Horner's syndrome following tonsillectomy

Horner syndrome after cervical spine corticosteroid injection

Horner syndrome is a rare condition caused by a lesion of the sympathetic cervical chain. Multiple cervical disorders are associated with such lesions. Here we report the first case of Horner syndrome after cervical facet joint corticosteroid injection.

Horner Syndrome from a Pediatric Otolaryngology Perspective

INTRODUCTION

Horner syndrome is described as the clinical triad of miosis, ptosis, and anhidrosis. In pediatric patients the condition may be congenital or acquired from neoplastic, infectious or traumatic conditions, including birth trauma. Most cases of pediatric Horner syndrome present first to a pediatric ophthalmologist however since the neural pathways involve the cervical sympathetic chain otolaryngologists should understand the pathophysiology to avoid delay in management of potentially malignant cases.

OBJECTIVES

To aid otolaryngologists in recognizing and managing pediatric Horner syndrome by describing 3 unique cases from malignant, traumatic and/or congenital causes.

METHODS

Case report of 3 pediatric patients with Horner syndrome presenting to our pediatric otolaryngology department.

RESULTS

Case #1 is 5-month-old female with ptosis and a left level II 1.5 cm neck mass. Magnetic resonance imaging showed the mass displacing the common carotid artery and excisional biopsy revealed a poorly differentiated neuroblastoma. Case #2 is a 9-year-old female with anisocoria appearing after suffering a severe playground injury. Case #3 is a 3-year-old-male who developed ptosis and anisocoria following re-excision of a recurrent cervical lymphatic malformation.

CONCLUSION

Pediatric Horner syndrome may be a benign finding that is easily overlooked but may reflect a serious underlying condition. Otolaryngologists should be aware of the pathophysiology and differential diagnosis, including malignant causes, to appropriately manage patients.

Horner Syndrome as a Rare Complication of Radiofrequency Tonsil Ablation

Horner syndrome is a rare but likely underdiagnosed complication of tonsillary surgery. The authors report the case of a 2.5-year-old boy who developed miosis and mild ptosis after radiofrequency tonsil ablation surgery. Pharmacologic testing with apraclonidine 0.5% eye drops confirmed left Horner syndrome. This case highlights the close anatomical relationship between the tonsils and cervical sympathetic trunk and draws attention to the occurrence of Horner syndrome after tonsillectomy. [J Pediatr Ophthalmol Strabismus. 2018;55:e14-e15.].

A Rare Complication of Radiofrequency Tonsil Ablation: Horner Syndrome

Chronic tonsillitis is a common disease, and several different surgical techniques are used to treat this condition. In recent years, techniques such as radiofrequency ablation and coblation have been commonly used for tonsil surgery. In this report, we present the cases of two pediatric patients who developed ptosis, miosis, and enophthalmos (Horner syndrome) after radiofrequency ablation for tonsil reduction and discuss the technique of radiofrequency ablation of the tonsils. In the early postoperative period, miosis and ptosis were observed on the right side in one patient and on the left side in the other patient. Both patients were treated with 1 mg/kg/day methylprednisolone, which were tapered by halving the dose every 3 days. Miosis and ptosis improved after treatment in both patients. Along with the case presentation, we discuss the effectiveness and complications of radiofrequency ablation of the tonsils. These unusual complications of tonsil ablation may help ENT physicians who do not yet have a preferred surgical technique for tonsillectomy to make an informed decision. Limited data are available about the possible complications of radiofrequency ablation of the tonsils. The present report contributes to the literature on this topic.

Horner syndrome after tonsillectomy: an anatomic perspective

BACKGROUND

Horner syndrome after tonsillectomy has been reported rarely in the literature. Furthermore, postoperative Horner syndrome lasting more than a 1 month is an even more rare occurrence.

PATIENT

We present a persistent postoperative Horner syndrome in a 5-year-old child following tonsillectomy.

RESULTS

Clinical diagnosis of Horner syndrome is confirmed pharmacologically, and damage to the oculosympathetic pathway at the level of the superior cervical ganglion is radiographically demonstrated.

CONCLUSION

Conventional monopolar electrosurgical dissection led to irreversible damage of ganglionic neural tissue at the level of the palatine tonsilar fossa and permanent Horner syndrome.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Does preincisional injection of levobupivacaine with epinephrine have any benefits for children undergoing tonsillectomy? An intraindividual evaluation

OBJECTIVE

To evaluate the effects of peritonsillar injection of levobupivacaine with epinephrine in children undergoing adenotonsillectomy, through an intraindividual study.

PATIENTS AND METHODS

20 children (age 6-13 years) undergoing elective tonsillectomy with or without adenoidectomy were enrolled in this prospective, randomized, intraindividual trial. After entubation and just prior to incision, 3 ml of 0.25% levobupivacaine with epinephrine was injected into one peritonsillar region while 0.9% saline was being used for the contralateral side. Amount of intraoperative blood loss, duration of tonsillectomy, postoperative pain, otalgia and hemorrhage were assessed for each side separately. Visual analog scale was used for postoperative pain assessment. Heart rate and mean arterial pressure during and after operation were also observed. The follow-up period after surgery was 10 days.

RESULTS

Median visual analog scale values for the levobupivacaine with epinephrine injected side was significantly lower than the saline injected side, during the first postoperative 16h (p<0.05). There were also significant differences between the intraoperative blood losses of the two sides (p<0.05). However; no significant differences were observed with respect to duration of surgery, postoperative otalgia and hemorrhage (p>0.05).

CONCLUSION

Preincisional injection of levobupivacaine with epinephrine decreases early postoperative pain and intraoperative blood loss as well.

Horner’s syndrome, Pseudo-Horner’s syndrome, and simple anisocoria

This discussion reviews the common causes of Horner's syndrome, with emphasis on case reports from the past several years. Much of the recent literature concerns the use of apraclonidine as a diagnostic test for Horner's syndrome, possibly as an alternative for the current gold standard of cocaine eye drops. This new literature is discussed in the context of the current standards for clinical diagnosis.