ABC: časopis urgentne medicine (Jan 2017)
Dysphonia as a presentation of aortic dissection
Abstract
Introduction: The most common clinical presentation of acute aortic dissection is chest pain, but every once in a while atypical symptom can occur. In rare cases, aortic dissection can present itself through the left reccurent laryngeal nerve palsy, which occurs due to the entrapment of the nerve between the left branch of pulmonary artery and aorta, causing the Ortner’s syndrome, known also as the cardiovocal syndrome. Norbert Ortner, the Austrian physician was the first to describe this vocal cord paralysis due to cardiovascular changes. The aim: The aim of this paper is to introduce the case of atypical aortic dissection presentation. Material and metods: Facts and data from the original medical reports were used. Case report: EMS team visited a female 78 year old patient with polymorphic complaints of long duration. The lady stated difficulty swallowing liquid and solid food, pain in the shoulders, headache, neck stiffness and loss of weight. She seemed depressed rather than adynamic, and sounded a bit hoarse. Hoarseness emerged that very morning. Physical exam showed normal results. Blood pressure was 100/70 mmHg on both arms, heart rate 62/minute, oxygen saturation 98%, ECG with the findings identical to the ones on the previous recording: sinus rhythm, left anterior fascicular block, slightly negative T wave in V5, V6. Although there was no suspicion of aortic dissection at that time, the patient was referred to cardiologist and gastroenterologist for further diagnostics. Cardiologist indicated chest X ray and blood analysis for cardiac enzymes, CK and troponin. Gastroenterologist and neurologist also examined the patient and excluded any urgent condition in their field of expertise. At one point while waiting for the results of blood testing, the patient suddenly collapsed. Since all the tests came back normal, CXR came back normal and CK and troponin were within reference values, and a collapse did occur, cardiologist decided to perform an echocardiography, which revealed a circular thickening of about 7 mm in the ascending aorta, possibly an intramural hematoma. MSCT aortography finally confirmed the diagnosis: dissection of the ascending aorta. Patient was then immediately introduced to the operating room. ‘Resectio aortae ascendentis ad longitudinem 5 cm et reconstructio cum Dacron grafti No 28’ was performed. There were no complications during the surgical procedure and the patient was discharged after 12 days. It was only after the ultrasound of the heart and MSCT aortography that it became clear how the localization of that intramural hematoma made pressure on the left recurrent laryngeal nerve that led to dysphonia. Conclusion: The incidence of dysphonia as a symptom of aortic dissection is around 5% and it occurs only when the ascending part of aorta is dissected. Nevertheless, the significance of this symptom should not be neglected.
