Benign thyroid swelling presenting as Horner’s syndrome
- Sherin K Shaji ,
- Jacquline Chan and
- Churunal Hari
- Department of Otolaryngology, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
- Correspondence to Dr Sherin K Shaji; sherin.shaji@nhs.net
Abstract
Horner’s syndrome is a rare neurological condition seen in association with the disruption in the sympathetic nerve supply. Thyroid swelling is a common condition but rarely causes cervical sympathetic chain compression. We describe a case of a 54-year-old man who presented with Horner’s syndrome secondary to a benign thyroid nodule with pressure effect on the sympathetic chain. An association between thyroid pathologies and Horner’s syndrome has been mentioned previously, however, to our knowledge, this is the first case of Horner’s syndrome being the initial presentation for an underlying benign thyroid swelling.
Background
Horner’s syndrome is a clinical condition that was formally described and named after ophthalmologist Johann Friedrich Horner in 1869.1 It is characterised by a triad of ipsilateral ptosis, miosis and anhidrosis caused by the paralysis of the ipsilateral cervical sympathetic tract.2 Up to 52% of thyroid, swellings are associated with compressive symptoms on adjacent structures.3 4 The most common structures are the trachea causing shortness of breath (32%) and oesophagus causing dysphagia (80%).4 Thyroid swellings can cause a pressure effect on the cervical sympathetic chain resulting in Horner’s syndrome.5 Thyroid neoplasms, benign or malignant, are one of the rare causes of Horner’s syndrome.6 We present a case of a patient with Horner’s syndrome whose symptoms improved following excision of a non-malignant thyroid swelling.
Case presentation
A 54-year-old Caucasian man presented to the ophthalmology outpatient department with 2 months history of blurred vision and diplopia in the left eye. Clinical examination demonstrated left upper lid ptosis and constricted pupils. Visual acuity was 6/6 in the right eye and 6/9–1 in the left eye, that improved to 6/6 with the use of a pinhole. His left upper eyelid was 2 mm lower than the right with good levator function bilaterally. Left miosis and failure of the pupil to dilate fully in dim illumination were also noted. Ocular alignment and motility were normal along with the rest of the ocular and cranial nerve examination. A diagnosis of left-sided Horner’s syndrome was made and confirmed on testing with apraclonidine 1% drops.
MRI of the brain revealed no significant abnormalities. Magnetic resonance angiography of the neck with contrast showed unremarkable appearance of common and internal carotid arteries, common vertebral and basal arteries. There was no evidence of aneurysm, dissection or significant stenosis of any of the arteries. However, a left-sided thyroid swelling was noted causing some displacement and distortion of the trachea at the level of the thoracic inlet (figure 1). The patient was subsequently reviewed in the otolaryngology outpatient department for management of left-sided thyroid swelling. Ultrasound scan identified a U3 thyroid nodule measuring approximately 4.05 cm in size (figure 2) and fine-needle aspiration results exhibited a Thy3f pattern confirming a follicular lesion.
Magnetic resonance angiography of neck illustrating thyroid (Thy) goitre causing mild compression and deviation of the trachea (T) along with pressure effect on left carotid sheath (CS).
Thyroid ultrasound displaying a thyroid nodule at least 4.05 cm in diameter.
Outcome and follow-up
Consequently, the patient underwent left thyroid lobectomy. Histological analysis was performed and confirmed a benign nodular hyperplasia. Postoperative period was unremarkable, and his symptoms of ptosis and miosis were fully recovered at 3 months follow-up, making an excellent recovery.
Discussion
Benign and malignant thyroid lesions are a less common cause of Horner’s syndrome and represent 1.3%–7.8% of the cases.7 The most common pathology that causes Horner’s syndrome is bronchogenic carcinoma occurring at the apex of the lung.6 Other causes include intrathoracic and cervical aneurysms, iatrogenic or accidental trauma and cervical adenitis.6 Giles and Henderson reported that Horner’s syndrome is more commonly associated with malignant thyroid pathology.8 Harding et al further reported an incidence of 0.14% of Horner’s syndrome being associated with underlying thyroid enlargement resulting in pressure on the sympathetic chain.9 Coskun et al described a large thyroid nodule causing compression on the sympathetic chain resulting in Horner’s syndrome.5 There was no improvement following surgery and this may be due to the large nodule being present for a long period of time, resulting in irreversible nerve damage.5
Symptoms of Horner’s syndrome and other compressive symptoms such as dysphagia, choking or dyspnoea occur as the thyroid enlarges due to the proximity between the adjacent anatomical structures and the thyroid gland.4 Our patient presented with Horner’s symptoms, however, was not aware of the thyroid swelling. He had a large thyroid nodule measuring 4.05 cm, but this was more of a deep-seated swelling than protruding outwards in the neck, thereby remained unnoticed. It was showing displacement of the carotid sheath on the affected side. This case illustrates a rare cause of Horner’s syndrome secondary to displacement compression of the cervical sympathetic chain by a thyroid swelling. Though rare, thyroid swellings should be considered as a differential diagnosis in patients presenting with Horner’s syndrome. As our case demonstrates, surgical removal of the thyroid swelling can result in full recovery. Conversely, long-term compression on the sympathetic chain can result in pressure-induced ischaemia and irreversible nerve damage despite surgical intervention.5
Learning points
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A rare case of Horner’s syndrome arising secondary to a benign thyroid nodule.
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Careful history taking, clinical examination along with relevant radiological imaging is important in investigating the cause of Horner’s syndrome.
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Thyroid nodules may be asymptomatic but be aware that both benign and malignant thyroid swellings can present as Horner’s syndrome.
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Early surgical intervention can successfully reverse the symptoms of Horner’s syndrome.
Footnotes
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Contributors SKS carried the literature review and wrote the case report. JC assisted in proof reading and drafting of the case report. CH provided the case report and participated in the layout and structure of the report.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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Patient consent for publication Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.
References
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