Delayed Presentation of Horner’s Syndrome after an Interscalene Block

 

Kenneth Hunt, MD, Anesthesiology Resident, University of Colorado School of Medicine

Parker Juels, MD Candidate 2027, University of Colorado School of Medicine

Alma Juels, MD, Associate Professor of Anesthesiology, University of Colorado School of Medicine, Denver Health and Hospital

 

Disclosures: The authors have no conflicts of interest to report.

35 yo female presented to the emergency department at midnight following a right shoulder rotator cuff repair earlier in the day. She complains of a droopy eyelid, constricted pupil, unequal pupils and facial numbness on the right. Patient’s past medical history is significant for mild asthma for which she takes symbicort daily and albuterol as needed, she also has anxiety for which she takes no medications. The patient received an ultrasound guided preoperative interscalene block at 7am, for post operative pain control. The anesthesiologist injected, without difficulty, 20cc of 0.5% bupivicaine. There was good visualization of the nerve roots C5-C7. The patient stated she felt short of breath immediately after the block and felt she could not swallow or speak, even though she was swallowing and speaking clearly. She thought this may be due to her anxiety. She was able to take deep breaths and symptoms resolved quickly. The patient was taken to the operating room following the block placement and general anesthesia was induced with lidocaine, propofol and rocuronuim. The patient was an easy mask and a 7.0 endotracheal tube was placed without difficulty. The patient was placed in a bench chair position. The surgery was uneventful. At the end of the case the patient was extubated and taken to the recovery room. PACU course was without issues and patient was discharged pain free with her shoulder, arm and hand completely numb. 

At approximately 10 pm, patient stated she noticed sudden onset of right ptosis, myosis,  enophthalmos, numbness/tingling along the right side of her face, she did not notice this earlier in the day. She was concerned and presented to the emergency department with her husband. Anesthesia was consulted and asked if symptoms could be related to the block even though typically symptoms present immediately after the block and this was delayed. Her block worked well and she was just starting to regain feeling in her fingers, arm and some pain in her shoulder at the operative site. She was not short of breath, had no problems speaking or swallowing. A work up was suggested to rule out other pathology due to the delayed presentation of symptoms. A CT scan was done that was completely normal, neurology was consulted and confirmed the symptoms and the diagnosis of Horner’s Syndrome. Despite the delayed onset of symptoms, due to a negative work up, the symptoms were attributed to the interscalene block performed 20 hours earlier the patient was sent home and the symptoms resolved over the next 24 hours.