Left recurrent laryngeal palsy (Ortner's syndrome) in schistosomal pulmonary hypertension

Abstract

A 34-year-old man developed dyspnea and intermittent hoarseness of his voice that soon became constant, two years before admission to the hospital. His disease evolved with progressive exertional dyspnea and palpitation. He comes from an endemic area for schistosomiasis mansoni in the state of Minas Gerais. Abdominal ultrasound and magnetic resonance of the liver showed periportal thickening suggestive of Symmer's fibrosis. His chest x-ray showed enlargement of the heart and main pulmonary artery (Figure A). On echocardiography, the left ventricle was normal; the right ventricle was dilated and the intraventricular septum moved paradoxically. Enhanced computed tomography disclosed a normal lung parenchyma and enlarged pulmonary arteries without lymph node swelling (Figure B - Ao= aorta; SVC=superior vena cava; PA=pulmonary artery truncus). Cardiac catheterization revealed a systolic pulmonary pressure of 130mmHg. Dynamic laryngoscopy documented complete paralysis of the left vocal cord (Figure C - arrow). Ortner's syndrome or the cardiovocal syndrome is the name originally given to paralysis of the left vocal cord in cases of mitral stenosis associated with a large left atrium and pulmonary artery dilation. It has been suggested that the nerve is pinched between an enlarged dilated pulmonary artery and the aorta.