HOARSE VOICE OF A FAILING HEART: CARDIO-VOCAL SYNDROME

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: A cardiopulmonary etiology of hoarseness of voice (HOV) is extremely uncommon. Here we describe a 71-year-old-male presenting with HOV due to an extremely enlarged Left Atrium (LA) that compressed the Left recurrent laryngeal nerve (LRLN). CASE PRESENTATION: A 71-year-old male with end stage renal disease and coronary artery disease presented with HOV and dyspnea of 8-month duration. He was seen at an otolaryngology clinic in the past and was diagnosed with left true vocal cord paralysis, however the etiology remained unclear. Family and social history were non-contributory. On physical exam, patient had a raspy HOV with conversational dyspnea. Also, he had a diastolic murmur, jugular venous distension, bibasilar rales and bilateral pitting edema in the lower extremities. Extensive laboratory work-up was negative except an elevated brain natriuretic peptide of 960 pg/ml, Creatinine 4.5 mg/dl and GFR 12 ml/min.Echocardiogram revealed ejection fraction of 25% with severe mitral stenosis and pronounced LA diameter of 7.9 cm [Figure1]. Indirect laryngoscopy demonstrated true left vocal cord paralysis [Figure 2]. A non-contrast computed tomography (CT) scan of the neck, chest and head did not reveal any relatable etiologies for hoarseness. With the findings on indirect laryngoscopy coupled with the echocardiographic findings, it was postulated that the patient's HOV was due to compression of the left recurrent laryngeal nerve from an enlarged LA and the diagnosis of Ortner's Syndrome was established. The patient was later discharged with guideline directed medical therapy for heart failure. During subsequent follow up visits the patient continued to have hoarseness and eventually expired due to decompensated heart failure. DISCUSSION: Cardio-vocal syndrome (CVS) is a rare condition in which the cardio-thoracic structures, classically an enlarged Left Atrium (LA), impinges on the left recurrent laryngeal nerve (LRLN) resulting in hoarseness of voice [2]. While Injury to the LRLN secondary to neck surgeries and extra-laryngeal malignancy are the most common cause of neurological voice change [3], multiple cardio-thoracic disorders causing LRLN palsy are described in the literature. LAE accounts for approximately 0.6-5% of all cases of CVS. It is a diagnosis of exclusion and can be supported by echocardiographic and CT findings. Unfortunately, there is no concrete medical treatment available for HOV due to LAE. In those with mitral stenosis accounting for LAE, mitral valve replacement is often curative. In our case, due to advanced age and significant morbidity burden, the patient was reluctant to pursue any surgical intervention which unfortunately led to persistent HOV and lethal outcome. CONCLUSIONS: A Cardio-thoracic etiology of HOV is rare. Clinicians should be aware of this possibility as it could aid in early recognition of silent cardiac disease and also identify a rare cause of HOV. REFERENCE #1: Subramaniam, V., Herle TV, A., Mohammed, N., & Thahir, M. (2011). Ortner's syndrome: case series and literature review. Brazilian journal of otorhinolaryngology, 77(5), 559-562. REFERENCE #2: Khan, I. A., Wattanasauwan, N., & Ansari, A. W. (1999). Painless aortic dissection presenting as hoarseness of voice: cardiovocal syndrome: Ortner's syndrome. The American journal of emergency medicine, 17(4), 361-363. REFERENCE #3: Plastiras, S. C., Pamboucas, C., Zafiriou, T., Lazaris, N., & Toumanidis, S. (2010). Ortner's syndrome: a multifactorial cardiovocal syndrome. Clinical cardiology, 33(6), E99. DISCLOSURES: No relevant relationships by Camelia Chirculescu, source=Web Response No relevant relationships by Sonia Dogra, source=Web Response No relevant relationships by Jeff Manfredonia, source=Web Response No relevant relationships by Niravkumar Patel, source=Web Response No relevant relationships by Leticia Peltzer, source=Web Response No relevant relationships by Dakota Robertson, source=Web Response