Cardiovocal Syndrome Research Articles

Rare Causes of Unilateral Vocal Fold Paralysis: Report of 3 Cases with Review of Literature.

Unilateral vocal fold paralysis is a common finding with a variety of underlying causes. The six main etiologic groups include neoplastic, traumatic (iatrogenic, accidental) neurological, inflammatory, congenital, and idiopathic. Various unusual causes have been described including foreign body ingestion, mediastinal lymph nodes, large pleural blebs, tracheal diverticulum, etc. It is therefore essential, that a thorough evaluation and methodical approach be undertaken to ascertain the etiology, before labelling it as idiopathic and offering any treatment. This review article focuses on the uncommon and rare causes of unilateral vocal fold paralysis that are presented through 3 representative case reports; a cardio-vocal (Ortner's) syndrome, Zenker's diverticulum and diffuse idiopathic skeletal hyperostosis. These examples are discussed with radiological findings in the context of current literature.

Left Vocal Cord Paralysis Secondary to Mitral Valve Disease

Introduction: Ortner’s syndrome, or cardio-vocal syndrome, is a clinical entity characterised by hoarseness (secondary to left-sided recurrent laryngeal nerve palsy) caused by cardiovascular disease. The incidence of Ortner’s syndrome ranges from 0.25 percent to 0.5 percent of all cases of recurrent laryngeal nerve paralysis. Case Report: A 44-year-old Malay gentleman presented with hoarseness and shortness of breath for 4 days. It was associated with mild orthopnea and aspiration symptoms. He denied history of dysphagia, chronic cough, sore throat, chest pain, palpitation and decreased effort tolerance. There was no history of hypertension, diabetes and asthma. He also gave no history of recurrent fever with sore throat during childhood. Results: On examination, the patient appeared tachypnoeic. There was no peripheral oedema, cyanosis or clubbing. His blood pressure was 100/60 mm Hg and his pulse was irregular with a rate of 78/min. Neck examination was normal. Apex beat was not displaced. On auscultation the first heart sound was loud. A grade 3/6 long rumbling diastolic murmur was heard at the mitral area and he had bilateral basal crepitations. Laryngoscopy using 700 scope showed left vocal cord palsy in paramedian position with phonatory gap. Computed tomography (CT) of the thorax showed left atrial enlargement with prominent pulmonary veins. Echochardiography showed left atrial dilatation with thickened mitral valve. Left ventricular systolic function was good with ejection fraction of 70% and coronary angiogram showed normal coronary artery. A diagnosis of severe mitral stenosis with heart failure was made. Preoperatively the patient was stabilized and was referred for dental clearance. Then he underwent surgery for mitral and aortic valve replacement. Post-operatively patient recovered uneventfully. His hoarseness recovered completely after 3 months. Conclusion: Cardiovascular disease should be considered as a differential diagnosis in a patient with hoarseness.

Thoracalgia in a Patient with Determined Coronary Heart Disease. Is there Always a Relapse of Angina Pectoris?

This article presents a clinical case of a 62-year-old man with a long history of coronary heart disease and smoking, whose main complaint upon admission to the hospital was voice hoarseness and atypical pain syndrome in the chest. During a preliminary medical examination, attention was paid to the clinical picture, atypical for a coronary heart disease – voice hoarseness was identified as a manifestation of the recurrent nerve compression, or cardio-vocal syndrome. Given the lack of connection between the chest pain and physical exertion, a high index of a smoking person as well as signs of the recurrent nerve compression syndrome, a multi-spiral computer tomography with contrasting of the chest organs was performed (in line with official recommendations of the Russian Associations of Oncologists and Otolaryngologists). The results revealed a proliferative lesion of the mediastinum and multiple focal lesions of both lungs. A subsequent thoracoscopy and biopsy confirmed the mediastinal form of a lung cancer. Promptly initiated poly-chemotherapy allowed stabilizing the patient’s condition and significantly improving his prospects. In this context, the article discusses the complexity of a timely diagnosis of a primary lung cancer and emphasizes the need to focus on specific and unique features of the disease course as well as on a broader clinical picture. Tactics of a multidisciplinary approach allows making a diagnosis in a timely manner, significantly improving the effectiveness of therapy and patient’s survival prognosis.

