A n 82-year-old man with a long-standing history of rheumatic mitral valve disease presented with a 1-year history of progressive vocal hoarseness. Chest radiography showed cardiomegaly, splaying of the carina (with a tracheal bifurcation angle of almost 180 degrees), and the classic "third mogul" sign (a convex left atrial appendage; Fig 1A, arrow). Computed tomography confirmed a massively dilated left atrium (Fig 1B, asterisk) with a maximum diameter of 20 cm, and also showed typical signs of a left vocal cord paralysis: vocal cord medialization (Fig 1C, arrow) and ipsilateral piriform sinus dilatation (Fig 1D, asterisk). A left vocal cord paralysis was confirmed on laryngoscopy, and Ortner syndrome (recurrent laryngeal nerve paralysis or paresis of cardiovascular origin) secondary to a massively dilated left atrium was diagnosed.Ortner syndrome (also known as cardiovocal syndrome) was originally described in patients with severe mitral stenosis causing left atrial enlargement, but it has also been seen in patients with aortic aneurysms (with or without rupture), aortic dissection, and cardiac tumors. Computed tomography of the neck and thorax, as it was done in our case, can evaluate the course of the left recurrent laryngeal nerve and detect common and less frequent pathologies associated with vocal cord paralysis. Fig 1.

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