Dr. Susan Little, of Bytown Cat Hospital on Ottawa, Canada is a listmember on one of the fanciers internet lists. She very graciously shared some information with the list about Horner's syndrome, and polyps so that we could all understand what was happening. 

Horner's Syndrome:

Named for Johann F. Horner, a Swiss ophthalmologist (1831-1886) who first described the syndrome.

Nasopharyngeal polyps are an important cause of chronic respiratory signs in cats, reportedly uncommon but often misdiagnosed. These polyps originate in the middle ear cavity and enter the Eustachian tube, where they can either enter the nasopharynx (the area in the back of the cat's throat) or they can grow into the external ear canal. They are made of inflammatory tissue often covered with respiratory epithelium.

There are 2 suspected mechanisms for their formation: a congenital defect of fetal development, and a response to chronic inflammatory middle ear disease, which may be caused by upper respiratory infection.

The average age of cats at diagnosis is about 1.5 years. However, polyps have been recorded in cats under 6 months old and as old as 15 years. They seem to appear equally frequently in males and females and have been found in both domestic short/longhairs and purebreds. The most common clinical signs are: noisy breathing, dyspnea (difficult breathing), nasal discharge, sneezing, coughing, and dysphagia (difficult swallowing). Also, signs of ear canal irritation or infection and very occasionally signs of vestibular disease such as a head tilt may be seen.

It can be quite difficult to confirm or deny the existence of polyps in an awake cat. The ears, nose and throat must be examined carefully. Sedation is almost always needed to visualize the polyp. If Horner's syndrome is present, other causes must be eliminated. Theoretically, facial nerve paralysis could be seen in cats with polyps (pre-operatively), but no cases have been reported.

In a sedated or anesthetized cat, the oropharynx (the central portion of the pharynx) and the nasopharynx (the part of the pharynx above the soft palate) can be examined. The polyp may be above the soft palate, so that its presence can be confirmed by palpating it, or by reflecting the soft palate to visualize above it with a small dental mirror. A flexible fiberoptic scope can also be used to visualize the area above the soft palate.

The polyps appear as round or oval masses on a stalk, and may be red, pink, gray or shiny. They may be very large and can completely fill the nasopharynx. The stalk may be seen appearing from the Eustachian tube. The ear canals and the eardrum should also be evaluated as the majority of cats with polyps have otitis media (inflammation of the middle ear). The polyps can grow from the Eustachian tube, rupture through the eardrum and extend out through the external ear canal. In this case, the external ear canal may be infected, inflamed and irritated. X-rays of the middle ear should be taken.

The treatment of choice is surgical removal of the polyp. Two methods are used. In the traction removal method, the polyp may be grasped with forceps and pulled out slowly and steadily while the cat is anesthetized. The stalk is usually 5-10 mm long. There will be a small amount of bleeding. Sometimes an incision must be made in the soft palate to gain access to the polyp. Many surgeons feel that the stalk will break in about 50% of the cases where traction is used to remove the polyp, leaving the base of the stalk in the middle ear. Therefore approximately 50% of polyps removed in this manner may regrow.

The other surgical treatment is a bulla osteotomy. This is a more complicated and controversial surgery and has more complications and more risk than the traction removal method. Some surgeons argue that if there is no evidence of middle ear disease, a bulla osteotomy is unnecessary. However, regrowth of the polyp is very rare after bulla osteotomy. Extreme care must be taken to avoid damaging many vital structures during this surgery, including nerves and blood vessels. A drain is usually placed when the incision is closed and stays in place for a few days.

Horner's syndrome is a common complication of both surgical methods and usually resolves within 3 weeks. As well, respiratory problems can occur after the traction method is used. After bulla osteotomy, vestibular symptoms (head tilt, nystagmus [abnormal eye movement], and ataxia [loss of balance]) may occur. Uncommonly, the facial nerve may be paralyzed leading to drooping of the lip, drooling, and inability of the eyelids to blink. This neuropathy usually resolves on its own within a few weeks.

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