Ortner’s Syndrome Secondary to a Huge Left Atrium

Abstract

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.

Ortner syndrome secondary to saccular thoracic aneurysm

“…Ortner's syndrome is a rare left recurrent laryngeal nerve palsy secondary to mechanical stretching by cardiovascular disease, usually by an enlarged left atrium 2,3 . Since its discovery, other causes of Ortner's syndrome have been reported including pulmonary hypertension, aortic J o u r n a l P r e -p r o o f dissection, and thoracic aneurysms [4][5][6] .…”

Disfonía como manifestación de fuga endoprotésica de aneurisma de aorta: Un caso de síndrome de Ortner

“…9 Actualmente, estos dos términos se usan de manera indistinta. [10][11][12][13][14] El nervio laríngeo recurrente o inferior, tanto izquierdo como derecho, es una rama del nervio vago y tiene una salida diferente a cada lado; el derecho se origina a nivel cervical, rodeando la arteria subclavia, mientras que el izquierdo tiene su origen a nivel torácico rodeando al cayado aórtico a través de la ventana aortopulmonar y por detrás del ligamento arterioso, luego ambos ascienden por el surco traqueoesofágico para introducirse en la laringe. 15 La parálisis del nervio laríngeo recurrente izquierdo es más frecuente que el derecho, además es más frecuente en varones.…”

Post partumdyspnoea: look beyond the lungs

“…Twodimensional echocardiography revealed rheumatic valvular heart disease with severe mitral stenosis (valve area 0.8 cm 2 ), severe tricuspid regurgitation, pulmonary hypertension with pulmonary artery systolic pressure (PASP) of 71 mmHg, mean diastolic gradient across mitral valve of 20 mmHg and left ventricle ejection fraction of 60% (figure 2a-f). In mitral valve stenosis there is an enlargement of left atrial appendage, which appears as a bulge in the left cardiomediastinal border just below the left main bronchus and is popularly known as "the third mogul sign" [7]. The second mogul refers to a bulge in the pulmonary artery bay and is seen in pulmonary hypertension.…”

“…In mitral valve stenosis there is an enlargement of left atrial appendage, which appears as a bulge in the left cardiomediastinal border just below the left main bronchus and is popularly known as “the third mogul sign” [ 7 ]. The second mogul refers to a bulge in the pulmonary artery bay and is seen in pulmonary hypertension.…”