When your heart takes your voice and your swallowing away: Massive Left Atrial Dilation Leading to Ortner's Syndrome and Dysphagia Megalatriensis

When your heart takes your voice and your swallowing away: Massive Left Atrial Dilation Leading to Ortner's Syndrome and Dysphagia Megalatriensis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report When your heart takes your voice and your swallowing away: Massive Left Atrial Dilation Leading to Ortner's Syndrome and Dysphagia Megalatriensis Yassine ETTAGMOUTI, Samia EJJEBLI, Mehdi BELHAKIM, Abdenasser DRIGHIL, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5427711/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 9 You are reading this latest preprint version Abstract Background Ortner’s syndrome, or cardiovocal syndrome, involves paralysis of the recurrent laryngeal nerve due to cardiac causes, while Dysphagia Megalatriensis, also known as cardiac or cardiogenic dysphagia, results from esophageal compression caused by left atrial enlargement. The coexistence of these entities is very rare and typically linked to significant left atrial dilation. The aim of this case report is to highlight the clinical progression and management considerations for such complex unusual cases. Case presentation: We report the case of a 79-year-old woman who was diagnosed late with a severe rheumatic mitral stenosis leading to massive left atrial enlargement, causing compression of both the recurrent laryngeal nerve (Ortner’s syndrome) and the esophagus (dysphagia megalatriensis). She was treated with anticoagulation and heart failure drugs as she refused any surgical intervention with improvement in her clinical condition. Conclusions This case emphasizes the importance of early managing of rheumatic heart disease to avoid complications like left atrial enlargement, which can lead to Ortner’s syndrome and dysphagia megalatriensis. This case also highlights the need for a holistic patient evaluation, as extracardiac symptoms can sometimes reveal serious underlying cardiac conditions requiring appropriate treatment. Ortner’s syndrome Dysphagia megalatriensis left atrial enlargement mitral stenosis Figures Figure 1 Figure 2 Background Ortner’s syndrome, also called cardiovocal syndrome, is a rare clinical entity characterized by recurrent laryngeal nerve paralysis secondary to a cardiac cause [ 1 ]. Dysphagia Megalatriensis, also referred to as cardiac dysphagia or cardiogenic dysphagia, is difficulty in swallowing due to mechanical extrinsic compression of the esophagus secondary to left atrial enlargement. The coexistence of these two clinical entities is even rarer in the literature and appears to be predominantly secondary to left atrial enlargement as the main cardiac cause [ 2 ]. Thus, the objective of this case report is to demonstrate the fatal evolution of rheumatic mitral stenosis leading to massive left atrial dilatation, which compresses the regional structures: namely the left inferior laryngeal nerve (Ortner’s syndrome) and the esophagus (dysphagia megalatriensis), with the aim of clarifying the management approach for such patients. Case presentation We describe the case of a 79-year-old widowed woman living alone in a rural area. She has a history of poorly treated recurrent tonsillitis during childhood, an appendectomy, and no known drug allergies. She presented to our cardiology department with rest dyspnea associated with palpitations that had persisted for one week. On admission, the patient was conscious (Glasgow Coma Scale 15/15), apyretic, cachectic and malnourished (body mass index BMI at 16.7 kg/m²) normotensive at 112/76 mmHg, tachycardic at 120 beats per minute with a saturation in free air at 95%. Upon thorough questioning, the patient reported dysphagia to solid foods and a deeper, hoarser voice indicating dysphonia. These symptoms had been ongoing for six months but had been neglected by the patient. The physical exam revealed signs of right-sided heart failure associating: jugular venous distension, hepatojugular reflux and bilateral soft edema of the lower limbs reaching up to the knees. Lung auscultation shows bilateral crackles at the lung bases, suggesting left-sided heart failure. Cardiac auscultation revealed a diastolic heart murmur (grade 4/6) at the mitral area. An electrocardiogram showed atrial fibrillation with a heart rate of 120 beats per minute. Echocardiography revealed(Fig. 1 ): Ectatic size of atria with small ventricular cavities. Left atrial volume was severely dilated at 565 ml/m² (Simpson biplane method), with no visible thrombus. A non-dilated non-hypertrophied left ventricle, with good global contractility ; left ventricular ejection fraction was 56% (Simpson Biplane method). Calcified mitral valve, with bicomissural fusion, and a thickened subvalvular apparatus, consistent with severe rheumatic mitral stenosis (mitral valve area measured at 1.1 cm² by planimetry, mean gradient at 7.8 mmHg, intervalvular gap