|Year : 2019 | Volume
| Issue : 2 | Page : 114-116
An unusual case of cardiovocal syndrome
Jyoti Bajpai1, Surya Kant1, Avishek Kar1, Akshyaya Pradhan2
1 Department of Respiratory Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||27-Jul-2018|
|Date of Decision||06-Sep-2018|
|Date of Acceptance||16-Oct-2018|
|Date of Web Publication||23-May-2019|
Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Hoarseness of voice is the most common presenting symptom of vocal cord palsy, which can be due to different etiologies. Ortener's syndrome is one of them and is defined as hoarseness of voice due to recurrent laryngeal nerve palsy secondary to cardiovascular disorders. Hoarseness due to aortic aneurysm is a rare entity. Here we report an unusual case of a 61 year smoker male who presented to us with persistent hoarseness of voice due to asymptomatic aortic aneurysm.
Keywords: Aortic aneurysm, contrast-enhanced computed tomography thorax, hoarseness of voice, vocal cord palsy
|How to cite this article:|
Bajpai J, Kant S, Kar A, Pradhan A. An unusual case of cardiovocal syndrome. CHRISMED J Health Res 2019;6:114-6
| Introduction|| |
Hoarseness of voice is a common complaint and most often has a benign cause. Persistent hoarseness of voice is a warning sign, and further workup is required to find the cause. The various causes of hoarseness of voice include malignancy (32%), post-surgical (30%), trauma (11%), idiopathic (16%), central nervous system disorders (8%), and 3% due to infections. The left recurrent laryngeal nerve is longer and thus more prone to injury than the right. Laryngeal carcinoma and trauma are the most common causes of vocal cord palsy while in one case series of extralaryngeal vocal cord palsy investigated by contrast tomography only one in 33, 62, and 115 cases were attributed to cardiovascular causes, respectively.,, A variety of cardiovascular causes of recurrent laryngeal nerve palsy have been described in the literature. Most cases are due to compression of the nerve by structures bounding the aortopulmonary window. Asymptomatic aortic aneurysm leading to hoarseness of voice is very uncommon presentation of cardiovocal or Ortner's syndrome. Thoracic aortic aneurysms (TAAs) are usually asymptomatic. Up to 5% of patients with TAAs develop cardiovocal hoarseness due to the left recurrent laryngeal nerve palsy.
| Case Report|| |
A sixty one year old male patient presented to the outpatient clinic with complaints of persistent hoarseness of voice for the past 9 months. The patient was a chronic smoker. He was nondiabetic and nonhypertensive. He had previously undergone indirect laryngoscopy which had revealed left vocal cord palsy. Chest radiograph revealed mediastinal widening [Figure 1]. Two-dimensional echocardiography did not reveal any valvular or myocardial disease. Endoscopy was planned for locoregional examination and to evaluate the cause of hoarseness. Fiberoptic nasoendoscopy revealed paralyzed left vocal cord without any other abnormality.
|Figure 1: Chest X-ray posteroanterior view showing mediastinal widening and absence of active pleuroparenchymal disease|
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A contrast-enhanced computed tomography (CT) of neck and thorax was done in view of chest X-ray findings. CT thorax revealed a saccular aneurysm arising from the arch of aorta 6 cm × 5 cm with narrow neck, suggesting the cause of left recurrent laryngeal nerve palsy [Figure 2]. Cardiothoracic surgery consultation was sought, and the patient was counseled for surgical as well as endovascular repair. However, due to financial constraints, he opted for medical follow-up with beta-blockers.
|Figure 2: Contrast-enhanced computed tomography (axial sections) showing large saccular aneurysm arising out of the arch of aorta (*)|
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| Discussion|| |
The left recurrent laryngeal nerve has a longer course than the right and thus is more prone to injury. As the nerve travels down into the superior mediastinum, it loops under the arch of aorta before ascending to the vocal cords. The small space between the aortic arch and the pulmonary artery through which the left recurrent laryngeal nerve travels is the aortopulmonary window. The window is bound anteriorly by the ascending aorta, superiorly by the arch of the aorta, posteriorly by the descending aorta, and inferiorly by the pulmonary artery. There are multitude of causes which lead to a hoarse voice; laryngeal nerve palsy is one of them. Laryngeal carcinoma and trauma are the most common causes of true vocal cord paralysis. Most common extralaryngeal malignancy causing vocal cord palsy is bronchogenic carcinoma. Most commonly, it involves left vocal cord, but it can also involve right recurrent laryngeal nerve if right-sided mediastinal lymphadenopathy extends above the right subclavian artery. Idiopathic causes including cardiocvocal syndrome contributed to only 11% of cases of left laryngeal nerve paralysis while lung cancer (42%) was most frequent followed by surgical manipulation (24%).
Ortner's syndrome described in 1897 (120 years ago!) originally referred to the left recurrent laryngeal nerve palsy caused by left atrial enlargement due to mitral stenosis. Although classically described for mitral stenosis, the incidence of Ortner's syndrome in mitral stenosis itself not common (0.5%–6%). The term is now used to describe recurrent laryngeal nerve palsy due to any cardiovascular abnormality and is commonly referred to as “cardiovocal syndrome.” A literature search revealed many other causes of cardiovocal syndrome such as mitral valve prolapse, left atrial myxoma, atrial septal defects, patent ductus arteriosus, primary pulmonary hypertension, dilated left ventricle, and Eisenmenger's syndrome., The original pathogenetic mechanism postulated by Ortner was compression of the nerve by an enlarged left atrium against the aorta. However, other contemporary studies pinpointed the enlarged pulmonary artery as the culprit and emphasized on the compression of the nerve in the narrow aortopulmonary window (as previously alluded to).,
To conclude, Hoarseness of voice though benign when persistent needs further workup and evaluation. Cardiovocal syndrome is a uncommon cause of vocal cord palsy. Aortic aneurysm rarely presents with hoarseness as the first manifestation. CT thorax plays a pivotal role in the early diagnosis of asymptomatic aortic aneurysm.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]