Ortner's Syndrome

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Vasc Endovascular Surg. 2006 January/February;40(1):75-78.
Ortner's Syndrome and Endoluminal Treatment of a Thoracic Aortic Aneurysm-A Case Report.
Escribano JF, Carnes J, Crespo MA, Anton RF.
Department of Vascular Surgery, Hospital Central de la Defensa ``Gomez Ulla,'' Madrid, Spain. jfge41@wanadoo.es.

Left recurrent laryngeal nerve paralysis was first described in 1897 by Ortner in a patient with mitral valve disease. However, this paralysis has also been attributed to other cardiovascular pathologies, such as thoracic aortic aneurysms. In 1971, Parodi introduced the endoluminal technique by inserting endovascular prostheses for the treatment of vascular aneurysms. The authors present a case of acute dysphonia following left recurrent laryngeal nerve paralysis, confirmed by laryngoscopy, in a patient who was diagnosed with a saccular thoracic aortic aneurysm and treated with endovascular prostheses. It was not necessary to perform any additional surgical procedures on the vocal folds because the patient showed sufficient improvement during speech therapy. Follow-up exams at 3 and 6 months demonstrated the lack of any swallowing or respiratory disorders.

Ann Acad Med Singapore. 2005 Nov;34(10):642-5.
Beyond Ortner's syndrome--unusual pulmonary complications of the giant left atrium.
Phua GC, Eng PC, Lim SL, Chua YL.
Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore. gheech@singnet.com.sg

INTRODUCTION: The giant left atrium (GLA) is a complication of severe mitral valve disease and causes morbidity by compressing adjacent intra-thoracic structures. CLINICAL PICTURE: We report 2 cases of unusual pulmonary complications of the GLA. Case 1 developed recurrent collapse of the left lung due to left main bronchus compression. Case 2 was diagnosed with right middle lobe compression and collapse. TREATMENT AND OUTCOME: Case 1 was successfully treated by mitral valve replacement and left atrial reduction surgery. Case 2 was treated conservatively. CONCLUSION: Pulmonary atelectasis may occur in patients with GLA due to bronchopulmonary compression. Surgical management with valve replacement and atrial reduction may be necessary to relieve airway compression.

Ann Otol Rhinol Laryngol. 2004 Jan;113(1):43-5.
Resolution of hoarseness after endovascular repair of thoracic aortic aneurysm: a case of Ortner's syndrome.
Stoob K, Alkadhi H, Lachat M, Wildermuth S, Pfammatter T.
Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland.

We report the case of a 75-year-old man with a 6-month history of hoarseness due to a left recurrent laryngeal nerve palsy. Investigations revealed a thoracic aortic aneurysm compressing the left recurrent nerve; thus, the diagnosis of Ortner's syndrome, ie, cardiovocal syndrome, could be established. The aortic aneurysm was repaired by implantation of an endovascular stent graft under local anesthesia. The patient was discharged 5 days later, and at the 1-year follow-up visit the hoarseness had resolved completely. This case demonstrates for the first time the reversal of Ortner's syndrome after endoluminal aneurysm repair.

Ann Thorac Surg. 2001 Aug;72(2):608-9.
A spontaneous ductal aneurysm presenting with left recurrent laryngeal nerve palsy.
Day JR, Walesby RK.
Department of Cardiothoracic Surgery, Middlesex Hospital, London, England.

A 76-year-old man was found to have a left recurrent laryngeal nerve palsy, due to a spontaneous patent ductus arteriosus aneurysm. Ortner's syndrome (left recurrent laryngeal nerve palsy caused by cardiovascular pathology) secondary to patent ductus arteriosus aneurysm has not previously been described in the literature. We present a case, illustrated with surface rendering computer tomogram reconstructions.

Clin Cardiol. 2000 Apr;23(4):295-7.
Ortner's syndrome in association with mitral valve prolapse.
Kishan CV, Wongpraparut N, Adeleke K, Frechie P, Kotler MN.
Department of Medicine, University of Arkansas for Medical Sciences, Little Rock 72205, USA.

The case of an 83-year-old woman with a history of hypertension, valvular heart disease, atrial fibrillation, and cardiomegaly is presented. The patient also had progressive hoarseness of her voice and intermittent dysphagia. Ear, nose, and throat examination revealed left vocal cord paralysis. Echocardiography revealed severely dilated left (LA) and right atria (RA), moderate mitral regurgitation, severe tricuspid regurgitation, and prolapse of both these valves. A review of literature of Ortner's or cardiovocal syndrome is presented. Ortner's syndrome due to mitral valve prolapse has not been reported previously.

Am J Emerg Med. 1999 Jul;17(4):361-3.
Painless aortic dissection presenting as hoarseness of voice: cardiovocal syndrome: Ortner's syndrome.
Khan IA, Wattanasauwan N, Ansari AW.
Division of Cardiology, Department of Medicine, Woodhull Medical Center, Brooklyn, New York, NY, USA.

