Ortner’s syndrome: an unusual cause of cough

Br J Cardiol 2012;19:48–9doi:10.5837/bjc.2012.011 Leave a comment
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A 57-year-old woman presented with a six-week history of non-productive cough associated with sharp chest pain. Her past medical history included a metallic aortic valve replacement for aortic regurgitation, hypertension and hypercholesterolaemia. The patient had a blood pressure of 97/60 mmHg and was afebrile. On examination, the metallic valve was audible with no added heart sounds. Examination of other systems was normal. Electrocardiogram (ECG) showed a normal sinus rhythm with no ischaemic changes. Admission blood tests showed an elevated white cell count (11.4 x 109 per litre) and a C-reactive protein of 225.8 mg/L. Her chest radiograph demonstrated a widened mediastinum, evidence of previous cardiac surgery and a metallic valve (figure 1). Transthoracic echocardiography showed a dilated aortic root measuring 62 mm at the level of the sinotubular junction. In addition, a thrombus was visualised in the ascending aorta with a dissection flap, which was confirmed by computed tomography (CT) scan (figure 2). The patient was transferred to a cardiothoracic unit to undergo surgical repair of the dissection and replacement of the metallic valve. The dissection was shown to arise from the suture line of the previous valve replacement. 

Figure 1. Chest X-ray showing widened mediastinum
Figure 1. Chest X-ray showing widened mediastinum

Discussion

Ortner’s syndrome, or cardiovocal syndrome, is a clinical condition associated with left recurrent laryngeal nerve palsy due to cardiovascular disease. The palsy arises from compression of the recurrent laryngeal nerve as it passes between the arch of the aorta and the pulmonary artery.1,2 The syndrome was first described in 1897 by Norbert Ortner, an Austrian physician who ascribed hoarseness of voice with left recurrent laryngeal nerve palsy secondary to a dilated left atrium in three patients with mitral valve stenosis.3 It has now been estimated that the incidence of Ortner’s syndrome in mitral stenosis ranges from 0.6 to 5%.4

Figure 2. Computed tomography (CT) of the thorax demonstrating aortic dissection
Figure 2. Computed tomography (CT) of the thorax demonstrating aortic dissection

Following the first description of Ortner’s syndrome, case reports have described other cardiovascular associations, including left atrial enlargement due to mitral regurgitation or atrial myxoma, severe pulmonary hypertension and congenital heart disease.5-8 In addition, aneurysms of the aorta and pulmonary artery causing Ortner’s syndrome have been reported and can present with dissection,9,10 as described here. However, cough is an unusual initial presentation of Ortner’s syndrome. Most case reports describe hoarseness of voice as the presenting symptom. Left laryngeal nerve palsy and paralysis of the left vocal cord can also present with dysphagia and shortness of breath during speech.11 Furthermore, effective cough cannot be mounted and patients are at risk of aspiration. Finally, our case describes chest pain symptoms not classically associated with aortic dissection. It has been reported that aortic dissection in patients with previous cardiac surgery does not always present with central tearing chest pain, and this is thought to be due to denervation of cardiac sympathetic supply as a result of the previous operation.12 This case highlights how a common symptom such as cough can be due to unsuspecting pathology and knowledge of the anatomy can assist in diagnosis.

Conflict of interest

None declared

References

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