Reversible Ortner's syndrome in a woman with decompensated rheumatic heart disease: a case report

Ortner's syndrome, or cardiovocal syndrome, is a rare form of left recurrent laryngeal nerve palsy caused by cardiovascular pathology. Historically associated with massive left atrial enlargement from rheumatic heart disease (RHD), it is now an uncommon diagnosis. However, in regions such as Nepal, where rheumatic heart disease remains endemic, it represents an important, though overlooked, complication.

A 48-year-old Tamang woman, working as a farmer from Nepal, with a history of percutaneous transvenous mitral commissurotomy (PTMC) performed 12 years prior for RHD with mitral stenosis, presented with acute decompensated heart failure. Echocardiography revealed severe mitral stenosis, a severely dilated left atrium (5.7 cm), and severely impaired left ventricular function (ejection fraction of 30%). During her hospital stay and subsequent follow-up, she reported persistent hoarseness. A definitive diagnosis of Ortner's syndrome was established via a multidisciplinary workup, which included nasopharyngolaryngoscopy confirming left vocal cord paralysis and a contrast-enhanced computed tomography (CECT) scan showing mediastinal compression from severe cardiomegaly. The patient was managed with medical therapy, including intravenous furosemide for decongestion, metoprolol for rate control, and warfarin 3 mg orally once daily targeting an international normalized ratio of 2.0-3.0 for anticoagulation, alongside conservative voice therapy, dietary modifications, and lifestyle changes.

Over a 3-month follow-up period, the patient's cardiac function improved dramatically, with her ejection fraction increasing from 30% to 46%, which correlated with almost complete resolution of her hoarseness, confirmed on repeat nasopharyngolaryngoscopy. This case documents the reversibility of Ortner's syndrome with medical management alone, reports a rare presentation in a post-PTMC female patient from an RHD-endemic region, and underscores the critical need for a collaborative diagnostic approach between cardiologists and otorhinolaryngologists.