Most of the neurological manifestations of the aortic dissection are due to neuronal ischemia secondary to either extension of the dissection process into a branch artery, or compression of an artery by the false lumen of the dissecting aortic hematoma. However, the enlarging false lumen may directly compress on an adjacent nerve, causing neuronal injury resulting in neurological symptoms. This may particularly take place when a distal intimal tear does not decompress the false lumen, resulting in formation of an expanding blind pouch. About 10% of aortic dissections are painless and may present with symptoms secondary to the complications of the dissection. Although cardiovocal syndrome, or Ortner's syndrome (hoarseness of voice due to involvement of recurrent laryngeal nerve in cardiovascular diseases) has been described with aortic dissection, it has not been reported as an initial presenting feature of this disorder. This report describes the first case of painless aortic dissection presenting with hoarseness of voice, the cardiovocal syndrome. The hoarseness remained the only symptom throughout the entire course of the disease. The aortic dissection was not suspected initially. During surgical exploration, the recurrent laryngeal nerve was found compressed by the false lumen at the level of aortic arch. Aortic root replacement was performed successfully, resulting in complete resolution of the hoarseness. The neurological manifestations of aortic dissection, and the cardiovocal syndrome, are discussed.

J Laryngol Otol. 1998 Apr;112(4):377-9.
Ortner's syndrome revisited.
Sengupta A, Dubey SP, Chaudhuri D, Sinha AK, Chakravarti P.
Department of Medicine, Port Moresby General Hospital, Papua New Guinea.

Hoarseness of voice due to paralysis of the left recurrent laryngeal nerve caused by a dilated left atrium in mitral stenosis as discussed by Ortner, is a subject of controversy. Different authors have cited different mechanisms as explanation. A variety of cardiac problems such as primary pulmonary hypertension, ischaemic heart disease, various congenital heart disorders can all lead to paralysis of the left recurrent laryngeal nerve. Most authors believe that pressure in the pulmonary artery causes the nerve compression. In Papua New Guinea cor pulmonale and rheumatic heart disease are the commonest cardiac disorders seen. Ortner's syndrome is a rarity and has never been reported from here before. Here three different case reports are presented with mitral stenosis, primary pulmonary hypertension and combined mitral stenosis and regurgitation and the pathogenesis of hoarseness is discussed.

Rev Esp Cardiol. 1997 Dec;50(12):902-3.
Paralysis of the left recurrent laryngeal nerve secondary to periprosthetic mitral insufficiency.
Zamora Mestre S, Ladron de Guevara Bravo F, Acosta Varo M.
Unidad de Cardiologia, Hospital del SAS. La Linea de la Concepcion, Cadiz.

The paralysis of the left laryngeal nerve secondary to mitral valvular disease (Ortner's syndrome) is quite rare. Ortner believed that the paralysis was due to the compression of the nerve by the enlargement of the left atrium. Other authors have shown, by observation at operation, that this compression is produced between enlarged, tense pulmonary artery and the aorta at the ligamentum arteriosum. This complication has also been described in different cardiovascular pathologies which also have pulmonary hypertension. Cases have been described in the literature of vocal cord function recovery after a pulmonary hypertension decrease. We present a case of hoarseness secondary to the paralysis of the left recurrent laryngeal nerve within a context of a mitral periprosthetic insufficiency with severe pulmonary hypertension and its disappearance after the valvular change, coinciding with a significant artery pulmonary estimated pressure decrease, confirmed by cardiac Eco-Doppler.

J Laryngol Otol. 1997 Sep;111(9):869-71.
Ortner's syndrome: a centenary review of unilateral recurrent laryngeal nerve palsy secondary to cardiothoracic disease.
Thirlwall AS.
Department of Neurosurgery, National Hospital of Neurological Diseases, London, UK.

Ortner's Syndrome (described 100 years ago in 1897) is a clinical entity with hoarseness due to a left recurrent laryngeal nerve (LRLN) palsy caused by cardiac disease. A 35-year-old woman presented with a LRLN palsy due to a huge thoracic aneurysm. The anatomy of the LRLN and the cardiothoracic complaints which may cause the palsy are discussed.

Eur J Med. 1992 Dec;1(8):492-5.
Cardiovocal (Ortner's) syndrome left recurrent laryngeal nerve palsy associated with cardiovascular disease.
Chan P, Lee CP, Ko JT, Hung JS.
Department of Cardiology, Tapiei Municipal Chung Hsiao Hospital, Taiwan.

Five patients with cardiovascular disease presented with hoarseness due to left recurrent laryngeal nerve palsy. One had secundum atrial septal defect, one had ventricular septal defect, two had mitral stenosis and the other had aortic aneurysm. All except the patient with aortic aneurysm had pulmonary artery dilatation and moderate to severe pulmonary hypertension. Four patients' hoarseness resolved after successful interventional therapy. As for the patient with the aortic aneurysm, hoarseness persisted; the patient died before surgery. We postulate that the dilated pulmonary artery or aortic arch was responsible for the compression of the left recurrent laryngeal nerve.

J Am Coll Cardiol. 1985 Mar;5(3):788-92.
Left recurrent laryngeal nerve palsy associated with primary pulmonary hypertension and patent ductus arteriosus.
Nakao M, Sawayama T, Samukawa M, Mitake H, Nezuo S, Fuseno H, Hasegawa K.

Two patients with left recurrent laryngeal nerve paralysis in association with pulmonary artery hypertension are described. One had primary pulmonary hypertension and the other had patent ductus arteriosus. The greatly dilated pulmonary artery in these patients resulted in compression of the left recurrent laryngeal nerve and produced a cardiovocal (Ortner's) syndrome. The pathogenesis of the vocal cord palsy was documented by cross-sectional computed tomography. In conclusion, computed tomography is of great help in differentiating this syndrome from other diseases such as mediastinal mass or lymphadenopathy whenever hoarseness is complicated by pulmonary hypertension.

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