Rowland Payne syndrome (RPS) is a rare neurological syndrome characterised by the simultaneous ipsilateral occurrence of Horner's syndrome, vocal cord paralysis, and hemidiaphragm paralysis, resulting from disruption of the cervical sympathetic chain, the recurrent laryngeal nerve (or its parent vagus nerve), and the phrenic nerve. It is named after Dr C M E Rowland Payne, a British dermatologist working at St Thomas' Hospital, London, who first described the condition in 1981 in three patients with metastatic breast cancer seen at the Royal Marsden Hospital. The syndrome is listed in Magalini's Dictionary of Medical Syndromes and appears in standard neurology textbooks. The syndrome is typically associated with serious underlying pathology, most commonly malignant neoplasms of the breast or lung. Although the complete triad is the classic presentation, an incomplete triad does not exclude the diagnosis.
Signs and symptoms The three cardinal signs of Rowland Payne syndrome, which occur on the same side of the body, are:
Horner's syndrome: caused by disruption of the cervical sympathetic chain, producing ipsilateral ptosis (drooping of the upper eyelid), miosis (constriction of the pupil), and anhidrosis (absence of sweating on the affected side of the face). Enophthalmos (apparent recession of the eyeball) may also be present. Vocal cord paralysis: caused by involvement of the recurrent laryngeal nerve or the vagus nerve, resulting in hoarseness, a weak voice, or dysphagia (difficulty swallowing). Hemidiaphragm paralysis: caused by dysfunction of the phrenic nerve, which may be clinically silent when unilateral in patients with adequate pulmonary reserve, or may manifest as dyspnoea and reduced breath sounds. It is identifiable on plain chest radiograph as a raised hemidiaphragm, and can be confirmed by diaphragmatic fluoroscopy or electromyography. Additional features commonly reported in the literature include ipsilateral shoulder pain and weakness, which may reflect involvement of adjacent cervical sensory nerve roots, as well as brachial plexopathy presenting as weakness or sensory deficits in the upper limb.
Causes Rowland Payne syndrome arises from a lesion that compresses or infiltrates all three of the relevant nerve structures at a single point.
Malignant causes Breast cancer is the most frequently identified cause, accounting for six of ten reported cases in a 2025 review of the published literature. Lung cancer, including epidermoid carcinoma, has also been implicated. Other reported neoplastic causes include anaplastic thyroid carcinoma and neuroblastoma, including a reported case in a five-month-old infant with a cervico-mediastinal tumour.
Non-malignant causes A small number of cases without an underlying malignancy have been described. These include cases attributed to birth trauma, in which shearing forces at the lower neck during delivery are proposed to stretch or injure the relevant motor nerves or their branches. Infectious lymphadenopathy, including a reported case complicating empyema thoracis in a child, and trauma to the lower cervical region have also been reported. Transient Rowland Payne syndrome has been described as a complication of interscalene nerve block. In non-malignant cases, the prognosis is generally more favourable and spontaneous recovery may occur.
Pathophysiology The key anatomical feature is that three nerve structures converge at the level of the sixth cervical vertebra (C6). Here, the cervical sympathetic chain, the vagus nerve (including its branch, the recurrent laryngeal nerve), and the phrenic nerve pass in close proximity, posterior to the carotid sheath, anterolateral to the scalenus anterior muscle, and anteromedial to the internal jugular lymphatic chain. The fifth cervical nerve runs immediately behind them. Below C6, the nerves diverge. The scalenus anterior muscle shields the phrenic nerve from masses arising in the neck, which explains why phrenic palsy is not a consistent feature of Pancoast's syndrome. C6 is therefore the site at which a single lesion, most often infiltrated lymph nodes or a spreading tumour, can compromise all three structures at once. The syndrome can also arise from lesions at the thoracic inlet, particularly larger masses that bridge the greater anatomical separation at that level. Cases related to trauma in the lower neck tend to affect the right side, reflecting the asymmetric course of the right recurrent laryngeal and phrenic nerves, both of which cross the right subclavian artery.
Diagnosis The diagnosis of Rowland Payne syndrome is clinical, supported by targeted investigations to confirm each component of the triad and to identify the underlying cause.
Confirming the triad Horner's syndrome may be confirmed pharmacologically. Topical cocaine drops fail to dilate the affected pupil, confirming a pre-ganglionic or post-ganglionic sympathetic lesion. Apraclonidine drops produce reversal of ptosis and miosis in the affected eye due to denervation hypersensitivity, and can be used as an alternative test. Vocal cord paralysis is confirmed by flexible laryngoscopy, which allows direct visualisation of impaired or absent movement of one vocal fold. Hemidiaphragm paralysis is identifiable on plain chest radiograph as a raised hemidiaphragm and is confirmed by fluoroscopic screening of diaphragmatic movement, or by electromyography in equivocal cases.
Imaging Cross-sectional imaging of the neck and thoracic inlet is central to identifying the causative lesion. Contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine and thoracic inlet can reveal lymphadenopathy, soft tissue masses, or direct tumour infiltration at the level of C6 or the thoracic inlet. Plain chest radiography may additionally show mediastinal widening, apical densities, pleural effusion, or an elevated hemidiaphragm. Where malignancy is suspected, further investigation may include fine-needle aspiration or biopsy of a mass for histological diagnosis, PET scanning to assess for metastatic spread, and analysis of pleural fluid if effusion is present.
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