Ortner's cardiovocal syndrome: A rare cause of hoarseness of voice

Ortner's cardiovocal syndrome: A rare cause of hoarseness of voice

Ortner's: A Cardiovocal Syndrome

In 1897, Norbert Ortner, an Austrian physician, described three cases of left-sided vocal cord palsy associated with mitral valve stenosis. He postulated that this was due to associated atrial enlargement causing a compressive effect on the left recurrent laryngeal nerve as it coursed under the aortic arch within the mediastinum. More recently, the syndrome, which bears his name – Ortner's syndrome – has come to refer to a vocal cord palsy associated with a number of cardiac and vascular conditions, and has also been referred to as the cardiovocal syndrome. This study presented the case of a 77-year-old male, along with a literature review, who presented with a 2-month history of a vocal hoarseness of unknown cause. Computed tomography of the brain, head, neck, and chest was undertaken to look for a lesion along the distribution of the vagus and recurrent laryngeal nerves. Computed tomography identified a large saccular aneurysm arising from the arch of the aorta, which was the likely cause of his left-sided vocal cord palsy. The patient was referred to a cardiothoracic surgeon at the current hospital for consideration of surgical management. He was also referred on to an otolaryngologist with an interest in voice and expertise in the treatment of vocal cord paralysis in the same vicinity. He underwent a total aortic arch replacement and frozen elephant trunk to treat the arch aneurysm. Postoperatively, his vocal cord palsy was noted to persist and remained unchanged. He ultimately underwent vocal cord medialisation and is being monitored.

An unusual case of cardiovocal syndrome

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.

Recurrent laryngeal nerve palsy (cardiovocal syndrome) in dilated cardiomyopathy - Reversal with optimal medical management

Recurrent laryngeal nerve palsy (cardiovocal syndrome) in dilated cardiomyopathy - Reversal with optimal medical management

Cardiovocal syndrome due to a dilated pulmonary artery

Cardiovocal syndrome, also known as Ortner's Syndrome, is a rare cause of unilateral vocal fold paralysis (UVFP) associated with cardiac failure. Typically, UVFP is left sided and related to compression or stretching of the left recurrent laryngeal nerve. The original clinical description relates UVFP to left atrium enlargement as heart failure progresses in the context of mitral stenosis. However, other cardiac abnormalities have since been described. Here we present the case of a 7-week old infant who initially came to the attention of pediatric cardiology due to failure to thrive in the context of a grade 4 systolic murmur. Laryngoscopy revealed UVFP on the left side. Echocardiography and MRI scanning confirmed atrial and ventricular septal defects and pulmonary artery dilatation as the likely cause of left recurrent laryngeal dysfunction.

Ortner's syndrome: Looking back at this rarity

Ortner's syndrome or the cardiovocal syndrome is characterized by hoarseness of voice which is caused by the paralysis of the left recurrent laryngeal nerve as a result of cardiovascular causes. We report two cases; the first one was a 40-year-old male, who presented with hoarseness of voice, dyspnea on exertion, and central chest pain of 6-month duration. Videolaryngoscopy revealed left vocal cord palsy and an echocardiograph showed severe calcific mitral stenosis. The patient underwent mitral valve (MV) replacement and recovered left vocal cord function within 3 months. The second patient was a 52-year-old female, who presented with dyspnea on exertion, intermittent palpitations, and hoarseness of voice. Videolaryngoscopy revealed left vocal cord palsy. Echocardiography revealed features of rheumatic heart disease with severe mitral stenosis, moderate mitral regurgitation, severe tricuspid regurgitation, dilated left atrium, right atrium and right ventricle, and a left atrial appendage thrombus. The patient was subsequently taken up for MV replacement and left atrial thrombectomy, but the left vocal cord palsy persisted after surgery. Cardiovocal syndrome is rare in the general population but associated with causes such as aneurysms and MV stenosis. A high index of suspicion is needed to make an early diagnosis which can lead to surgical correction of the underlying cardiovascular disease, and the pals may resolve spontaneously following treatment.

