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Painful Horner syndrome: pharmacologic testing, imaging, when to worry and why

- ptosis, miosis plus or minus anyhdrosis

Classic w/u:

- 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)

- tinnitus

Chest tumors which tend to be malignant in Horners'

- tend to be slowly progressive development of symptoms

Anhydrosisis a BAD sign, usually pre-ganglionic

Intracranial mass

- horners with numbness of face or other CN

Headache syndromes

- usually produce postganglionic

Confirm it, decide if need to localize, determine etiology, don't order imaging when can't think of reason not to.