at 6 mm), and mild mitral regurgitation. Right ventricle was not dilated and had good systolic function (tricuspid annular plane systolic excursion (TAPSE) of 19 mm). A dilated tricuspid annulus measuring 41mm with grade 3 tricuspid regurgitation. Elevated systolic pulmonary artery pressures at 55 mmHg. A very dilated, non-compliant inferior vena cava measuring 28 mm and a small pericardial effusion adjacent to the right chambers. Additionally, The aortic valve was tricuspid without significant valvulopathy, the aorta was not dilated in its ascending segment, and no endocardial vegetations were detected. Biologically, brain natriuretic peptide (BNP) levels were elevated at 4500 pg/ml, troponins were negative, hemoglobin was 13.5 g/dl, coagulation was normal, and renal clearance was 92 ml/min/m². Given the chronic dysphonia and dysphagia in the context of general deterioration, we performed a cervico-thoracic CT scan (Fig. 2 ), to rule out the eventuality of a neoplasm. The scan showed no mediastinal mass, enlarged lymph nodes, laryngeal mass, or suspicious lung nodules.The aorta was not dilated. However, CT revealed signs of left vocal cord paralysis, cardiomegaly, minimal cardiac effusion, and esophageal compression by the left atrium. Therapeutically, the patient was placed on a low-sodium diet, oxygen therapy at 3 Litres/min, and volume depletion with injectable furosemide 40 mg three times daily, with potassium supplementation to prevent hypokalemia. Anticoagulation therapy with vitamin K antagonists (acenocoumarol 4 mg) was initiated, targeting an INR ( national index ratio ) between 2.5 and 3.5. Additionnaly, dapagliflozin 10 mg /day and spironolactone 50 mg/day, followed by bisoprolol 5 mg/day (after decongestion) were introduced. The evolution was marked by a clinical improvement in patient’s dyspnea, heart failure symptoms and regression of her BNP levels under intravenous diuretic treatment later transitioning to oral therapy. Her heart rate also slowed under beta-blocker treatment. For her severe mitral valve disease, mitral valve replacement surgery with left atrial reduction, left atrial appendage closure,and tricuspid repair were recommended. However, the patient refused any interventional procedure given the high surgical risk and the improvement in her symptoms opting to continue with medical treatment alone. The patient is currently monitored monthly for her anticoagulation therapy treatment with dose adjustments based on her INR. She also undergoes cardiology follow-up every three months and an echocardiographic assessment twice a year. Discussion Ortner’s syndrome, first described by Norbert Ortner in 1897 in three patients with severe mitral stenosis, involves left atrial leading to left vocal cord paralysis and subsequent dysphonia [ 3 ]. The left recurrent laryngeal nerve, a branch of the vagus nerve, innervates all intrinsic muscles of the larynx except the cricothyroid muscle. In general, lesions of the nerve on the left are more common than those on the right, probably because of its proximity to intrathoracic cardiovascular structures. Recurrent injury to the left recurrent laryngeal nerve can result in unilateral vocal cord paralysis and hoarseness [ 4 ]. Dysphagia megalatriensis, coined by Le Roux and Williams in 1969, described dysphagia caused by left atrial enlargement. The close anatomical relationship between left atrium dilatation and the esophagus causes compression and/or displacement of the esophagus leading to dysphagia [ 5 ]. A recent systematic review, published in 2023, on the diagnostic and therapeutic management of Ortner’s syndrome, showed that the association of symptoms, dysphagia and dysphonia of cardiac origin, was found in only 11.97% of cases. Patients initially consulted either an Otorhinolaryngology specialist, gastroenterologist or cardiologist, either in scheduled consultations or in the emergency settings, due to the overlapping clinical signs across several specialties. Diagnostic tools such as chest X-ray, cervico-thoracic CT scan, echocardiography or endoscopic investigations like laryngoscopy or digestive fibroscopy were employed to confirm the diagnosis. Echocardiography remains the key tool for assessing atrial dilation and its involvement in laryngeal and esophageal compression syndromes. Given the wide range of differential diagnoses, several additional examinations were required in most cases before establishing a definitive diagnosis.There are four common mediastinal causes: dilatation of the thoracic aorta (aortic aneurysms), pulmonary artery dilatation, cardiomegaly with enlargement of the left atrium mainly or other cardiac chambers. Among the patients studied in the systematic review, only one-third underwent surgery for the underlying cause. This was primarly due to advanced age, various comorbidities, surgical risk or patient refusal. The remaining patients were treated medically. Both medically and surgically treated patients showed