Horner’s Syndrome Birth Injury

Horner’s syndrome is a neurological condition that arises when the sympathetic nerve pathway supplying the eye and face is disrupted. The injury may occur anywhere along a three-neuron chain from the hypothalamus down into the thoracic spinal cord and then back up to the face. Classic signs include ptosis (drooping eyelid), miosis (constricted pupil), anhidrosis (reduced sweating) on the affected side, and sometimes enophthalmos (apparent sinking of the eye).

While Horner’s syndrome can present at any age and from many causes, in pediatric and congenital cases, birth trauma or injuries during delivery are among the more common etiologies. The literature notes that trauma during birth, especially involving forceps, vacuum extraction, or excessive traction on the neck or shoulder region, can damage components of the sympathetic chain or adjacent plexus nerves and lead to Horner’s syndrome.

Other documented causes of Horner’s include neuroblastoma (especially in children), carotid artery dissection or occlusion, cervical spine trauma, apical lung masses (Pancoast tumors), surgical injury to the sympathetic chain, and iatrogenic causes (e.g. neck or chest surgeries). Because the sympathetic pathway traverses the neck and chest, lesions or tumors in those regions are of particular concern.

What Is Horner’s Syndrome?

Horner syndrome occurs when there’s a problem with the nerve pathway connected to the eye and face.  The most noticeable features of Horner syndrome are drooping of the eyelid, constriction of the pupil size, and the absence of normal sweating on the affected side of the face.

The eyelid droops because the nerve supply to a muscle called Müller’s muscle is disrupted. Similarly, the lower eyelid can slightly raise (reverse ptosis), making the eye-opening appear smaller. Additionally, since the nerve that normally controls pupil enlargement is affected, the pupil stays small, especially in low light, due to the unbalanced action of the opposing nerve, which makes the pupil smaller.

What Causes Horner’s Syndrome?

Horner’s syndrome is caused explicitly by an interruption of the sympathetic nerve fibers, which run down from the brain on either side of the face and connect with the eyes.

Many different things, including certain kinds of stroke and carotid artery injuries, can potentially cause the interruption of these nerve fibers.

However, the leading cause of Horner’s syndrome is physical damage and injury to the nerve pathway caused by childbirth trauma.

Horner’s Syndrome Due to Birth Trauma

Physical injury or trauma during childbirth is the most common cause of Horner’s syndrome. Well over half of all Horner’s syndrome cases are related to birth injuries.

There are many different situations or medical mistakes during childbirth that damage a baby’s sympathetic nerve fibers and cause Horner’s syndrome or other conditions. Obstetrical complications during vaginal deliveries, such as shoulder dystocia, breach position, and cephalopelvic disproportion, usually require the doctors to intervene and maneuver the baby through the birth canal.

This is always a delicate process that requires a high degree of medical skill, training, and judgment to be employed in a high-pressure, time-sensitive environment. The use of assistive techniques such as vacuum extraction or forceps can often cause excessive pressure, force, or lateral traction on the baby and potentially injure the nerve pathways and cause Horner’s syndrome.

Error in judgment, such as failing to perform a timely emergency C-section in response to fetal distress, can also result in injury to the sympathetic nerve fibers.

What Are the Symptoms of Horner’s Syndrome?

Horner’s syndrome is a combination of physical symptoms that appear when the pathway of the sympathetic nerves on one side of the face is disrupted. Usually first seen by a nurse, these characteristic symptoms of Horner’s syndrome are:

• Miosis – a chronic constriction of the pupil of the affected eye, making it appear smaller than the other eye’s pupil.
• Ptosis – a persistent drooping of the upper eyelid. Sometimes the lower eyelid may appear elevated (“upside-down ptosis”).
• The affected eye may also have a sunken or deep-set appearance compared to the other eye.
• Lack of normal sweating (anhidrosis) only on the affected side of the face.
• The pupil of the affected eye may show very little or slow dilation in dim light.
• In babies under 12 months, Horner’s syndrome may result in one eye having a somewhat lighter color than the other.

Diagnosing Horner’s Syndrome

Diagnosis usually involves a clinical examination and may require imaging studies like MRI or CT scans to determine the exact cause and location of the injury. Treatment of Horner’s Syndrome resulting from a car accident focuses on addressing the underlying cause of the nerve damage.

The Prognosis for Horner’s Syndrome

The prognosis depends on the severity and type of trauma, as well as the timeliness and effectiveness of the treatment. In some cases, if the nerve damage to the infant is minor, the symptoms of Horner’s Syndrome may partially or fully resolve over time. However, in cases of severe trauma, the symptoms might be permanent.

How Is Horner’s Syndrome Diagnosed in Infants?