List of Societies

Hoarseness of voice resulting from left recurrent laryngeal nerve (RLN) palsy. Ortner's or cardiovocal syndrome, is a rare clinical entity manifesting by hoarseness of voice due to left RLN palsy, secondary to cardiovascular disease. Dilated main pulmonary artery may lead to nerve compression between the aorta and pulmonary artery within the aortic window. We report a rare case of a patient suffering from hoarseness of voice that was the first symptom of unknown severe pulmonary arterial hypertension.

Disfonija kao prezentacija disekcije aorte

Introduction: The most common clinical presentation of acute aortic dissection is chest pain, but every once in a while atypical symptom can occur. In rare cases, aortic dissection can present itself through the left reccurent laryngeal nerve palsy, which occurs due to the entrapment of the nerve between the left branch of pulmonary artery and aorta, causing the Ortner’s syndrome, known also as the cardiovocal syndrome. Norbert Ortner, the Austrian physician was the first to describe this vocal cord paralysis due to cardiovascular changes. The aim: The aim of this paper is to introduce the case of atypical aortic dissection presentation. Material and metods: Facts and data from the original medical reports were used. Case report: EMS team visited a female 78 year old patient with polymorphic complaints of long duration. The lady stated difficulty swallowing liquid and solid food, pain in the shoulders, headache, neck stiffness and loss of weight. She seemed depressed rather than adynamic, and sounded a bit hoarse. Hoarseness emerged that very morning. Physical exam showed normal results. Blood pressure was 100/70 mmHg on both arms, heart rate 62/minute, oxygen saturation 98%, ECG with the findings identical to the ones on the previous recording: sinus rhythm, left anterior fascicular block, slightly negative T wave in V5, V6. Although there was no suspicion of aortic dissection at that time, the patient was referred to cardiologist and gastroenterologist for further diagnostics. Cardiologist indicated chest X ray and blood analysis for cardiac enzymes, CK and troponin. Gastroenterologist and neurologist also examined the patient and excluded any urgent condition in their field of expertise. At one point while waiting for the results of blood testing, the patient suddenly collapsed. Since all the tests came back normal, CXR came back normal and CK and troponin were within reference values, and a collapse did occur, cardiologist decided to perform an echocardiography, which revealed a circular thickening of about 7 mm in the ascending aorta, possibly an intramural hematoma. MSCT aortography finally confirmed the diagnosis: dissection of the ascending aorta. Patient was then immediately introduced to the operating room. ‘Resectio aortae ascendentis ad longitudinem 5 cm et reconstructio cum Dacron grafti No 28’ was performed. There were no complications during the surgical procedure and the patient was discharged after 12 days. It was only after the ultrasound of the heart and MSCT aortography that it became clear how the localization of that intramural hematoma made pressure on the left recurrent laryngeal nerve that led to dysphonia. Conclusion: The incidence of dysphonia as a symptom of aortic dissection is around 5% and it occurs only when the ascending part of aorta is dissected. Nevertheless, the significance of this symptom should not be neglected.

Ortner’s Syndrome as First Clinical Presentation of Severe Pulmonar Arterial Hypertension

A 40 year old female, non-smoker with a past medical history of urticaria and allergic rhinitis presented with hoarseness of voice of 3 months duration without any accompanying symptoms or limitation of daily activities. Direct laryngoscopy identified palsy of the left vocal cord. The magnetic resonance imaging of the chest indicated abnormal signal intensity in the left vocal cord. The thoracic computed tomography revealed only an enlargement of the pulmonary artery, while transthoracic echocardiography estimated systolic pulmonary artery pressure of 75 mmHg. Pulmonary function tests were compatible with pulmonary vascular disease and cardiopulmonary exercise test showed exercise limitation of cardiocirculatory origin (maximum O2 consumption 60% of pred.). Catheterization of the right heart showed precapillary pulmonary hypertension (mean pulmonary artery pressure 40 mmHg) with a positive response to vasoreactivity test. A diagnosis of idiopathic pulmonary arterial hypertension (IPAH) was made, with hoarseness of voice as the only manifestation of the disease. The hoarseness of voice is believed to be the result of the compression of the left recurrent laryngeal nerve between aorta and the dilated pulmonary artery. This is an unusual case of cardiovocal syndrome (or Ortner’s syndrome) in a patient with IPH who had no perception of dyspnea or limitation of daily activities.

