CARDIOVOCAL SYNDROME

IMAGE OF THE WEEK 2013

WEEK 16

CARDIOVOCAL SYNDROME (ORTNER'S SYNDROME)

Figure 1a: Aortic arch aneurysm with traction injury to the left phrenic nerve resulting in vocal cord palsy, a condition known as Cardiovocal syndrome or Ortner's syndrome.

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Figure 2: Aortic arch aneurysm showing mural ulcers (black arrows) and intramural thrombus (white star).

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Ortner's syndrome is a rare cardiovocal syndrome in which the a recurrent laryngeal nerve palsy results from compression or traction injury in cardiovascular disease^. It is named after the author who described it in 1897 – Dr Ortner.

It is almost exclusively on the left side due to the long course of the left recurrent laryngeal nerve around the aortic arch.

Ortner’s original description was attributed to a case of left vocal fold paralysis due to compression of the recurrent laryngeal nerve by a dilated left atrium in a patient with mitral valve stenosis. Subsequent descriptions have been documented regarding other intra-thoracic cardiac causes for cardio-vocal syndrome, including aortic arch aneurysms, which cause traction type injury to the nerve, as in this case.

This elderly patient’s left vocal cord paralysis was found to be due to compression from a large thoracic aortic aneurysm, involving the arch of aorta (Figure 1). The aneurysm contains a large volume of atheroma and penetrating ulcers (Figure 2 and 3).

Figure 3: Coronal plane CT chest showing the mural ulcer (black arrow) and mural clot (white star) in the aortic arch aneurysm.

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Figure 4: Schematic diagram showing the anatomical pathway of the nerve

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The left recurrent laryngeal nerve is not observed on CT. However, the inference between the clinical and radiological findings, with knowledge of the anatomical path of the nerve (Figure 4 – courtesy of Wikipedia) and absence of a cause for the palsy in the head and neck, clinches the diagnosis.

Images and text contributed by

Dr Ian Bickle, Department of Radiology,RIPAS Hospital