection injury. Additionally,
retropharyngeal dissection may expose the ganglion, which may be
mistakenly identified as the node of Rouviere and excised.
• The more inferior aspects of the cervical sympathetic chain may be
encountered during operations near the carotid bulb and
parapharyngeal space. Injuries to the sympathetic chain or its ganglia
may similarly occur.
• In the case discussed, the cervical sympathetic chain was not
exposed, dissected, or knowingly injured. We hypothesize the cervical
sympathetic chain experienced traction or compressive forces during
retraction of lymph node contents and dissection of the floor of the
neck, resulting in temporary dysfunction of the cervical sympathetic
nervous system.
HORNER’S SYNDROME
Findings
• Full loss of sympathetic tone results in the classic triad of miosis, ptosis,
and anhidrosis.
• Additional physical findings may include harlequin syndrome,
characterized by hemifacial flushing and sweating secondary to an
impaired vasomotor response; dry nostril, from vasoconstriction of nasal
mucosal vasculature; and the appearance of enophthalmos secondary to
ptosis.
• The presence of only a subset of physical exam findings is possible. The
specific findings depend on the anatomic location of injury.
Clinical Considerations
• The duration of Horner’s syndrome may be temporary or permanent,
depending on the mechanism of injury.
• Management is guided by patient symptoms. Most patients, however,
are asymptomatic and require no specific treatment.
• The inability to accommodate has been reported; ophthalmological
consultation should be considered for patients with visual complaints.
RELEVANT LITERATURE
• Horner’s syndrome following neck dissection is a rarely reported
complication, occurring in four of 714 patients (0.56%) undergoing neck
dissection (levels II-VI) in a recent series of patients with laryngeal or
hypopharyngeal primary tumors. The authors found no association
between neurologic injury and clinical parameters (age, gender, smoking,
alcohol use, etc.) or other complications (wound, vascular, or chylerelated). Preoperative radiation therapy was one of the exclusion criteria
and therefore was not assessed. It was not reported whether these four
cases were temporary or permanent. (Prim et al, 2006)
• A case of permanent Horner’s syndrome after radical neck dissection
was recently reported. The authors describe injury to the cervical
sympathetic trunk during dissection deeper to the carotid sheath than
intended. (Bucci and Califano, 2008)
CONCLUSIONS
• Injury to the cervical sympathetic chain resulting in Horner’s syndrome
is an uncommon but potential complication of selective neck
dissection.
• Horner’s syndrome may be temporary or permanent depending on the
nature of the injury. Traction, compression, and mild thermal injuries
may result in temporary neurologic deficits, while transactions or
severe thermal injuries may lead to permanent deficits.
• The specific physical findings of Horner’s Syndrome are dependent
upon the location of injury to the cervical sympathetic chain.
• Appreciation of the relevant anatomy and potential mechanisms of
injury may help to prevent this complication.
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anatomy of the cervical sympathetic trunk during anterolateral approach to cervical
spine. Europ Spine J. 2008 Aug;17(8):991-5.
Collins SL. The cervical sympathetic nerves in surgery of the neck. Otolaryngol Head Neck
Surg. 1991 Oct;105(4):544-55.
Darvall JN, Morsi AW, Penington A. Coexisting harlequin and Horner syndromes after
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