The pediatrician will likely identify the initial signs of Horner’s syndrome in a baby from observation and physical exam. If there are sufficient indications of Horner’s syndrome, your pediatrician may use eye drops to dilate the pupils and see if they respond normally to light stimulation. The next and final step in diagnosis may be an MRI, which can help to identify specific birth injuries that may have resulted in the condition.

What Is the Treatment for Horner’s Syndrome?

Treatment options for Horner’s syndrome largely depend on the condition’s specific cause. Unfortunately, when Horner’s syndrome is the result of a birth injury, the options for effective treatment are more limited. There are still options for treating and managing the condition with a newborn with medications and sometimes surgery.

The long-term prognosis of infants with Horner’s syndrome may also vary depending on severity and whether it is diagnosed early on. In some babies, the condition may simply go away on its own or with treatment.

Horner’s Syndrome After birth: Is It Malpractice?

So how often is Horner’s syndrome caused by malpractice at birth? That is the right question, and there is real debate.

Some birth injury lawyers, and you can lump us into the school of thought, say most pediatric cases are tied to birth injuries. The peer-reviewed medical literature, which is written by…doctors, is more cautious. It recognizes birth trauma as a known cause, but it also points to other explanations that have nothing to do with negligence, including tumors like neuroblastoma, carotid artery injury, and surgical or anesthesia complications. The truth is that Horner’s syndrome can be caused by rough traction during a difficult delivery, but we also acknowledge that it can also be caused by conditions no doctor could prevent.

What Malpractice Looks Like in These Cases?

What does a malpractice case look like here? It is not enough to show that a child has Horner’s syndrome. You must prove that the delivery team failed to follow accepted practices and that this failure probably damaged the sympathetic chain. That usually means one of the following: excessive lateral traction on the head or neck during shoulder dystocia, improper use of forceps or vacuum, or pulling on the arm in a way that stretches the lower brachial plexus. Records that describe a difficult extraction, multiple vacuum attempts, or prolonged shoulder dystocia can be significant. So do neonatal notes of a new ptosis, anisocoria, or a concurrent brachial plexus palsy.

There is a second pathway to liability that lawyers see. Even when the delivery does not cause Horner’s syndrome, a delayed or incomplete workup can be negligent. In an infant with new anisocoria or ptosis, reasonable care includes timely referral and appropriate imaging to rule out mass lesions, carotid issues, or other urgent causes. If a child goes months without that basic workup and a serious condition is missed, the claim is about delay, not traction.

Here are the three most common examples:

1. Medical Procedures: Mismanagement or errors during surgical procedures involving the neck or chest can damage the sympathetic nerves responsible for Horner’s syndrome.
2. Anesthesia Errors: Improper anesthesia administration, especially in neck surgeries, can lead to nerve damage and Horner’s syndrome.
3. Incorrect Diagnosis or Treatment: Failure to diagnose and treat underlying conditions that can cause Horner’s syndrome, such as tumors or spinal cord injuries, may be medical malpractice if it results in harm to the patient.

How Do You Figure Out If It Is Malpractice?

How do families and lawyers sort this out? Start with the facts, not assumptions. We look at the fetal monitoring, the timing and description of the pushing phase, whether shoulder dystocia was documented, the number and manner of vacuum or forceps attempts, Apgar scores, and the first notes that describe the eyelid or pupil difference. We also check what the pediatric team did next. Was ophthalmology or neurology involved. Was imaging ordered. Were tumor screens considered. Causation often comes from this timeline.

So where does that leave us. Horner’s syndrome can be a sign of preventable traction injury at birth. It can also arise from non-negligent causes during delivery or from conditions that appear later. Courts and juries focus on the standard of care and the chain of events. If the delivery was managed within accepted guidelines or if the condition was worked up promptly and appropriately, there may be no case. If the delivery strayed from safe technique or if an obvious red flag went unworked and harm followed, there may be one.

If your child has a new droopy eyelid or unequal pupils after birth, the safest next step is a full medical evaluation. If you want legal guidance to interpret what it all means, we can review the delivery records and diagnostic timeline to provide a clear assessment of whether the facts support a malpractice claim.

Horner’s Syndrome as a Sign of Other Birth Injuries

Horner’s syndrome itself may not be a very serious or disabling condition. However, if a baby is born with Horner’s syndrome, it may be an indication of significant trauma during childbirth that might have caused more severe injuries. Horner’s syndrome could be the first indication of birth injuries like Erb’s palsy or Klumpke’s palsy – both of which can be caused by the same type of birth trauma that causes Horner’s syndrome.

