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Paediatric Horner’s syndrome: is investigation for underlying malignancy always required?
  1. Sarah Braungart1,2,
  2. Ross J Craigie2,
  3. Paul Farrelly2,
  4. Paul Damian Losty1,3
  1. 1 Department of Pediatric Surgery, Alder Hey Children’s Hospital, Liverpool, UK
  2. 2 Department of Paediatric Surgery, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
  3. 3 Institute of Child Health, University of Liverppol, Liverpool, Merseyside, UK
  1. Correspondence to Professor Paul Damian Losty, Institute of Child Health, University of Liverpool, Liverpool L69 3BX, UK; paul.losty{at}


Objective Horner’s syndrome (HS) is characterised by a triad of ocular miosis, ptosis and anhidrosis. HS may be a subtle sign of occult pathology in otherwise asymptomatic children, neuroblastoma (NBL) being the the most common associated malignant tumour. Despite such knowledge, the incidence of underlying malignancy in children with HS remains unclear and robust evidence to guide best clinical practice is sparse. We performed a systematic review of the literature with the aim of identifying the incidence of NBL in children with HS of unknown aetiology, and establishing if screening for NBL should be routinely performed in this patient population.

Methods Systematic review of the literature (PubMed and Ovid/Medline database, 1961–2018).

Results The initial search identified 334 manuscripts, of which 8 studies were included in the final analysis. All reports were single-centre retrospective studies without control groups and included a total of 152 patients (age range 0–20 years). All studies investigated patients with HS but without previously established diagnosis. In the studies included, 17 out of a total of 152 patients were diagnosed with a space-occupying lesion. 12 out of the 152 patients were subsequently detected with NBL.

Conclusion HS in children may be the first sign of occult malignancy. We report the first systematic review that comprehensively investigates the incidence of malignancy in this unique patient cohort. We show that HS of unknown aetiology in children warrants further investigation(s) to exclude an underlying space-occupying lesion. This should include cross-sectional imaging of the brain, neck and thorax, plus urinary catecholamines for prompt diagnosis and treatment.

  • horner’s syndrome
  • neuroblastoma
  • paediatric surgery
  • oncology
  • paediatric practice

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  • Contributors Study conception and design: SB, PDL. Data acquisition: SB. Analysis and data interpretation: SB, RJC, PF, PDL. Drafting of manuscript: SB. Critical revision: SB, RJC, PF, PDL.

  • 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.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Presented at This work was presented at the 50th annual meeting of SIOP, Kyoto, Japan 2018.

  • Patient consent for publication Not required.

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