Painful Horner syndrome: pharmacologic testing, imaging, when to worry and why
- ptosis, miosis plus or minus anyhdrosis
- make sure Horners
- localize lesion
- determine cause
Don't really need cocaine testing but useful in small sub-population
- topical cocaine block re-uptake norepinephrine to increase its concentration so pupil should dilate if it is normal
- what do you consider abnormal vs normal?
- partial symp denervation may produce lesser response
- most people would like to see at least a 1mm change
- not that easy to get the cocaine commercially; get from hospital pharmacy, non-preserved, and degrades strength over time
Apraclonidine test taking over from cocaine
- if you have denervation super-sensitivity, the pupil will dilate from apraclonidine
- so positive test is a reversing of the dilated pupil
Localize lesion cos central, preganglionic, is usually BAD and post ganglionic is usually GOOD
- Hydroxyamphetamine helps localize, as if neuron injured, no release, therefore no mydriasis
- again look for change in the anisocoria
- postganglionic lesion not necessarily very good as carotid dissection is post ganglionic as are skull based lesions
- people who say that localizing is important claim that it will focus where you will look for a lesion - but would you not image everyone anyway?
Where is the pain?
If Horner's these could be dissecting aorta Sx:
- any facial pain, hemicranial or neck pain?
- dysgeusia (metallic taste)
Chest tumors which tend to be malignant in Horners'
- tend to be slowly progressive development of symptoms
Anhydrosisis a BAD sign, usually pre-ganglionic
- horners with numbness of face or other CN
- usually produce postganglionic
Confirm it, decide if need to localize, determine etiology, don't order imaging when can't think of reason not to.