Kerala Heart Journal -praveen

Case report

Kerala Heart J  2016; 6(2):xx-xx.


Cardio vocal syndrome revisited



Satheesan Praveena, Baiju RB ,Vijayalakshmic, V.V.Radhakrishnand


a
Assistant Professor,Department of Cardiology,Government Medical College,Thiruvananthapuram

b Additional  Professor,Department of Cardiology,Government Medical College,Thiruvananthapuram

c Senior Resident,Department of Cardiology,Government Medical College,Thiruvananthapuram

d  Professor,Department of Cardiology,Government Medical College,Thiruvananthapuram


Correspondng author

Dr Satheesan Praveen
Assistant Professor,Department of Cardiology,Government Medical College,Thiruvananthapuram

Email:praveensatheesan@gmail.com



INDRODUCTION

Cardio vocal syndrome or ortners syndrome refer to vocal cord palsy due to cardiovascular pathology.First described in  a mitral stenosis patient in 1897 by an Austrian Physician Norbert Ortner.1The recurrent laryngeal nerve is compressed by a dilated LA as in Mitral stenosis or extra cardiac compressions like aneurysmn.Here we report a case of cardio vocal syndrome due to saccular aneurysmn in the arch of aorta.

Case summary

A  82 yr old diabetic and hypertensive male  presented with 3 months history of  hoarseness of voice with no history of dyspahagia .He also had no history of fever, recent significant weight loss or any valvular heart disease in the past.He was an Ex smoker and had no other addictions.He was evaluated initially under  ENT department for hoarseness  of  voice .Laryngoscopy revealed  a left vocal cord palsy with no obvious cause .Patient was referred to  cardiology for further evaluation. Cardiovascular  system examination  showed  normal cardiac  size , normal heart sounds and no significant murmurs.His electrocardiogram was normal and the chest X ray showed a possible unfolding of aorta with both diaphragms at the same level.

As his symptoms were persisting and considering his age ,a possibility of a extra cardiac compression was considered and  a CT thorax was done.

A contrast enhanced CT followed by a CT angiography  done for this patient  revealed a partially saccular  aneurysmn  arising from the arch of aorta in the left suprahilar region just distal to the origin of left subclavian artery .The sac measured 4.5 x 4 cm in the greatest dimension.Intraluminal thrombus was noted with a luminal diameter of only 14 mm.The aneurysmn was seen projecting infero laterally and anteriorly  reaching upto the left main pulmonary artery.No evidence of any wall calcification/leak/aneurysmn rupture noted.He was further worked up for Tuberculosis and malignancy,but the investigations were negative for the same.



FIGURE 1 : chest x ray showing the unfolding of aorta




Figure 2. CT contrast and CT angiography showing the saccular aneurysmn just distal to origin of left subclavian artery

Discussion

Ortners syndrome or cardio vocal syndrome results from a vocal cord palsy due to recurrent laryngeal nerve injury and  can happen on both sides.The left recurrent laryngeal nerve during its long course hooks around the ligamentum arteriosum medial to  arch of aorta,ascends in the groove between trachea and oesophagus to reach larynx.Thus left recurrent laryngeal because of its longer course is prone for compression compared to the right side.

This syndrome was first reported in three patients  with mitral stenosis with dilated left atrium and later in patients with Mitral regurgitation,LA myxoma,severe pulmonary hypertension ,ASD,PDA and in patients with aneurysmn of the aorta or pulmonary artery2.

Our patient presented with hoarseness of voice alone and further evaluation revealed a saccular aneurysmn of the arch of aorta. Around 5% of patients with recurrent laryngeal nerve paralysis the cause is thoracic aortic aneurysmn compression In patients presenting with dysphonia it is advisable to evaluate with CT chest  if no primary pathology is identified.

 

Surgery should be considered in patients who have an aortic arch  aneurysmn with a maximal diameter of  > 55 mm or who are symptomatic3.Asymptompatic aneurysmns can be managed conservatively.The surgery carries higher mortality and stroke risk compared to surgery in ascending or descending aorta.For smaller aneurysms it is reasonable to reimage at 6 -12 months interval .This patient was advised  an early surgery in view of the symptoms but he declined the same.Cardio vocal syndrome thus remains an important differential diagnosis in patients presenting with hoarseness of voice.In any patient presenting with hoarseness of voice causes outside larynx should also be considered.A CECT  can be an excellent diagnostic modality in this context.

 

Conflicts of Interest

The authors have none to declare

Refrences

1.     Ortner N. Recurrenslahmung bei mitral stenose. Wien Klin Wochenschr 1897;10:7535.

2.     Shi-Min Yuan  Kuwait Medical Journal 2014; 46 (1): 3 - 13

3.     Raimund Erbei  ,Victor Aboyans, Catherine Boileau, et al 2014 ESC guidelines on the diagnosis and treatment of aortic diseases European Heart Journal  volume 35 issue 41:2873-2926

 

                                                                     


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