DR.A.MEENAKSHIPROF.S.TITOS UNIT.

M6 UNIT

Case :

45 yr old Mrs .Panjalai was admitted with the presenting complaints of

Hoarseness of voice – 1 year Breathlessness – 2 weeks Bilateral swelling of legs-2weeks Palpitation-2weeks

History of presenting illness :

Hoarseness of voice for 1yrNot associated with difficulty in

swallowing.Breathlessness-2weeksInsidious onset ,gradually progressive Present at rest.grade 4Associated with orthopnoea and

paroxysomal nocturnal dyspnea.

Pedal oedema -2wksInsidious onset,progressiveNot associated with swelling of faceNot associated with decreased urine output.

h/o palpitation for 2wksIrregular,increased by exertionNot associated with syncopal episodes.No h/o chest painNo h/o abdominal painNo h/o abdominal distensionNo h/o cough with expectorationNo h/o feverNo h/o any skin rash No h/o involuntary movements

No h/o loss of appetite No h/o loss of weightNo h/o altered bowel and bladder habits.Past historyKnown case of rheumatic heart disease on

treatment for 3 yrs duration.No h/o HT,DM,TB,ischaemic heart disease.Family h/oNo similar complaints in family.

General examination Pt conscious

oriented afebrile

dyspneic not anaemic no cyanosis no clubbing

b/l pedal oedema + no significant lymphadenopathy.

Vital signsPulse rate-100/min irregularly irregular.Low volume,palpable in all peripheral vessels ,no

radioradial or radio femoral delay.Pulse deficit-12Respiratory rate-30/minBlood pressure-100/70 mm hg Jvp elevated

System examinationCardiovascular systemInspectionTrachea in midlineApical impulse visible in left 5th intercostal

space.Chest wall symmetricalNo kyphosis/scoliosisNo precordial bulgeNo visible pulsations No dilated veinsNo scars of previous surgery

PalpationTracheal position confirmedApical impulse in left 5th intercostal space ½ an

inch medial to midclavicular line.Tapping in characterAssociated with diastolic thrill Parasternal heave present.grade-1Palpable p2 presentno palpable thrill over precordiumNo epigastric pulsations

AuscultationMitral area-s1s2+s1 variable,mid diastolic

murmur+.Pulmonary area-s1 s2+ .loud p2Aortic area-s1 s2+Tricuspid area-s1 s2+Respiratory system-normal vesicular breath

sounds .bilateral basal crepitations present.Abdomen-soft ,no tenderness,liver enlarged 4cm

from the right costal margin.Central nervous system-no focal neurologicdeficit

Cardiology opinionEcho-mitral valve annulus 0.7cm2 diastolic

doming of aml No AS/AR.TR SEVERE.Moderate pulmonary hypertension .auto

contrast in left atrium. Trans oesophageal echoDense auto contrast in Left atriumLeft atrial appendage clot seen 2.1*1.*3 cm.Left atrial size was about 4.8cm

ENT OPINIONIndirect laryngoscopyLeft vocal cord no movement.right vocal cord

normal.Posterior 1/3 of tongue,both

vallecula ,epiglottis and aryepiglottic fold normal.

OGD scopy-Normal study

InvestigationsHb % 11.5

PCV 34

MCV 89

MCHC 31

TC 8400

DC P60 L37 E3

ESR 10/22

PLATELETS 1.2 LAKH

Blood sugar 113

urea 24

creatinine 0.7

sodium 136

pottasium 3.2

Prothrombin time 25.8

APTT 38.2

INR 2.7

freeT4 1.32

TSH 3.49

TreatmentTab digoxin 0.25 mg odTab enalapril 2.5mg ½ bdTab warfarin 5 mg odTab furusemide 40 mg bdTab ranitidine 150 mg bdTab penicillin 250 mg bd Tab spironolactone 25mg odPatient was registered in cardiothoracic dept

for surgery.

It is development of unilateral vocal cord palsy secondary to cardiovascular disease.

Other namesCardiovocal syndrome,laryngeal paralysis

syndrome,cardiovascular syndrome.First described by N.ORTNER an australian

physician in 1897Incidence-0.6-5%Ortners syndrome II refers to abdominal

angina.

CausesMitral stenosisPulmonary hypertensionThoracic aortic aneurysmAberrant subclavian artery syndromeCongenital heart

disease(PDA,ASD,VSD,eisenmingers syndrome)

Ischaemic heart diseaseHigh altitude

In mitral stenosis enlarged left atrium pushes the laryngeal nerve upward compressing it against the aortic arch.

Ischaemic injury and degenaration of nerve fibre occur.

In pulmonary hypertension laryngeal paralysis occurs due to compression the nerve between dilated pulmonary artery and aorta.

Hoarseness of voice is a change in pitch ,a rough sound of the voice or increased effort in speaking.

It is divided into acute and chronicAcute is sudden onset less than two weeks.Chronic lasts longer than two weeks.ACUTELaryngitisAortic aneurysmAortic dissectionAnaphylaxisStrokeForeign bodyHead injuryEpiglottitisSmoke irritationUpper respiratory tract infection

ChronicLeft atrial enlargementHypothyroidismMyasthenia gravisMalignancy of oesophagus,larynx,lungAmyotrophic lateral sclerosisVocal cord nodule,cyst,polypGastro oesophageal reflux diseaseThyroid tumour

SymptomsHoarseness of voice Postural aphoniadysphagia

investigationCT is helpful to diagnose this syndrome and

to differentiate it from other causes.TreatmentTreatment of the underlying cardiovascular

etiology helps in resolution of the symptoms.