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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 114-116

An unusual case of cardiovocal syndrome


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 Submission27-Jul-2018
Date of Decision06-Sep-2018
Date of Acceptance16-Oct-2018
Date of Web Publication23-May-2019

Correspondence Address:
Akshyaya Pradhan
Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_115_18

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  Abstract 


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

How to cite this URL:
Bajpai J, Kant S, Kar A, Pradhan A. An unusual case of cardiovocal syndrome. CHRISMED J Health Res [serial online] 2019 [cited 2019 Aug 18];6:114-6. Available from: http://www.cjhr.org/text.asp?2019/6/2/114/258966




  Introduction Top


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.[1] 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.[2],[3],[4] 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.[5] Up to 5% of patients with TAAs develop cardiovocal hoarseness due to the left recurrent laryngeal nerve palsy.[6]


  Case Report Top


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 Top


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%).[7]

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.[8] Although classically described for mitral stenosis, the incidence of Ortner's syndrome in mitral stenosis itself not common (0.5%–6%).[9] 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.[6],[10] The original pathogenetic mechanism postulated by Ortner was compression of the nerve by an enlarged left atrium against the aorta.[11] 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).[12],[13]

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ramadan HH, Wax MK, Avery S. Outcome and changing cause of unilateral vocal cord paralysis. Otolaryngol Head Neck Surg 1998;118:199-202.  Back to cited text no. 1
    
2.
Glazer HS, Aronberg DJ, Lee JK, Sagel SS. Extralaryngeal causes of vocal cord paralysis: CT evaluation. AJR Am J Roentgenol 1983;141:527-31.  Back to cited text no. 2
    
3.
El Badawey MR, Punekar S, Zammit-Maempel I. Prospective study to assess vocal cord palsy investigations. Otolaryngol Head Neck Surg 2008;138:788-90.  Back to cited text no. 3
    
4.
Song SW, Jun BC, Cho KJ, Lee S, Kim YJ, Park SH, et al. CT evaluation of vocal cord paralysis due to thoracic diseases: A 10-year retrospective study. Yonsei Med J 2011;52:831-7.  Back to cited text no. 4
    
5.
Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr., et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010;121:e266-369.  Back to cited text no. 5
    
6.
Mulpuru SK, Vasavada BC, Punukollu GK, Patel AG. Cardiovocal syndrome: A systematic review. Heart Lung Circ 2008;17:1-4.  Back to cited text no. 6
    
7.
Loughran S, Alves C, MacGregor FB. Current aetiology of unilateral vocal fold paralysis in a teaching hospital in the West of Scotland. J Laryngol Otol 2002;116:907-10.  Back to cited text no. 7
    
8.
Eccles SR, Banks J, Kumar P. Ascending aortic aneurysm causing hoarse voice: A varient of Ortner's syndrome. BMJ Case Rep 2012;10:1136-8.  Back to cited text no. 8
    
9.
Solanki SV, Yajnik VH. Ortner's syndrome. Indian Heart J 1972;24:43-6.  Back to cited text no. 9
    
10.
Runge V, Pieper CC, Schiller W, Praeger AJ, Probst C, Wilhelm KE, et al. Endovascular repair of an ductus arteriosus aneurysm causing Ortner syndrome. Vasc Endovascular Surg 2014;48:271-4.  Back to cited text no. 10
    
11.
Andjelkovic K, Kalimanovska-Ostric D, Djukic M, Vukcevic V, Menkovic N, Mehmedbegovic Z, et al. Two rare conditions in an eisenmenger patient: Left main coronary artery compression and Ortner's syndrome due to pulmonary artery dilatation. Heart Lung 2013;42:382-6.  Back to cited text no. 11
    
12.
Fetterolf G, Norris G. The anatomical explanation of the left recurrent laryngeal nerve paralysis which is found in certain cases of mitral stenosis. Am J Med Sci 1911;141:625-38.  Back to cited text no. 12
    
13.
Ari R, Harvey WP, Hufnagel CA. Etiology of hoarseness associated with mitral stenosis: Improvement following mitral surgery. Am Heart J 1955;50:153-60.  Back to cited text no. 13
    


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  [Figure 1], [Figure 2]



 

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