Cardio-vocal Syndrome as a Complication Patient with Severe Mitral Regurgitation and Moderate Aortic Regurgitation with Pulmonary Hypertension

ABSTRACT Hoarseness due to paralysis of vocal cord, as in Cardio-vocal syndrome, is caused by mechanical affection of left recurrent laryngeal nerve from enlarged cardiovascular structures. Mitral valve prolapse is rarely found to cause this syndrome. Case report presenting a 47 years old male visited the outpatient department with a clinical history of dyspnea and hoarseness since a year ago. Physical examination revealed late systolic murmur in apex and low-grade diastolic murmur in right second intercostal space. Echocardiography confirmed severe mitral regurgitation due to flail anterior mitral valve leaflet with severe left atrium dilatation (9.0 cm) and moderate aortic regurgitation due to mal-coaptation of aortic valves. Laryngoscopy revealed an immobile left vocal cord. He underwent successful double valve replacement after three months follow up the patient showed improvement of hoarseness. The incidence of Cardio-vocal syndrome in mitral valve disease varies from 0.6% to 5%. In cases diagnosed with thoracic disease, paralysis of the left vocal cord was reported 1.75 times more frequent than the right side. The aim of this case report is we have to aware that Cardio-vocal syndrome is a rare cause of vocal cord paralysis and should be considered as a differential diagnosis of hoarseness, particularly if the patient has a cardiac history. Comprehensive evaluation and prompt treatment may allow reversal of the damage to left recurrent laryngeal nerve. Permanent nerve damage can occur due to late diagnosis. Keywords : Cardio-vocal syndrome, Mitral regurgitation, Aortic RegurgitationCorrespondence : [email protected]

Left Vocal Cord Paralysis Secondary to Mitral Valve Disease

Introduction: Ortner’s syndrome, or cardio-vocal syndrome, is a clinical entity characterised by hoarseness (secondary to left-sided recurrent laryngeal nerve palsy) caused by cardiovascular disease. The incidence of Ortner’s syndrome ranges from 0.25 percent to 0.5 percent of all cases of recurrent laryngeal nerve paralysis. Case Report: A 44-year-old Malay gentleman presented with hoarseness and shortness of breath for 4 days. It was associated with mild orthopnea and aspiration symptoms. He denied history of dysphagia, chronic cough, sore throat, chest pain, palpitation and decreased effort tolerance. There was no history of hypertension, diabetes and asthma. He also gave no history of recurrent fever with sore throat during childhood. Results: On examination, the patient appeared tachypnoeic. There was no peripheral oedema, cyanosis or clubbing. His blood pressure was 100/60 mm Hg and his pulse was irregular with a rate of 78/min. Neck examination was normal. Apex beat was not displaced. On auscultation the first heart sound was loud. A grade 3/6 long rumbling diastolic murmur was heard at the mitral area and he had bilateral basal crepitations. Laryngoscopy using 700 scope showed left vocal cord palsy in paramedian position with phonatory gap. Computed tomography (CT) of the thorax showed left atrial enlargement with prominent pulmonary veins. Echochardiography showed left atrial dilatation with thickened mitral valve. Left ventricular systolic function was good with ejection fraction of 70% and coronary angiogram showed normal coronary artery. A diagnosis of severe mitral stenosis with heart failure was made. Preoperatively the patient was stabilized and was referred for dental clearance. Then he underwent surgery for mitral and aortic valve replacement. Post-operatively patient recovered uneventfully. His hoarseness recovered completely after 3 months. Conclusion: Cardiovascular disease should be considered as a differential diagnosis in a patient with hoarseness.

SPINDLE CELL CARCINOMA OF LARYNX- A DISTINCT CLINICOPATHOLOGICAL AND HISTOLOGICAL ENTITY

Spindle cell carcinoma (SpCC) is a variant of squamous cell carcinoma with biphasic components and more aggressive behaviour. Its rarity and histopathological pattern pose a diagnostic challenge. Early diagnosis and treatment result in a decrease in local and distant metastasis. Case 1 is a 71-year-old female presented with hoarseness of voice and dyspnoea for 2 years without any risk factors. Fibre-optic laryngoscopy (FOL) revealed smooth polyp hanging from anterior two-third of the left vocal cord. Microlaryngoscopic excision revealed SpCC followed by post-operative radiotherapy and is currentlyalive. Case 2 is a 72-year-old male presented with worsening stridor for 2 years post-excision of laryngeal nodule and history of smoking and hookah use for >20 years. He developed dysphonia after a few months with fixed hard level 3 nodes at the right side. FOL showed a polypoid mass extending from the left vocal cord into the supraglottis. Fine-needle aspiration cytology of the neck swelling confirmed the diagnosis of SpCC. Computerised tomography (CT) chest/abdomen showed distant metastasis. Palliative radiotherapy was given, but the patient died after 3 months due to locoregional failure. Case 3 is a 35-year-old male presented with a history of hoarseness for 3 years with no risk factors. FOL showed a 1.2-cm polypoid growth on the right vocal cord. Total laryngectomy was performed and histopathology showed SpCC. Radiotherapy was given and the patient is alive without disease with regular follow-ups. Smoking and alcohol are thought to be the contributing factors causing this disease. Biphasic nature of the tumour requires pathological sampling for diagnostic confirmation. Surgery combined with radiotherapy has a better survival outcome. SpCC is a rare tumour with a tendency for locoregionalrecurrence. Surgery should remain the mainstay of treatment followed by post-operative radiotherapy for a better control.Key words: Larynx, radiotherapy, spindle cell carcinoma