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| LETTER TO EDITOR |
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| Year : 2019 | Volume
: 3
| Issue : 4 | Page : 280-281 |
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Ortner's cardiovocal syndrome: A rare cause of hoarseness of voice
Swetabh Purohit1, Varsha Joshee2
1 Department of Pulmonary Medicine, Government Doon Medical College, Dehradun, Uttarakhand, India
2 Department of Pathology, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| Date of Submission | 25-Jul-2019 |
| Date of Acceptance | 08-Sep-2019 |
| Date of Web Publication | 03-Dec-2019 |
Correspondence Address:
Dr. Varsha Joshee
B404 Windlass Residency, Curzon Road, Dallanwala, Dehradun, Uttarakhand
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/bbrj.bbrj_103_19
How to cite this article:
Purohit S, Joshee V. Ortner's cardiovocal syndrome: A rare cause of hoarseness of voice. Biomed Biotechnol Res J 2019;3:280-1 |
Sir,
Hoarseness is a common symptom in clinical practice. Numerous conditions ranging from the common cold to systemic disorders involving the larynx can cause hoarseness of voice with main etiology being neoplastic (32%), traumatic (11%), iatrogenic (16%), surgical (30%), central (8%), or infectious (3%).[1],[2],[3] Here, we present an interesting case of an 84-year-old male patient in which the cause of hoarseness of voice was a rare Ortner's cardiovocal syndrome (OCVS).
An 84-year-old man presented with complaints of hoarseness of voice for 2 months and cough with blood-tinged sputum for 4 days. He was a Known case of chronic obstructive pulmonary disease (COPD) on irregular treatment for the same. He was a known diabetic on regular oral hypoglycemic drugs. There was no history of tuberculosis, sore throat, voice abuse, neck surgery, trauma, or cerebrovascular disease. He smoked 20–25 cigarettes/day over the past 35 years. On auscultation, air entry was decreased bilaterally with occasional wheeze on prolonged expiration. He was normotensive, and all vitals were within normal limits. Considering his age and smoking history and presenting complaints, he was further evaluated for any lung malignancy.
Chest radiograph [Figure 1] showed COPD consistent changes. Complete hemogram, renal functions, liver functions, and HbA1c were within normal limits. Ear, nose, and throat evaluation by indirect laryngoscopy revealed left vocal cord palsy, with no local pathology. Echocardiography was within normal limits with an ejection fraction of 55%. Ultrasound abdomen was also normal. Contrast-enhanced CT of the thorax [Figure 2] revealed a well-defined saccular aneurysm, measuring 3 cm × 1.8 cm at the level of the left subclavian artery projecting laterally toward the left lateral. Smooth concentric mural thrombus measuring 16 mm × 11.5 mm was present within the thrombus. There was surrounding hematoma displacing lung vasculature and segmental bronchi. A three-dimensional image reconstruction was carried out to assess the exact position and orientation of the aneurysm. Flexible bronchoscopy was essentially normal, and analysis of bronchial washing was insignificant. Spirometry revealed a small airway obstruction suggestive of COPD. The patient was referred to cardiothoracic surgery team for review. An elective aneurysm repair was discussed with the patient. The patient opted for conservative management in view of his age. | Figure 1: Chest X-ray posteroanterior showing chronic obstructive pulmonary disease consistent changes
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 | Figure 2: Contrast-enhanced computed tomography thorax showing well-defined saccular aneurysm at the level of the left subclavian artery with mural thrombus within the aneurysm
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| Discussion | |  |
Hoarseness is a symptom of laryngeal diseases caused by interference to normal opposition of vocal cords. The left recurrent laryngeal nerve is mainly vulnerable to lesions due to its intimate anatomic relation to the aortic arch, left lung apex, trachea, esophagus, left pulmonary artery, and mediastinal lymph nodes. Most vocal cord paralysis is due to neoplasia, followed by iatrogenic procedures.[1] Aortic aneurysm causing laryngeal nerve palsy is reported to be around 0.3% in some series.[4] OCVS was first described by an Austrian physician, Norbert Ortner, in patients of mitral stenosis with left atrial enlargement that compressed the left recurrent laryngeal nerve.[5] As time passed, other cardiovascular causes were included and patients with pulmonary hypertension, congenital heart diseases, aortic aneurysm, cardiac abnormalities, recurrent pulmonary emboli,[6] etc., were also included under the spectrum of OCVS. Only about 5% of cases have been reported in the literature as a rare situation in which aneurysm causes unilateral vocal cord paralysis.[7] Thoracic aneurysms occur most commonly in the sixth and seventh decades of life, and males are affected approximately 2–4 times more commonly than females, as in our case, the patient was an 84-year-old male.[8] Even though the history, smoking status, and presenting complaints pointed to a malignant etiology, meticulous physical examination identified a probable cardiovascular cause for the symptom. This case underlines the importance of appropriately working up a patient presenting with persistent hoarseness, keeping in mind the various differentials. To conclude, OCVS is a rare entity. In patients presenting with hoarseness of voice without any obvious neck or lung pathology, one should never overlook the cardiovascular causes, and thoracic aortic aneurysm needs to be considered as a possible cause. Early referral to otorhinolaryngology and cardiothoracic team is mandatory to ensure the optimal management of the patient.
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. | Gupta J, Varshney S, Bist SS, Bhagat S. Clinico-etiolological study of vocal cord paralysis. Indian J Otolaryngol Head Neck Surg 2013;65:16-9.  |
| 2. | Lim GC, Lee J. Pulmonary tuberculosis initially presented by hoarseness. Int J Mycobacteriol 2012;1:94-5. [Full text] |
| 3. | Ali Chaudhry L, Al-Solaiman S. Multifocal tuberculosis: Many faces of an old menace. Int J Mycobacteriol 2013;2:58-69. |
| 4. | Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: A longitudinal analysis of etiology over 20 years. Laryngoscope 2007;117:1864-70. |
| 5. | Dutra BL, da Campos LC, de Marques HC, Vilela VM, Carvalho RE, Duque AG. Ortner's syndrome: A case report and literature review. Radiol Bras. 2015;48:260-2. |
| 6. | Yuan SM. Ortner (cardio-vocal) syndrome: A collective review. Kuwait Med J 2014; 46:3-13. |
| 7. | Yuan SM. Hoarseness subsequent to cardiovascular surgery, intervention, maneuver and endotracheal intubation: The so-called iatrogenic ortner's (cardiovocal) syndrome. Cardiol J 2012;19:560-6. |
| 8. | Elzamzamy UA, Joharjy IA. Thoracic aortic aneurysm presenting only as vocal cord paralysis. Neurosciences (Riyadh) 2007;12:245-8. |
[Figure 1], [Figure 2]
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