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| CASE REPORT |
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| Year : 2023 | Volume
: 12
| Issue : 1 | Page : 61-63 |
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Cardio-vocal syndrome revisited
Shivank, Yogendra Mishra
Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
| Date of Submission | 20-Nov-2022 |
| Date of Decision | 23-Jan-2023 |
| Date of Acceptance | 24-Jan-2023 |
| Date of Web Publication | 15-Mar-2023 |
Correspondence Address:
Shivank
Department of Internal Medicine, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sjhs.sjhs_140_22
Ortner Syndrome or Cardiovocal Syndrome encompasses any cardiovascular cause causing vocal cord paralysis by compression of the recurrent laryngeal nerve along its pathway. Historically, it was described as a case of vocal cord paralysis due to an enlarged left atrium compressing on the left recurrent laryngeal nerve in mitral valve stenosis. We describe a case of 71 years male, who presented with insidious onset hoarseness of voice. Contrast-enhanced computed tomography neck and chest revealed two aneurysms from the arch of aorta compressing on the left recurrent laryngeal nerve. With other causes being ruled out, the diagnosis of Cardiovocal syndrome was retained.
Keywords: Cardiovocal syndrome, Ortner syndrome, recurrent laryngeal nerve
How to cite this article:
Shivank, Mishra Y. Cardio-vocal syndrome revisited. Saudi J Health Sci 2023;12:61-3 |
| Introduction | |  |
Hoarseness of voice is often encountered in symptomatology in the elderly, and neoplastic etiology is usually the first differential. Rarely, cardiovascular conditions cause compression of the recurrent laryngeal nerve along its course, leading to vocal cord paralysis. This refers to cardiovocal syndrome. It is described to be more common in men because possibly of a higher incidence of cardiovascular conditions than in females.[1] Furthermore, cardiovocal syndrome has a peak incidence in older age but is known to occur in any age group.[2] We present a similar case of Ortner's Syndrome, reiterating the importance of phonation and cardiac anatomic pathology.
| Case Report | | |
A 71 years old male, with a known case of Type 2 Diabetes Mellitus for the past year with good glycaemic control, presented with insidious onset hoarseness of voice for the past month. Indirect laryngoscopy for hoarseness of voice revealed left vocal cord palsy. CECT Neck and Chest was suggestive of the prominence of the left laryngeal ventricle with medialisation of the left posterior cord margin showing left vocal cord palsy. [Figure 1] There was no neoplastic lesion. However, the aortogram revealed two saccular aneurysms arising from the distal arch of aorta-larger measuring 3 cm × 1.6 cm × 2.5 cm infero-medially along the expected course of the left recurrent laryngeal nerve and smaller measuring 2 cm × 1.7 cm × 0.8 cm directed postero-superiorly. [Figure 2] The clinical symptoms in combination with imaging findings were consistent with the cardio-vocal syndrome. The patient was counselled about the disease and planned for vascular surgery however, the patient was unwilling for any intervention. He was asked for regular follow-up on an outpatient basis. | Figure 1: Contrast-enhanced CT neck and chest axial section illustrating prominence of left laryngeal ventricle and medialization of left posterior cord (red arrow) suggestive of left vocal cord palsy. CT: Computed tomography
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 | Figure 2: (a) Contrast enhanced CT Neck and Chest coronal section illustrating the saccular aneurysm from the arch of aorta (red arrow) compressing on left recurrent laryngeal nerve; (b) Contrast enhanced CT Neck and Chest sagittal section illustrating the saccular aneurysm from the distal arch of aorta (green arrow). CT: Computed tomography
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| Discussion | | |
