Left vocal cord paralysis most probable due to a thoracic aortic aneurysm: Ortner’s syndrome

A 72-year-old obese male patient with hypertension, diabetes and a history of smoking presented to the otolaryngologist with persistent hoarseness after a severe common cold two weeks ago. The hoarseness worsened during the day. No other complaints were present.

The main findings on computed tomography were a small hypovascular thyroid nodule in the left lobe (Fig. 1), paralysis of the left true vocal cord (Fig. 2) and a 2,5 cm saccular aneurysm of the anterolateral wall of the aortic arch (Fig. 3).

We present a case of most probable Ortner’s cardiovocal syndrome caused by a saccular aneurysm of the anterolateral wall of the aortic arch, prolonging the left recurrent laryngeal nerve.

In 1897 Norbert Ortner was the first to describe this cardiovocal syndrome [1-4]. It is a rare condition in which recurrent laryngeal nerve palsy is caused by cardiovascular pathology such as thoracic aortic aneurysm, dilatation of the left pulmonary artery, pulmonary hypertension, or dilatation of the left side of the heart. The left recurrent laryngeal nerve is a branch of the vagal nerve that innervates all left vocal muscles with exception of the cricothyroid muscle, and therefore it is indispensable for voice production. It descends anterolateral of the aortic arch, hooks under it lateral to the ligamentum arteriosum Botali, and ascends into the tracheo-oesophageal groove [2]. The aneurysm emerges from the anterolateral side of the aortic arch (Fig. 3), and although being rather small, it is located in exactly the area known to cause Ortner’s syndrome [5, 6]. Though Ortner’s syndrome exists for more than 100 years, limited comparable cases have been described in literature.  This case stresses the importance to exclude thoracic aortic disease in patients with hoarseness.

In our case there was a second possible cause of the paralysis, namely a small hypovascular thyroid nodule. Although very unlikely given its size, it should be mentioned in the radiology report.

Ortner’s syndrome is an absolute indication for surgery, thoracic aortic aneurysm with symptoms, therefore an accurate and fast diagnosis is paramount. Thoracic endovascular aneurysm repair (TEVAR) is the therapy of first choice. TEVAR is more cost effective and associated with reduced risk of mortality and morbidity than open surgery [2].

Written informed patient consent for publication has been obtained.