www.elsevier.com/locate/jpedsurg

Journal of Pediatric Surgery (2009) 44, 2012–2014

Case reports

Iatrogenic Horner syndrome after tube thoracostomyRobert Baird a,⁎, Zainab Al-Balushi b, Jeff Wackett c, Sarah Bouchard b

aMontreal Children's Hospital, McGill University Health Center, Montreal, Quebec, CanadabHôpital Sainte Justine, Center Hospitalier Université de Montréal, Montreal, Quebec, CanadacSherbrooke University Hospital

Received 18 March 2009; revised 4 May 2009; accepted 4 May 2009

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Key words:Horner syndrome;Complication;Iatrogenic;Tube thoracostomy

Abstract Iatrogenic Horner syndrome is a rare complication of chest tube insertion, with littleinformation available on this topic in the pediatric literature. We present a case of a 13-month-old boywith a left-sided pneumonia and an associated pleural effusion for which a chest tube was inserted.His respiratory and septic parameters improved, but he was noted to have ptosis, miosis, andanhydrosis of the left side. These resolved in the days after chest tube removal. Although tubethoracostomy is a common procedure in surgical practice, little is written about the potential for injuryto the ipsilateral sympathetic chain. This report reviews the available literature, with an emphasis oncomplication avoidance.© 2009 Elsevier Inc. All rights reserved.

Iatrogenic Horner syndrome is a rare complication of tubethoracostomy, and it has been poorly characterized in thepediatric literature. Given the frequency of this procedure, itis likely underreported. We report a case of Horner syndromeafter placement of a tube thoracostomy for empyema in a 13-month-old boy. Review of the patient's chest radiographsdemonstrates malposition of the tube. Complete resolution ofsymptoms was achieved after removing the tube, suggestinga neuropraxic injury to the ipsilateral sympathetic chain.

1. Case presentation

An otherwise healthy 13-month-old boy was referredfrom an outside institution with worsening shortness ofbreath and fever. On initial examination, the boy had a

⁎ Corresponding author.E-mail address: robert.baird@mail.mcgill.ca (R. Baird).

022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved.oi:10.1016/j.jpedsurg.2009.05.022

temperature of 39.2°C and was tachycardic with a heart rateof 170/min. There were no breath sounds on the left, and achest radiograph confirmed complete “whiteout” of the leftlung field. Initial white blood cell count was 13,000, but thispeaked to 29,000 on admission day 2. Resuscitation andantibiotics were begun promptly, and the patient wastransferred to the intensive care ward for chest tube insertion.A 20F chest tube was placed in the fifth intercostal interspaceby a third-year general surgery resident yielding 300 mL ofseropurulent fluid. Cultures grew group A Streptococcus.

The patient's clinical state improved, with resolution ofhis tachycardia and fever. On the third day of admission, thechest tube output had diminished to zero. Chest radiographrevealed no residual effusion but suggested that the tube tipwas positioned inappropriately high (Fig. 1). It wasremoved, and several hours after removal, the patient'smother volunteered noting that the child was only sweatingon one side of his face—contralateral to the side of chesttube insertion. Further examination revealed ptosis andmiosis of the ipsilateral eye (Fig. 2). This was managed

Fig. 1 Posteroanterior and lateral chest x-ray 6 hours afterinsertion of a 20F chest tube for pleural effusion.

Fig. 2 Patient 3 days after insertion of left chest tube.

2013Iatrogenic Horner syndrome after tube thoracostomy

conservatively, while the patient remained hospitalized forintravenous antibiotics. These findings resolved for thefollowing 72 hours. The patient was discharged on oral

antibiotics 6 days after admission, with complete resolutionof his Horner syndrome.

