A rare case of Ortner’s syndrome Shahul Hameed Aboobackar1, Aswini Kumar Mohapathra2, Manu Mohan K3, Rahul Magazine3 1 Post graduate student, 2 Professor , 3 Associate Professor, Department of Pulmonary Medicine, Kasturba Medical College Manipal, Manipal University, Manipal, Karnataka, India Abstract Figure 3 Ortner’s syndrome is hoarseness of voice due to recurrent laryngeal nerve involvement in cardiovascular disease1. Thoracic aortic aneurysms are usually asymptomatic. When symptomatic, they usually present with chest pain. Hoarseness as a symptom without chest pain in a case of aortic aneurysm is a rare presentation2. Introduction Hoarseness is a common symptom in clinical practice and a variety of local laryngeal and extra laryngeal conditions are implicated in hoarseness. The most common extra laryngeal cause of left vocal cord palsy is bronchogenic carcinoma. Ortner’s syndrome is hoarseness of voice due to recurrent laryngeal nerve involvement in cardiovascular disease. Aortic aneurysms usually present with chest pain, back pain or epigastric pain, depending on the site of aneurysm. Here we present a case of aortic arch aneurysm causing hoarseness as a rare occurrence.   Outcome Patient was referred to cardiothoracic surgeon for further management. A hybrid covered stent procedure was planned by cardiothoracic surgeon with the help of cardiologist. However, the patient was not willing for surgery and lost for followup. History Discussion A 42-year-old male presented with productive cough and exertional dyspnea for past 1 year and change of voice for past 2 months. No history of fever, chest pain or hemoptysis. He was a known diabetic on regular oral hypoglycemic drugs and had a positive HBsAg status. No history of pulmonary tuberculosis in the past. Past history was negative for sore throat, voice abuse, neck surgery, trauma or cerebrovascular accident. He had a smoking score of around 20 pack years. Hoarseness results from any change in the anatomy or function of any of the structures involved in voice production. It may be due to a pathology confined to the larynx or beyond the larynx. In the absence of an upper respiratory tract infection, any patient with hoarseness persisting for more than two weeks requires evaluation.  Common causes of vocal cord palsy are malignant neoplasms affecting lung, oesophagus or thyroid, surgical or blunt trauma, inflammatory lesions compressing over recurrent laryngeal nerve, brain injuries, laryngeal TB or even idiopathic3. Thoracic aortic aneurysm is a rare cause of hoarseness. They are, in most cases, picked up by a routine chest radiograph as most patients remain asymptomatic until the aneurysm expands or undergoes dissection. The most common presenting symptom is chest pain, back pain or epigastric pain, depending on the site of aneurysm. Cough, wheeze or stridor may appear when the trachea or main bronchi are compressed. Hoarseness appears rarely due to compression of left recurrent laryngeal nerve by the aneurysm2. The presentation of the patient is almost always attributed to lung malignancy, primarily due to the similarity in symptoms and abnormal Chest radiographic findings. A Contrast Enhanced Computed Tomogram (CECT) will help to clinch the diagnosis and rule out differentials. Patients, who do not present with classical symptoms, as in our case, may be misdiagnosed or diagnosis may be delayed, resulting in increased morbidity and treatment cost. In every case of hoarseness, especially with left vocal cord palsy, mediastinal pathologies must be kept in mind and a CECT is mandatory initially to evaluate these lesions before undertaking invasive procedures like bronchoscopy4. Surgery is offered in all high risk and symptomatic cases5. Prognosis after surgery is good. In the absence of symptoms and complications like rupture or dissection, and if the aneurysm is of very small size, the patient may be kept under observational follow up. Control of risk factors like hypertension and diabetes is important. Complications like rupture, embolism, dissection and infection have to be anticipated. Physical examination No pallor, clubbing, lymphadenopathy or neck swellings. Respiratory system examination was unremarkable. An early diastolic murmur was heard over the aortic area. Abdominal examination was normal. Investigations Chest radiograph showed mediastinal widening [Figure 1]. Cardiac evaluation showed grade 2 aortic regurgitation (AR) without features of cardiac failure. ENT evaluation by video diagnostic scopy (VDS) revealed left vocal cord palsy, with no local pathology. CECT thorax revealed a well defined saccular aneurysm, measuring 5.3cmx3.6cm, arising from the inferior aspect of arch of aorta, extending into the aorto pulmonary window causing indentation of the left main pulmonary artery [Figure 2]. A 3D image reconstruct was created [Figure 3]. Flexible bronchoscopy was essentially normal and BAL analysis was insignificant. Spirometry revealed small airway obstruction suggestive of early COPD. Figure 1 and 2 References 1. Plastiras, S. C., Pamboucas, C., Zafiriou, T., Lazaris, N. and Toumanidis, S. (2010), Ortner's Syndrome: A Multifactorial Cardiovocal Syndrome. Clin Cardiol, 33: E99–E100. 2.Khan IA, Wattanasauwan N, Ansari AW. Painless aortic dissection presenting as hoarseness of voice: cardiovocal syndrome: Ortner’s syndrome. Am J Emerg Med 1999;17:361-3. 3.Rosen CA, Anderson D, Murry T. Evaluating Hoarseness: Keeping Your Patient's Voice Healthy. Am Fam Physician 1998; 57:2775-2782. 4.Gupta KB, Vishvkarma S, Shandilya R. Dissecting Aortic Aneurysm Presenting with Cardiovocal Hoarseness. J Assoc Physicians India 2009; 57:464-5. 5.Zipfel B, Hammerschmidt R, Krabatsch T, Buz S, Weng Y, Hetzer R. Stent-grafting of the thoracic aorta by the cardiothoracic surgeon. Ann Thorac Surg. 2007;83:441-8.