When gas travels: a case report of partial Horner’s syndrome from subcutaneous emphysema post-laparoscopic hiatal hernia repair

Introduction: Postoperative partial Horner’s syndrome associated with subcutaneous emphysema after laparoscopic hiatal hernia repair has not been previously reported. In this particular case, this rare complication is due to compression of the cervical sympathetic plexus surrounding the carotid artery by subcutaneous emphysema. Case presentation: A 59 year-old female awoke postoperatively from laparoscopic hiatal hernia repair and complained of blurred vision in the left eye and difficulty opening it. This prompted the general surgery team to consult neurology. The patient was examined and underwent a workup for brainstem infarct, carotid artery aneurysm or dissection, and myasthenia gravis. The examination revealed complete left-sided ptosis with equal, round, and reactive pupils. MRI of the brain and myasthenia gravis laboratory workup were unremarkable. CT angiography of the neck revealed subcutaneous emphysema adjacent to the carotid arteries. The symptoms resolved on their own on the second postoperative day. Discussion: After exclusion of neurologic and ischemic vascular causes, transient partial Horner’s syndrome was attributed to postoperative subcutaneous emphysema compressing the cervical sympathetic pathway. Although facial subcutaneous emphysema during laparoscopy has been described, its association with Horner’s syndrome after laparoscopic hiatal hernia repair has not been reported. This case highlights a rare neurologic manifestation of a common perioperative complication. Conclusion: Recognition of postoperative subcutaneous emphysema as a benign cause of ptosis or partial Horner’s syndrome may narrow the differential diagnosis and reduce unnecessary investigations. While prompt evaluation of time-sensitive neurologic events remains essential, this entity should be considered in atypical postoperative presentations, as gas may compress adjacent neurovascular pathways.