Review
Cardiovocal Syndrome: A Systematic Review

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Hoarseness associated with mitral stenosis was initially described by Ortner. Several cardiopulmonary conditions were associated with left recurrent laryngeal nerve palsy over the last 100 years; thus, the syndrome is termed as cardiovocal syndrome or Ortner's syndrome. This study aimed to classify the various predisposing conditions and to explain the pathophysiology and treatment opportunities available for these patients.

Introduction

Nobert Ortner ascribed hoarseness of voice to the left recurrent laryngeal nerve palsy (LRLNP) in three patients with severe mitral stenosis.1 He postulated that an enlarged left atrium was responsible for the recurrent laryngeal nerve palsy. Although it was initially associated with mitral stenosis, several other case reports suggested that hoarseness can be caused by a myriad of clinical situations (Table 1). The association of hoarseness with a cardiovascular pathology was termed as cardiovocal syndrome. The term cardiovocal syndrome was first comprehensively described in English journals in 1958 by Stocker and Enterline.2

Section snippets

Anatomy of Laryngeal Nerves

The nerves that supply the larynx are terminal branches of the vagus nerve. After entering the neck from the jugular foramen, the vagus nerve runs in the carotid sheath between the vein and the artery. It has two main branches that innervate the larynx.

The superior laryngeal nerve that runs behind the internal carotid artery divides into internal and external laryngeal nerves. The internal laryngeal nerve, along with the superior laryngeal artery, pierces the thyrohyoid membrane and serves as a

Clinical Features of LRLN Palsy

The LRLN paralysis causes the left vocal cord to be in the paramedian position; on a laryngoscopy, the position can be variable. Symptoms include hoarseness, dysphagia, and shortness of breath during speech because of loss of air, which is secondary to glottic incompetence. Effective cough cannot be mounted. LRLN palsy can be a significant risk for aspiration because the paralysed vocal cord cannot protect from aspiration especially from liquids. The degree of symptoms depends on the extent of

Incidence

A prospective study from Scotland suggested that left sided recurrent laryngeal nerve palsy is more common than the right recurrent laryngeal palsy and it is more common in men and can occur in any age group. Lung cancer was the most common cause (42%) and surgical manipulation accounted for 24% of the cases. The idiopathic causes that included the cardiovocal syndrome accounted for less than 11% of the cases.34 However, in the same study, LRLN palsy caused by lung cancer was noted to be high

Conditions Associated with LRLN Palsy

Cardiovocal syndrome was described in various congenital abnormalities like atrial septal defect, ventricular septal defect, and type 2 aortopulmonary window.3, 4 It was also associated with double outlet right ventricle,5 Ebstein's anomaly,6 patent ductus arteriosus (PDA),7 and Eisenmenger's complex.8 Ductal ligation and transcatheter closure of PDA is associated with a risk of LRLN palsy.9, 10 Infants, who are less than 1500 g, premature, and younger, are have a higher risk of developing LRLN

Pathophysiology

In 1990, Sunderland classified nerve injuries into five major types with prognostication with each class and modified the previous Sneddon's classification (Table 2). He suggested a classification depending on injury to different parts of the nerve. Class I injuries with virtually no damage to the nerve were associated with complete recovery, whereas class V injuries with disruption of perineurium had a dismal prognosis unless the offending agent is removed and surgical reconstruction of the

Treatment

Clinical recognition of hoarseness in patients with cardiovascular disease is important because prompt referral can be made for laryngoscopy for confirmation of LRLN palsy. A prompt assessment for aspiration, increased vocal effort, altered voice quality, dyspnoea on exertion, and decreased quality of life should be made. If the symptoms are well tolerated with out any evidence of aspiration, a reassessment of laryngeal function can be made within a year.

The physiological basis of surgery is

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