Horner’s Syndrome in Car Accidents

Horner’s Syndrome is a neurological condition that can sometimes occur as a result of a car accident, particularly if the accident results in neck or head trauma. People sometimes view Horner’s Syndrome as a disease.  It is not. The fact that car crashes can cause Horner’s reminds us that Horner’s Syndrome is not a disease but a sign of an underlying problem that has affected the sympathetic nerves. Our lawyers have seen car and truck accidents where the condition is caused by direct physical trauma, whiplash injuries, or even penetrating injuries that damage the neck or chest area.

In the context of a car accident, the trauma might involve injury to the carotid artery (a major artery in the neck), cervical spine (neck vertebrae), or the base of the skull, all of which can disrupt the oculosympathetic pathway. This nerve route originates from the hypothalamus in the brain, extends down the spinal cord, and then ascends to the face and eyes.

Horner’s Syndrome Verdicts & Settlements

Because the condition is often tied to brachial plexus injuries or nerve damage during delivery, most of the verdicts and settlements reported in these cases involve newborns who suffered permanent neurological deficits after shoulder dystocia and improper use of force. These cases are unusual and infrequently reach a jury, but when they do, the outcomes show that jurors are willing to award significant compensation for lifelong impairments.

Below are examples of verdicts and settlements involving Horner’s Syndrome:

$2,348,339 Verdict (Missouri): A premature male infant suffered a permanent right brachial plexus injury (C5–C7) and right eye Horner’s syndrome after the delivering obstetrician encountered shoulder dystocia and, according to the plaintiff, used excessive force during a vaginal delivery. The child was left with limited use of the right arm, facial asymmetry, and inability to elevate the right eyelid, and the clinic was pursued on a vicarious liability theory. The jury awarded $2,348,339, including $1,000,000 for pain and suffering, $148,339 for past medical expenses, and $1,200,000 for future medical care. This is the most recent Horner’s syndrome verdict we have seen, and it was in 2023, which underscores that very few of these cases reach a jury.

$2,000,000 Verdict (Illinois): During delivery, a female newborn experienced a severe and permanent brachial plexus injury, resulting in shoulder dystocia, the development of a neuroma across her entire right brachial plexus, lesions in the cervical roots, and Horner’s Syndrome affecting her right eye. The plaintiff argued that the defendant applied excessive lateral traction to the baby’s head during delivery, did not properly monitor the fetal position, failed to adequately address the shoulder dystocia, was negligent in not performing a cesarean section, and did not adhere to the proper standard of medical care. The defendant, however, denied any wrongdoing, asserting that the risk of shoulder dystocia was low, a cesarean section was unnecessary, and their treatment of the plaintiff consistently met acceptable medical standards. An Illinois jury saw it differently and awarded $2 million to the family.

$350,000 Settlement (Texas):  The plaintiff, an infant, suffered brachial plexus injury, right arm Erb’s palsy, and right Horner’s syndrome when her birth was assisted by the female defendant physician. The plaintiff’s parent contended that the defendant assisted in the birth in a negligent manner, failed to recognize the risk factors for shoulder dystocia, failed to prevent the complication, and failed to provide the proper standard of care.

$700,000 Settlement (Oregon): A newborn male sustained Erb’s palsy and Horner’s syndrome following his delivery by the defendant obstetrician. The defendant encountered shoulder dystocia during delivery and performed a forceps delivery, causing evulsion of the nerve roots and brachial plexus. The plaintiff contended that the defendant should have performed a sonogram to determine the size of the fetus, particularly in light of the plaintiff’s mother’s obesity, and that the unusually large size of the fetus warranted a Cesarean delivery.

$300,000 Settlement (California): The plaintiff claimed he suffered a right brachial plexus injury resulting in permanent paralysis of his right arm and Horner’s Syndrome during delivery attended by the defendants. The plaintiff contended the defendants were negligent in their care and treatment of him during labor and delivery and mismanaged his delivery by performing a vaginal delivery instead of a cesarean section despite a prolonged labor, macrosomia, and impending shoulder dystocia.

$150,000 Settlement (Nevada): A 35-year-old female sustained Horner’s syndrome in her right eye as a result of negligence during a surgical procedure. The defendant admitted to making a mistake but contested whether the plaintiff’s eye issues were related.

$16,5000 Settlement (Oregon): The plaintiff was injured in a motor vehicle collision resulting in various injuries, including a concussion with headaches, Horner’s Syndrome, and facial and cranial nerve disorder. She settled for policy limits with the at-fault driver and then sought UIM damages from her own insurance company.

The Birth Injury Lawyers at Miller & Zois Can Help

If your baby has been diagnosed with Horner’s syndrome, there is a possibility that it may have been caused by medical malpractice during childbirth. It is also possible that your baby may have more severe injuries.

Miller & Zois birth injury lawyers can thoroughly investigate your case at no cost to you. We can determine exactly what happened and tell you whether you have a malpractice claim. Call 800-553-8082 today or get a free online consultation.