A 34-year-old Asian female is hospitalized with progressive exertional dyspnea, lower extremity edema and cough. She also describes frequent nocturnal episodes of breathlessness and recent hoarseness. She does not use tobacco, alcohol or drugs. Auscultation reveals loud first and second heart sounds and a mid-diastolic rumble best heard at the cardiac apex. This patient's hoarseness is most likely caused by:

Question

A 34-year-old Asian female is hospitalized with progressive exertional dyspnea, lower extremity edema and cough.  She also describes frequent nocturnal episodes of breathlessness and recent hoarseness.  She does not use tobacco, alcohol or drugs.  Auscultation reveals loud first and second heart sounds and a mid-diastolic rumble best heard at the cardiac apex.  This patient's hoarseness is most likely caused by:

Quizplus · Accepted Answer

In rare instances, the left recurrent laryngeal nerve may be compressed to the point of neurapraxia (failure of nerve conduction due to blunt injury) by enlargement of the left atrium and/or other structures in the vicinity of its course as it loops behind the ligamentum arteriosum, underneath and around the aortic arch, and back up alongside the trachea to the larynx. Mitral stenosis can cause left atrial dilatation sufficient to impinge on the left recurrent laryngeal nerve (Ortner syndrome). The recurrent laryngeal nerves innervate all of the intrinsic muscles of the larynx except the cricothyroid muscle. Paresis of vocal cord muscles innervated by left recurrent laryngeal nerve can cause hoarseness. (Choice A) Laryngeal edema can cause hoarseness but is commonly due to direct laryngeal inflammation (e.g. by an upper respiratory infection). (Choice B) Vascular disease or injury resulting in ischemia of the vocal cords, the recurrent laryngeal nerves, and/or the vagal motor nuclei in the brain stem could result in laryngeal neuromuscular dysfunction, producing hoarseness. However, the patient's history and presentation make MS a more likely culprit. (Choice D) Hoarseness is predominantly due to vocal cord disease (including mucosal inflammation or edema) or vocal cord malfunction. Epithelial sloughing could be associated with laryngeal mucosal disease and might be seen in asthma or airway exposure to noxious external gases or gastric acid. However, the other components of the patient's history and physical make severe MS more likely as an underlying pathogenic factor. (Choice E) Vocal cord epithelial or mucosal polyps can also cause hoarseness, but are less likely etiologies here, given the patient's history. Educational Objective: Left atrial enlargement can sometimes cause left recurrent laryngeal nerve impingement. Neurapraxia resulting in left vocal cord paresis and hoarseness may result.

A 34-Year-Old Asian Female Is Hospitalized with Progressive Exertional Dyspnea