Aortic Aneurysm: A Rare Cause of Ortner’s Syndrome

Abstract

A 60 year old male patient presented with hoarseness of voice lasting for 2 months. First he was examined by the otorhinolaryngologist of our hospital, who noticed absence of movements of the left vocal cord. Chest X-ray showed a large opacity in the left upper zone and the patient was referred to the pulmonologist. His general physical examination was unremarkable not having any stigmata of Marfan's or Ehler Danlos syndrome. On chest auscultation, a systolic flow murmur was audible and there was decreased breath sound in the left infraclavicular area. Bronchoscopy revealed absence of movement of left vocal cord. His trans-thoracic echocardiography revealed degenerative aortic and mitral valve disease with mild aortic regurgitation and mild mitral regurgitation with dilated aortic aneurysm. A contrast enhanced CT scan of thorax and CT Angio Aortogram revealed fusiform aneurysmal dilatation of the arch of aorta with diameter of 6.2 cm over a length of 12.3 cm showing intraluminal partial thrombus with wall calcification. The patient was advised to undergo surgery. However, after detailed discussion with him and his family, they decided for medical management in view of his advanced age.

Hoarseness Due to Aortic Arch Aneurysms

“…Hoarseness was a sole symptom in 32 (36.8%) patients [ 1 , 9 , 11 , 12 , 18 , 21 , 22 , 31 - 34 , 36 , 41 , 43 , 45 , 47 , 50 , 54 - 56 , 58 , 59 , 62 , 63 , 65 - 68 , 74 , 75 ] , a major symptom in 34 (39.1%) patients [ 2 , 5 , 6 , 8 , 10 , 13 - 16 , 19 , 24 , 28 , 31 , 32 , 38 , 39 , 44 , 46 , 49 , 51 - 53 , 57 , 61 , 64 , 70 ] , and an accompanying symptom in 21 (24.1%) patients [ 3 , 4 , 7 , 17 , 20 , 23 , 25 - 27 , 29 , 30 , 32 , 35 , 37 , 40 , 42 , 48 , 60 , 69 , 72 , 73 ] (χ [ 2 ] =5.1, P =0.079).…”

“…The shapes of arch aneurysms were described for 47 patients: 36 (76.6%) aneurysms were saccular nine (19.1%) were fusiform [ 27 , 42 , 44 , 51 , 54 , 57 , 61 , 62 , 72 ] , one (2.1%) was bilobed [ 73 ] , and one (2.1%) was irregularly shaped [ 38 ] . A mural thrombus was present in 34 (20.7%) patients [ 1 , 2 , 7 , 8 , 11 - 14 , 18 , 19 , 22 , 29 , 31 , 34 , 38 , 39 , 42 , 45 , 46 , 48 - 52 , 54 - 56 , 60 , 62 , 63 , 68 - 70 ] . In 12 (13.8%) patients, the arch aneurysms were pseudoaneurysms [ 4 , 17 , 26 , 33 , 36 , 41 , 43 , 46 , 48 , 55 ], 73 ] .…”

“…In 12 (13.8%) patients, the arch aneurysms were pseudoaneurysms [ 4 , 17 , 26 , 33 , 36 , 41 , 43 , 46 , 48 , 55 ], 73 ] . Left vocal cord paralysis was evidenced in 39 (44.8%) patients: by laryngoscopic examination in 34 (87.2%) patients [ 2 - 5 , 7 - 9 , 11 , 12 , 14 , 18 , 20 , 21 , 23 - 26 , 33 - 39 , 41 , 42 , 45 - 47 , 52 , 56 - 59 , 62 ]- 64 ,[ 66 , 68 , 71 , 73 - 75 ] , by nasopharyngoscopy in three (7.7%) patients [ 55 , 69 , 70 ] , and by bronchoscopy in two (5.1%) patients [ 48 , 54 ] . Nevertheless, one patient had right vocal cord paralysis instead [ 67 ] .…”

“…Two patients were on a follow-up [ 66 , 67 ] . Nine patients chose conservative treatment due to their poor conditions that could not support a surgical treatment [ 2 , 11 , 44 , 47 , 54 , 61 , 71 , 72 , 74 ] . Of the remaining 42 patients, 19 (19/42, 45.2%) patients underwent a surgical treatment (an arch replacement in 16 [16/19, 84.2%] patients [ 5 , 10 , 12 , 15 , 21 , 27 , 29 - 32 , 38 , 48 , 65 ] , patch reconstruction of the aorta in two [2/19, 10.5%] patients [ 13 , 17 ] , and the operation method was not indicated in one [1/19, 5.3%] patient [ 57 ] ), 18 patients (18/42, 42.9%) received an endovascular aortic repair by a stent graft insertion [ 6 , 26 , 28 , 33 , 34 , 40 - 42 , 56 , 58 , 75 ] , and five (5/42, 11.9%) patients were treated with hybrid procedures, including stent graft plus woven Dacron vascular graft in two patients [ 50 , 53 ] , and endovascular frozen elephant trunk replacement of the ascending aorta and aortic arch [ 70 ] , left carotid-subclavian bypass plus stent graft [ 4 ] , and open-arch repair and descending aorta stent grafting [ 43 ] in one patient, each.…”

“…The left recurrent laryngeal nerve arises from the left vagus nerve at the level of the aortic arch curve, and then it curves around the aorta on the outer side of the ligamentum arteriosum ascending along the tracheoesophageal groove. This prolonged course makes it vulnerable to injury by the lesions of the surrounding structures [ 54 ] .…”