Hoarse voice, first symptom of severe pulmonary hypertension

Hoarseness of voice resulting from left recurrent laryngeal nerve (RLN) palsy. Ortner's or cardiovocal syndrome, is a rare clinical entity manifesting by hoarseness of voice due to left RLN palsy, secondary to cardiovascular disease. Dilated main pulmonary artery may lead to nerve compression between the aorta and pulmonary artery within the aortic window. We report a rare case of a patient suffering from hoarseness of voice that was the first symptom of unknown severe pulmonary arterial hypertension.

Ortner’s syndrome: Cardiovocal syndrome caused by aortic arch pseudoaneurysm

72-year-old hypertensive presented with two weeks history of left sided chest pain and hoarseness. Workup demonstrated a pseudoaneurysm in the lesser curvature of the distal aortic arch opposite the origin of the left subclavian artery from a penetrating atherosclerotic ulcer. Following a left carotid-subclavian bypass, endovascular stenting of the aorta was performed excluding the pseudoaneurysm. Patient had excellent angiographic results post-stenting. Follow up at 12weeks demonstrated complete resolution of his symptoms and good stent position with no endo-leak.Ortner’s syndrome describes vocal changes caused by cardiovascular pathology. It should be included in the differential diagnosis of patients with cardiovascular risk factors presenting with hoarseness. This case demonstrates the use of endovascular stents to treat the causative pathology with resolution of symptoms. In expert hands, it represents low risk, minimally invasive therapeutic strategy with excellent early results in patients who are high risk for open procedure.

Cardiovocal Syndrome Secondary to an Aortic Aneurysm.

We reported that a 68-year-old man presented to the ENT outpatient department complaining of hoarseness for more than 10 months. Clinical exam identified left vocal palsy in the paramedian position and atrophic vocal folds were noted. Chest radiography revealed a large bulging contour overlying aorta and left hilar shadow. Aortic aneurysm was proved by CT scanning. Contrast-enhanced chest computed tomography for further evaluation showed a broad-based aortic aneurysm at proximal descending aorta, projecting anterolaterally. Cardiovocal syndrome was proved. The syndrome is a rare clinical presentation. While a patient with unilateral vocal palsy is encountered, one might keep in mind the possibility of cardiovocal syndrome especially in an adult who had a cardiovascular disease.

Delayed recurrent nerve paralysis following post-traumatic aortic pseudoaneurysm.

Blunt trauma to the neck or to the chest are increasingly observed in the emergency clinical practice. They usually follow motor vehicle accidents or may be work or sports related. A wide pattern of clinical presentation can be potentially encountered. We report the uncommon case of a patient who was referred to our observation presenting with hoarseness and disphagia. Twenty days before he had sustained a car accident with trauma to the chest, neck and the mandible. Laryngoscopy showed a left recurrent laryngeal nerve palsy. Further otolaryngo-logical examination showed no other abnormality. At CT and MR imaging a post-traumatic aortic pseudoaneurysm was revealed. The aortic pseudoaneurysm was consequently repaired by implantation of an endovascular stent graft under local anesthesia. The patient was discharged 10 days later. At 30-days follow-up laryngoscopy the left vocal cord palsy was completely resolved.Hoarseness associated with a dilated left atrium in a patient with mitral valve stenosis was initially described by Ortner more than a century ago. Since then several non malignant, cardiovascular, intrathoracic disease that results in embarrassment from recurrent laryngeal nerve palsy usually by stretching, pulling or compression; thus, the correlations of these pathologies was termed as cardiovocal syndrome or Ortner’s syndrome. The reported case illustrates that life-threatening cardiovascular comorbidities can cause hoarseness and that an impaired recurrent laryngeal nerve might be correctable.

Hollow in the Lung with Hoarseness: An Uncommon Association with Pulmonary Thromboembolism

A case is presented where focus of all investigations centred around a lung cavity which in association hoarseness appeared in all probability a lung cancer after no response to anti tuberculosis chemotherapy. Oxygen desaturation on few steps of walk lead to further work up concluding with diagnosis of pulmonary thromboembolism with cavitary infract and cardiovocal syndrome.