The two recurrent laryngeal nerves, on the left and right, are the branches of the vagus nerve and supply the intrinsic muscles of the larynx (except cricothyroid). The nerves follow an indirect course with initial descent into the thoracic cavity and then rise between the trachea and esophagus to reach the neck. In this due course, the right recurrent laryngeal nerve hooks around the right subclavian artery and the left one hooks under the arch of the aorta. Both the nerves provide an ipsilateral innervation to vocal cords and unilateral damage usually causes hoarseness, as in our patient.[3] The left recurrent laryngeal nerve, because of its longer course, is more susceptible and commonly involved in the etiology of cardiovocal syndrome. Initially, this nerve injury was attributed to the pressure effect of the left dilated atrium in a case of mitral stenosis. During later decades, it was found that the pressure effect on recurrent laryngeal nerves can be because of any thoracic structure like a dilated pulmonary artery, aortic aneurysm, or even pericardial effusion.[4] Moreover, in a case series of seven patients of Ortner syndrome studied over 8 years, the left atrium was, in fact, of normal diameter (<40 mm) in 3 cases and only marginally dilated (41 mm) in one case.[5]
Hoarseness of voice, as mentioned, is due to unilateral vocal cord palsy and can be due to underlying inflammatory, neuromuscular, or some neoplastic etiology. There is no specific mention of the incidence of Ortner syndrome in the literature; however, various case series ascribe approximately 1%–3% of cases of extra laryngeal causes of hoarseness to this entity.[6],[7] In a case series of 115 patients, intrathoracic etiology was responsible for nerve compression in 70 patients. Only one patient among those was found to have a vascular cause, such as an aortic arch aneurysm.[8]
The management of vocal cord palsy is guided by underlying etiology. The confirmation of vocal cord palsy should be done by fiber-optic laryngoscopy.[9] Further, based on the age of presentation and clinical scenario, imaging evidence may be required from the base of the skull to the upper part of the abdomen, especially in the elderly. The treatment of Ortner syndrome warrants the correction of underlying pathology, which in most cases, is not easy and may require morbid vascular surgery. Moreover, in the followed up cases of Ortner Syndrome in a case series, hoarseness of voice did not improve in any patient. By the time, the patients become symptomatic, and a diagnosis is made, the nerve has, most likely, sustained permanent damage.[5] It is likely that diagnosis at an early stage, followed by advanced management of vocal cord palsy, might cause symptomatic improvement.[10]
Cardiovocal syndrome is a rare entity, and a high degree of suspicion is required by the treating physician for a timely diagnosis of this condition. However, the complex cardiac anatomy and the operative intervention required still keeps us far from providing treatment with low mortality rates, even in the present era.
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 | | |
| 1. | 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.  |
| 2. | Zaki SA, Asif S, Shanbag P. Ortner syndrome in infants. Indian Pediatr 2010;47:351-3. |
| 3. | Heikkinen J, Milger K, Alejandre-Lafont E, Woitzik C, Litzlbauer D, Vogt JF, et al. Cardiovocal syndrome (Ortner's Syndrome) associated with chronic thromboembolic pulmonary hypertension and giant pulmonary artery aneurysm: Case report and review of the literature. Case Rep Med 2012;2012:230736. |
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| 5. | Monwarul Islam AK, Shimu IJ, Ananya KF, Sultana R, Alam S. Ortner's syndrome in the modern era: A series of 7 cases. Glob J Rare Dis 2018;3:001-4. |
| 6. | Shahul HA, Manu MK, Mohapatra AK, Magazine R. Ortner's syndrome. BMJ Case Rep 2014;2014:bcr2013200950. |
| 7. | Klee K, Eick C, Witlandt R, Gawaz M, Didczuneit-Sandhop B. Unilateral recurrent nerve palsy and cardiovascular disease – Ortner's syndrome. J Cardiol Cases 2017;15:88-90. |
| 8. | Song SW, Jun BC, Cho KJ, Lee S, Kim YJ, Park SH. CT evaluation of vocal cord paralysis due to thoracic diseases: A 10-year retrospective study. Yonsei Med J 2011;52:831-7. |
| 9. | Subramaniam V, Herle A, Mohammed N, Thahir M. Ortner's syndrome: Case series and literature review. Braz J Otorhinolaryngol 2011;77:559-62. |
| 10. | Yumoto E, Minoda R, Hyodo M, Yamagata T. Causes of recurrent laryngeal nerve paralysis. Auris Nasus Larynx 2002;29:41-5. |
[Figure 1], [Figure 2]
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