Review Question - QID 109044

This patient with a long-standing smoking history most likely has a Pancoast tumor compressing the sympathetic stellate ganglion, resulting in Horner's syndrome.

Pancoast tumors are non-small cell lung tumors located in the apex of the lung. They often present with symptoms related to compression of regional structures. One common presentation is Horner's syndrome due to compression of the nearby sympathetic stellate ganglion and brachial plexus (C5-T1). This compression can lead to ipsilateral myosis, ptosis, and anhydrosis.

Figure A is a right-sided ptosis and miosis. Anhydrosis is also seen with Horner syndrome but is more difficult to assess on exam.

Incorrect Answers:
Answer 1: The middle cervical ganglion is a sympathetic ganglion that lies superior to the stellate ganglion. It innervates the thyroid gland and cardiac plexus in the thorax and would not be responsible for Horner’s syndrome in this syndrome.

Answer 2: Although Pancoast tumors may result in compression of the superior vena cava, this is often a very late presentation and would present with symptoms of facial plethora. It is a medical emergency and should be addressed without delay.

Answer 4: Due to their location, Pancoast tumors may result in compression of the recurrent laryngeal nerve. However, the associated symptom would be hoarseness rather than ptosis and anisocoria.

Answer 5: Oculomotor nerve injury results in ipsilateral deviation of the eye “down and out.” In addition, parasympathetic innervation from the oculomotor nerve supplies the sphincter pupillae and ciliary muscles of the eye. Therefore, in an oculomotor nerve injury the pupillary response would be ipsilateral mydriasis not myosis.

Bullet Summary:
Pancoast tumors are associated with compression of regional structures including the stellate ganglion, superior vena cava, and recurrent laryngeal nerve.