Presentation
Chronic shortness of breath and recent hoarseness.
Patient Data
The CT study shows left-sided unilateral vocal cord paralysis evidenced by abduction of the left vocal cord accompanied by enlarged pyriform sinus and ipsilateral laryngeal ventricle, creating the so-called "sail sign" and compensatory medial bowing of the right cord, with no evidence of sizable masses or enlarged suspicious cervical lymph nodes. The examined mediastinum shows severe dilatation of the pulmonary trunk and main pulmonary arteries (the pulmonary trunk reaches 41 mm in axial diameter, compared to 20 mm maximum aortic diameter at the same level) with no evidence of sizable mediastinal masses or suspicious mediastinal lymphadenopathy.
An atrial septal defect was noted as the cause of the right heart overload and severe dilatation of the pulmonary arterial system.
Case Discussion
Cardiovocal (Ortner's) syndrome is an infrequent cause of unilateral vocal cord paralysis. The left recurrent laryngeal nerve provides innervation to the intrinsic laryngeal muscles responsible for voice production. It has a unique course, which arises anteriorly at the level of the arch of the aorta and loops posteriorly under the aortic arch and back up through the neck. The enlarged pulmonary artery in this case is likely responsible for mechanical compression of the left recurrent laryngeal nerve against the aorta.
A moderately sized atrial septal defect (18–20 mm) with a left-right shunt was confirmed later by echocardiography.
Cardiovocal syndrome should be considered in the differential diagnosis of unilateral left recurrent laryngeal nerve palsy.
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