Can Ortner's Syndrome Cause Bilateral Recurrent Laryngeal Nerve Palsy?
No, Ortner's syndrome does not cause bilateral recurrent laryngeal nerve (RLN) palsy—it specifically affects only the left recurrent laryngeal nerve due to its unique anatomical course around the aortic arch. 1, 2
Anatomical Basis for Unilateral Involvement
The left RLN follows a distinctly different path than the right nerve, making it uniquely vulnerable to cardiovascular compression:
The left RLN loops around the aortic arch and ascends in the tracheoesophageal groove in a deeper position, rendering it susceptible to compression by adjacent cardiovascular structures. 2
The right RLN follows a more superficial course along the lateral esophageal edge and does not traverse extensively into the chest, making it less commonly involved in cardiovascular compression syndromes. 1, 2
Ortner's syndrome is explicitly defined as compression of the left recurrent laryngeal nerve by enlarged cardiovascular structures, causing unilateral hoarseness secondary to inflammation or stretching of this nerve. 1
Modern Understanding of Ortner's Syndrome
While historically associated with mitral stenosis, the etiology has evolved:
Aortic aneurysms (41%) and pulmonary hypertension (35%) are now the most common causes, followed by mitral stenosis (17%). 3
The right recurrent laryngeal nerve can be compressed by cardiovascular structures (such as brachiocephalic trunk aneurysm or right subclavian artery aneurysm), and this is now also associated with the term Ortner's syndrome. 4
However, even when the right side is involved, this represents a separate unilateral process—not bilateral involvement. 4
Clinical Implications
Bilateral RLN palsy represents a medical emergency due to potential complete airway obstruction and requires immediate intervention. 5
Bilateral RLN injury has fundamentally different etiologies than Ortner's syndrome, most commonly occurring from surgical procedures (particularly thyroidectomy, re-operative neck surgery, or bilateral neck dissections). 1, 5
If a patient with cardiovascular disease presents with bilateral vocal cord paralysis, alternative diagnoses must be pursued—this is not Ortner's syndrome. 5
Common Pitfalls to Avoid
Do not assume that extensive cardiovascular disease can compress both recurrent laryngeal nerves simultaneously—the anatomical courses are too different. 2
In patients with hoarseness and cardiovascular history, perform laryngoscopy to confirm which vocal cord is affected before attributing symptoms to Ortner's syndrome. 5
If bilateral RLN palsy is identified, immediately assess for surgical causes, malignancy with bilateral mediastinal involvement, or systemic neurological conditions rather than cardiovascular compression alone. 1, 5