Ortner's syndrome: - case series and literature review

AbstractMore than a century ago, Ortner described a case of cardiovocal syndrome wherein he attributed a case of left vocal fold immobility to compression of the recurrent laryngeal nerve by a dilated left atrium in a patient with mitral valve stenosis. Since then, the term Ortner's syndrome has come to encompass any nonmalignant, cardiac, intrathoracic process that results in embarrassment of either recurrent laryngeal nerve-usually by stretching, pulling, or compression; and causes vocal fold paralysis. Not surprisingly, the left recurrent laryngeal nerve, with its longer course around the aortic arch, is more frequently involved than the right nerve, which passes around the subclavian artery. ObjectivesTo discuss the pathogenesis of hoarseness resulting from cardiovascular disorders involving the recurrent laryngeal nerve along with the findings of literature review. Materials and methodsThis paper reports a series of four cases of Ortner's syndrome occurring due to different causes. DesignCase study. ResultOrtner's syndrome could be a cause of hoarseness of voice in patients with cardiovascular diseases. ConclusionAlthough hoarseness of voice is frequently encountered in the Otolaryngology outpatient department, cardiovascular- related hoarseness is an unusual presentation. Indirect laryngoscopy should be routinely performed in all cases of heart disease.

Atrial Septal Defect and Left Recurrent Laryngeal Nerve Paralysis: A Case of Ortner’s Syndrome and Literature Review

Introduction: Cardiovocal syndrome, or hoarseness resulting from vocal fold paralysis secondary to cardiovascular pathology, is commonly referred to as Ortner’s syndrome. We present a brief overview of vocal fold paralysis, present an illustrative case of Ortner’s syndrome, and provide a review of the pertinent literature. Here we aim to broaden one’s differential for vocal fold paralysis, discuss its importance as pertains to cardiovascular pathology and outcomes, and highlight the difficulties in therapeutic planning for these unique patients. Methods: A case report and literature review. Results: A 26-year-old female with an atrial septal defect and pulmonary hypertension presented with 5 months of hoarseness. Laryngoscopy revealed left vocal fold paralysis. Imaging from the skull base to chest showed an enlarged pulmonary artery (PA) in the absence of other abnormalities. Literature review suggests that this left laryngeal nerve paralysis results from nerve compression within the aortopulmonary window, a triangle defined by the aortic arch, PA, and ligamentumarteriosum. Imaging in our patient over 8 months demonstrated an increase in PA size from 3.9 to 4.2 cm correlating with the onset of hoarseness. Conclusions: Importantly, hoarseness second ary to laryngeal nerve compression in cardiovascular disease may correlate with a poorer prognosis, i.e., in thoracic aortic aneurysms and mitral valvestenosis. Awareness of vocal changes in the setting of cardiovascular disease improves diagnostic acumen in vocal foldparalysis.

Acute contained ruptured aortic aneurysm presenting as left vocal fold immobility.

Objective. To recognize intrathoracic abnormalities, including expansion or rupture of aortic aneurysms, as a source of acute onset vocal fold immobility. Methods. A case report and review of the literature. Results. An 85-year-old female with prior history of an aortic aneurysm presented to a tertiary care facility with sudden onset hoarseness. On laryngoscopy, the left vocal fold was immobile in the paramedian position. A CT scan obtained that day revealed a new, large hematoma surrounding the upper descending aortic stent graft consistent with an acute contained ruptured aortic aneurysm. She was referred to the emergency department for evaluation and treatment by vascular surgery. She was counseled regarding surgical options and ultimately decided not to pursue further treatment. Her vocal fold immobility was subsequently treated via office-based injection medialization two weeks after presentation and again 5 months after the initial injection which dramatically improved her voice. Follow-up CT scan at 8 months demonstrated a reduction of the hematoma. The left vocal cord remains immobile to date. Conclusion. Ortner's syndrome, or cardiovocal syndrome, is hoarseness secondary to left recurrent laryngeal nerve palsy caused by cardiovascular pathology. It is a rare condition and, while typically presenting gradually, may also present with acute symptomatology.