2. Discussion

The Swiss ophthalmologist Johann Friedrich Hornerdescribed the classic symptoms of miosis, ptosis, andanhydrosis in a 40-year-old woman in 1869 [1]. Horner'striad is because of interruption of the sympathetic innerva-tion of the eye. Second-order preganglionic pupillomotornerves exit the spinal cord at T1 that places them near thelung apex. These sympathetic ganglia are only separatedfrom the parietal pleura by the endothoracic fascia, which is athin membranous layer, rendering them susceptible to injury.These fibers ascend and synapse in the superior cervicalganglion located near the bifurcation of the carotid artery.Branches are given off immediately after leaving theganglion that supplies the vessels and sweat glands of theface. The remaining pupillomotor nerves enter the cavernoussinus, join with the abducens nerve, and enter the orbit withthe fibers of the ophthalmic branch of the trigeminal nerve.These innervate the Müller muscle and pupilatory dilator viathe long ciliary nerves.

Horner syndrome is most commonly detected in adultswith apical tumors, although numerous other causes havebeen described. Several adult case reports describe iatrogenicHorner syndrome either after a thoracic operation [2,3] orafter placement of a thoracostomy tube for pneumothorax[4-7]. A recent European publication describes 5 cases ofHorner syndrome after chest tube insertion in 662 con-secutive adult patients (0.79% of cases). Four of these caseshad complete resolution of symptoms within 2 months; thefifth case had incomplete resolution after 2 months. This

2014 R. Baird et al.

trend toward early resolution of symptoms contrasts to otheriatrogenic cases of Horner syndrome reported in the samearticle; the publication reports 7 additional cases of Hornerafter either chest trauma or operative intervention, none ofwhom had documented resolution of symptoms with follow-up between 6 months and 3 years [8].

Tube thoracostomy is a surprisingly rare cause of Hornersyndrome in the pediatric literature. A Turkish publicationdescribes the case of a 3-year-old girl who developedHorner syndrome after repair of a diaphragmatic hernia—with placement of an intrapleural chest drain. She hadalmost total improvement of symptoms 1 month after heroperation [9]. An Indian article described a 3-month-oldbaby girl who developed Horner syndrome as a complica-tion of pneumonia with empyema. A chest tube was placedfor treatment of the pneumonia, but the authors did notconsider this as a potential cause of the findings as it wasnever mentioned. She was discharged home withoutresolution of her symptoms [10].

Insertion of a tube thoracostomy remains one of the mostfrequent procedures in the armamentarium of the pediatricsurgeon. This case illustrates an important avoidablecomplication of tube thoracostomy. Careful insertiontechniques should include ensuring that no resistance ismet while installing the tube. Radiologic confirmation oftube position should be performed after insertion, and

repositioning should be performed if the tube tip appearsnear the lung apex.

References

[1] Horner JF. Über eine Form von Ptosis. Klin Monatsbl Augenheilk1869;7:193-8.

[2] Fleishman JA, Bullock JD, Rosset JS, et al. Iatrogenic Horner'ssyndrome secondary to chest tube thoracostomy. J Clin Neuro-ophthalmol 1983;3:205-10.

[3] Bourque PR, Paulus EM. Chest-tube thoracostomy causing Horner'ssyndrome. Can J Surg 1986;29:202-3.

[4] Shen SY, Liang BCC. Horner's syndrome following chest drainmigration in the treatment of pneumothorax. Eye 2003;17:785-8.

[5] Campbell P, Neil T, Wake PN. Horner's syndrome caused by anintercostal chest drain. Thorax 1989;44:305-6.

[6] Pearce SH, Rees CJ, Smith RH. Horner's syndrome: an unusualiatrogenic complication of pneumothorax. Br J Clin Pract 1995;49:48.

[7] Bertino RE, Wesbey GE, Johnson RJ. Horner syndrome occurring as acomplication of chest tube placement. Radiology 1987;164:745.

[8] Kaya SA, Liman ST, Bir LS, et al. Horner's syndrome as acomplication in thoracic surgical practice. Eur J Cardiothorac Surg2003;24:1025-8.

[9] Ozel SK, Kazez A. Horner's syndrome secondary to tube thoracost-omy. Turk J Pediatr 2004;46:189-90.

[10] Bhaskar G, Lodha R, Kabra SK. Unusual complications of empyemathoracis: diaphragmatic palsy and Horner's syndrome. Indian J Pediatr2006;73:941-3.