Grand slam to the neck leading to Horner’s syndrome

<h3>Introduction</h3> Horner’s syndrome, characterised by upper eyelid ptosis, miosis, facial anhidrosis and enophthalmos, is due to reduced sympathetic innervation to the eye, caused by a lesion in this three-neuron pathway. We report a novel post-ganglionic cause of Horner’s syndrome. <h3>Case Report</h3> A 42-year-old gentleman, with a background of psoriasis, presented with persisting right-sided neck pain and odynophagia after being struck by a tennis ball in the anterior neck. Four weeks later, pain worsened with new ipsilateral headache and partial ptosis. Intermittent tachycardia and relative hypertension were reported. Clinical examination revealed right eye ptosis and miosis, with intact sweating. Imaging excluded hyoid fracture, thyroid cartilage injury, carotid stenosis and carotid dissection. MRI head was normal. MRI showed soft-tissue inflammation around the carotid bifurcation, involving the right thyroid cartilage cornua, right lateral thyrohyoid ligament and greater cornu of the hyoid. PET-CT confirmed localised fluorodeoxyglucose uptake. MRI whole spine showed erosive spondyloarthropathy. A course of low-dose prednisolone, naproxen and omeprazole was initiated. Repeat MRI showed resolution of soft tissue swelling, with continued gadolinium enhancement. <h3>Conclusion</h3> Horner’s syndrome likely resulted from soft tissue swelling and inflammation around the carotid bifurcation, after trauma from a tennis ball. Focal inflammation linked to psoriasis is less likely.