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LETTER TO EDITOR
Year : 2017  |  Volume : 1  |  Issue : 2  |  Page : 32-33

An unusual case of recurrent laryngeal nerve palsy presenting as hoarseness due to an aortic arch saccular aneurysm causing neurovascular conflict!


1 Department of Radiodiagnosis, KMC, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Department of Chest Medicine, KMC, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Web Publication26-Sep-2018

Correspondence Address:
Dr. Santosh PV Rai
Department of Radiodiagnosis, KMC, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_3_18

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How to cite this article:
Rai SP, Acharya V. An unusual case of recurrent laryngeal nerve palsy presenting as hoarseness due to an aortic arch saccular aneurysm causing neurovascular conflict!. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2017;1:32-3

How to cite this URL:
Rai SP, Acharya V. An unusual case of recurrent laryngeal nerve palsy presenting as hoarseness due to an aortic arch saccular aneurysm causing neurovascular conflict!. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2017 [cited 2018 Nov 18];1:32-3. Available from: http://www.aiaohns.in/text.asp?2017/1/2/32/242233



Vocal cord paralysis can be the presenting symptom of various mediastinal abnormalities including neoplasm, vascular cause, and inflammation.[1] In many cases, the cause of the symptoms can be clinically occult. This can be due to invasion or compression of the recurrent laryngeal nerve. One of the less common causes for this condition is aneurysm from the thoracic aorta causing compression of the nerve.[2] Here, we present a case of a 62-year-old man who presented with the chief complaints of hoarseness of voice, breathlessness, and cough for 15 days. He was evaluated in the Department of Otorhinolaryngology and was found to have left vocal cord palsy in intermediate position.

Chest radiograph revealed superior mediastinal widening [Figure 1]a, white arrow] with left upper zone haziness. A contrast-enchanced computed tomography (CT) scan of the chest was performed in our center to further characterize the mediastinal mass. A well-defined saccular aneurysm was found arising from the inferior aspect of the arch of the aorta at the level of origin of the left subclavian artery. The aneurysm measured 41 mm × 30 mm [Figure 1]b and [Figure 1]c, white arrows]. It projected posterolaterally into the aortopulmonary window. The periphery of the aneurysm was thrombosed. Mild compression over the main pulmonary artery was noted.
Figure 1: Chest radiograph revealed superior mediastinal widening (a, white arrow) with left upper zone haziness. Computed tomography scan of the chest shows a well-defined saccular aneurysm arising from the inferior aspect of the arch of the aorta at the level of origin of the left subclavian artery (b and c, white arrows)

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The patient was evaluated for syphilis with the Venereal Disease Research Laboratory which was negative. Biomarkers for collagen vascular disease and vasculitis were also negative. Ultrasonogram of the abdomen did not reveal any abdominal aortic aneurysm and CT head study also was normal. The patient was refered to a cardiothoracic surgeon and was advised surgical correction which was declined by the patient.

The left recurrent laryngeal nerve leaves the vagus nerve at the level of the aortic arch, makes a loop around the fibrous remnant of the ductus arteriosi Botalli (lig. Arteriosum).[3] Any structure that compresses the nerve within the aortopulmonary window can lead to paralysis of the left vocal cord.

Some abnormalities in the mediastinum such as tumor (benign/malignant) inflammatory conditions and vascular lesions can potentially cause the compression of the recurrent laryngeal nerve and further cause vocal cord paralysis. In a study by Song et al., 31.3% of the patients with vocal cord paralysis was caused by chest diseases and 29.6% was caused by neck diseases and 39.1% was idiopathic.[4]

Ortner's syndrome or cardiovocal syndrome, was introduced by Norbert Ortner in 1897, who described three cases of left vocal fold immobility due to the recurrent compression of the laryngeal nerve, caused by dilatation of the left atrium in patients with mitral valve stenosis.[5] Since then, the term Ortner's syndrome has been used to describe any nonmalignant intrathoracic heart condition that results in recurrent compression of the laryngeal nerve. The possible causes are left ventricular failure, atrial septum failure, arterial canal persistency, primary pulmonary hypertension, pulmonary artery relapsing embolism, left ventricular aneurysm, and other types of aortic aneurysm that cause vocal fold paralysis. Thoracic aortic artery aneurysm represents 5% of the cases.[6] The left recurrent laryngeal nerve is the most frequently affected, due to its longer course bypassing the aortic arch, compared with the right one, which goes around the subclavian artery.

In conclusion, we draw attention to a rare cause of recurrent laryngeal nerve palsy due to the aortic arch aneurysm. Palsy of the recurrent laryngeal nerve is an unusual presentation of thoracic aortic aneurysm where the usual symptoms would include chest pain or upper back pain. Less than a dozen case reports have been found in the English literature.[2] Whether it is a prodrome of imminent aneurysm rupture has to be explored. This case shows the importance of a high degree of suspicion with a thorough evaluation to rule out subtle yet important causes of the condition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Paquette CM, Manos DC, Psooy BJ. Unilateral vocal cord paralysis: A review of CT findings, mediastinal causes, and the course of the recurrent laryngeal nerves. Radiographics 2012;32:721-40.  Back to cited text no. 1
    
2.
Ohki M. Thoracic saccular aortic aneurysm presenting with recurrent laryngeal nerve palsy prior to aneurysm rupture: A Prodrome of thoracic aneurysm rupture? Case Rep Otolaryngol 2012;2012:367873.  Back to cited text no. 2
    
3.
Krmpotić-Nemanić J, Draf W, Helms J. Surgical Anatomy of the Head-Neck Region. Berlin: Springer Verlag; 1985.  Back to cited text no. 3
    
4.
Song SW, Jun BC, Cho KJ, Lee S, Kim YJ, Park SH, et al. CT evaluation of vocal cord paralysis due to thoracic diseases: A 10-year retrospective study. Yonsei Med J 2011;52:831-7.  Back to cited text no. 4
    
5.
Chan P, Lee CP, Ko JS. Cardiovocal (Ortner's) syndrome: Left recurrent laryngeal nerve palsy associated with cardiovascular diseases. Eur J Med 1992;1:492-5.  Back to cited text no. 5
    
6.
Yuan SM. Hoarseness subsequent to cardiovascular surgery, intervention, maneuver and endotracheal intubation: The so-called iatrogenic Ortner's (cardiovocal) syndrome. Cardiol J 2012;19:560-6.  Back to cited text no. 6
    


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