significant improvements in dysphonia and dysphagia compared to those who received no treatment [ 6 ]. While rheumatic heart disease has become rare in developed countries, it remains dominant in developing nations. This is due to difficulties in managing acute rheumatic fever, compounded by a lack of information, financial resources, and delayed diagnosis [8].These factors sometimes lead to rare extracardiac complications, such as dysphonia (Ortner's syndrome) and dysphagia (dysphagia megalatriensis), as illustrated by our clinical case. Conclusions Dysphonia and dysphagia are common reasons for consultation across various medical specialties. Although these symptoms related to a cardiac pathology are extremely rare and there are few cases published in the literature. This case highlights the importance of prevention of acute rheumatic fever and early management of rheumatic heart disease to prevent complications such as left atrial enlargement leading to of Ortner’s syndrome and dysphagia megalatriensis. This case also underscores the need for a holistic patient evaluation, as extracardiac symptoms can sometimes reveal serious underlying cardiac conditions requiring appropriate treatment. Declarations Funding : None. Ethics approval and consent to participate Ethical approval was exempted by the Ethical Committee at Ibn Rochd University Hospital for reporting this case. Consent for publication : Written informed consent was obtained from the patient for the publication of this case report and accompanying images. Author Contribution Dr. EY conducted the literature review, designed, and wrote the manuscript. Dr ES, BM, DA and HR revised the literature review. Dr BG, EN wrote the radiological part. All authors have read and accepted the fnal version of the manuscript. References Coen M, Leuchter I, Sussetto M, Banfi C, Giraud R, Bendjelid K. Progressive dysphonia: Ortner syndrome. Am J Med. 2018; 131:e494-e495. https://doi.org/10.1016/j.amjmed.2018.08.004 Fasseas P, Lee-Dorn R, Sokil AB, VanDecker W. Giant left atrium. Tex Heart Inst J. 2001;28(2):158–9. PMID: 11453134; PMCID: PMC101162 Dutra BL, Campos Lda C, Marques Hde C, Vilela VM, Carvalho RE, Duque AG. Ortner's syndrome: Acase report and literature review. Radiol Bras. 2015; 48:260–262. https://doi.org/10.1590/0100-3984.2013.1836 Loughran S, Alves C, MacGregor FB. Current aetiology of unilateral vocal fold paralysis in a teaching hospital in the West of Scotland. J Laryngol Otol. 2002; 116:907–910. https://doi.org/10.1258/00222150260369426 B. T. Le Roux, M. A. Williams. Dysphagia megalatriensis. Thorax (1969), 24, 603. https://doi.org/10.1136/thx.24.5.603 Verma S, Talwar A, Talwar A, Khan S, Krishnasastry KV, Talwar A. Ortner's syndrome: A systematic review of presentation, diagnosis and management. Intractable Rare Dis Res. 2023;12(3):141–147. doi: 10.5582/irdr.2023.01047 . PMID: 37662622; PMCID: PMC10468413. https://doi.org/10.5582/irdr.2023.01047 Remenyi, Boglarka et al. Valvular aspects of rheumatic heart disease. The Lancet, Volume 387, Issue 10025, 1335–1346. March 26, 2016. https://doi.org/10.1016/s0140-6736(16)00547-x Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 18 Feb, 2026 Reviews received at journal 16 Feb, 2026 Reviewers agreed at journal 03 Feb, 2026 Reviews received at journal 24 May, 2025 Reviewers agreed at journal 18 May, 2025 Reviewers invited by journal 15 Apr, 2025 Editor assigned by journal 12 Nov, 2024 Submission checks completed at journal 12 Nov, 2024 First submitted to journal 10 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5427711","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":380606231,"identity":"df71751b-a7d0-47da-87b4-cf5d8dca7ced","order_by":0,"name":"Yassine 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21:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5427711/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5427711/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71612519,"identity":"612cb1be-d8db-427d-aab0-10f426497c34","added_by":"auto","created_at":"2024-12-17 07:01:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":476544,"visible":true,"origin":"","legend":"\u003cp\u003ea: Parasternal long axis view showing a thickened, calcified mitral valve with a flexed knee appearance (red arrow)\u003c/p\u003e\n\u003cp\u003eb: Left atrial volume calculated at 565 ml/m² (Simpson biplane method)\u003c/p\u003e\n\u003cp\u003ec: Apical 4-chamber view showing severe mitral stenosis and bi-atrial dilatation\u003c/p\u003e\n\u003cp\u003ed: Continuous Doppler on the mitral valve with a mean gradient at 7.8 mmHg\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5427711/v1/6136b3381643204756c624b9.png"},{"id":71612520,"identity":"d44f211c-270c-4e18-9588-c7fb0adad06a","added_by":"auto","created_at":"2024-12-17 07:01:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":269892,"visible":true,"origin":"","legend":"\u003cp\u003eA : paralysis of the left vocal cord\u003c/p\u003e\n\u003cp\u003eB : The sagittal section showed compression of the thoracic esophagus by the heart (white star)\u003c/p\u003e\n\u003cp\u003eC : cardiomegaly with significant cavo-hepatic reflux (orange arrow) and moderate pericardial effusion (star)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5427711/v1/80262ce1ca6ab489fe3252fc.png"},{"id":71612545,"identity":"8d839be8-3267-406b-a314-282d7f03e6f5","added_by":"auto","created_at":"2024-12-17 07:01:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1175566,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5427711/v1/0a32bd7d-bd04-4813-8e07-77846c72d17e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"When your heart takes your voice and your swallowing away: Massive Left Atrial Dilation Leading to Ortner's Syndrome and Dysphagia Megalatriensis","fulltext":[{"header":"Background","content":"\u003cp\u003eOrtner\u0026rsquo;s syndrome, also called cardiovocal syndrome, is a rare clinical entity characterized by recurrent laryngeal nerve paralysis secondary to a cardiac cause [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Dysphagia Megalatriensis, also referred to as cardiac dysphagia or cardiogenic dysphagia, is difficulty in swallowing due to mechanical extrinsic compression of the esophagus secondary to left atrial enlargement. The coexistence of these two clinical entities is even rarer in the literature and appears to be predominantly secondary to left atrial enlargement as the main cardiac cause [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Thus, the objective of this case report is to demonstrate the fatal evolution of rheumatic mitral stenosis leading to massive left atrial dilatation, which compresses the regional structures: namely the left inferior laryngeal nerve (Ortner\u0026rsquo;s syndrome) and the esophagus (dysphagia megalatriensis), with the aim of clarifying the management approach for such patients.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eWe describe the case of a 79-year-old widowed woman living alone in a rural area. She has a history of poorly treated recurrent tonsillitis during childhood, an appendectomy, and no known drug allergies.\u003c/p\u003e\n\u003cp\u003eShe presented to our cardiology department with rest dyspnea associated with palpitations that had persisted for one week.\u003c/p\u003e\n\u003cp\u003eOn admission, the patient was conscious (Glasgow Coma Scale 15/15), apyretic, cachectic and malnourished (body mass index BMI at 16.7 kg/m\u0026sup2;) normotensive at 112/76 mmHg, tachycardic at 120 beats per minute with a saturation in free air at 95%.\u003c/p\u003e\n\u003cp\u003eUpon thorough questioning, the patient reported dysphagia to solid foods and a deeper, hoarser voice indicating dysphonia. These symptoms had been ongoing for six months but had been neglected by the patient.\u003c/p\u003e\n\u003cp\u003eThe physical exam revealed signs of right-sided heart failure associating: jugular venous distension, hepatojugular reflux and bilateral soft edema of the lower limbs reaching up to the knees. Lung auscultation shows bilateral crackles at the lung bases, suggesting left-sided heart failure.\u003c/p\u003e\n\u003cp\u003eCardiac auscultation revealed a diastolic heart murmur (grade 4/6) at the mitral area.\u003c/p\u003e\n\u003cp\u003eAn electrocardiogram showed atrial fibrillation with a heart rate of 120 beats per minute.\u003c/p\u003e\n\u003cp\u003eEchocardiography revealed(Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e): Ectatic size of atria with small ventricular cavities. Left atrial volume was severely dilated at 565 ml/m\u0026sup2; (Simpson biplane method), with no visible thrombus. A non-dilated non-hypertrophied left ventricle, with good global contractility ; left ventricular ejection fraction was 56% (Simpson Biplane method). Calcified mitral valve, with bicomissural fusion, and a thickened subvalvular apparatus, consistent with severe rheumatic mitral stenosis (mitral valve area measured at 1.1 cm\u0026sup2; by planimetry, mean gradient at 7.8 mmHg, intervalvular gap at 6 mm), and mild mitral regurgitation. Right ventricle was not dilated and had good systolic function (tricuspid annular plane systolic excursion (TAPSE) of 19 mm). A dilated tricuspid annulus measuring 41mm with grade 3 tricuspid regurgitation. Elevated systolic pulmonary artery pressures at 55 mmHg. A very dilated, non-compliant inferior vena cava measuring 28 mm and a small pericardial effusion adjacent to the right chambers. Additionally, The aortic valve was tricuspid without significant valvulopathy, the aorta was not dilated in its ascending segment, and no endocardial vegetations were detected.\u003c/p\u003e\n\u003cp\u003eBiologically, brain natriuretic peptide (BNP) levels were elevated at 4500 pg/ml, troponins were negative, hemoglobin was 13.5 g/dl, coagulation was normal, and renal clearance was 92 ml/min/m\u0026sup2;.\u003c/p\u003e\n\u003cp\u003eGiven the chronic dysphonia and dysphagia in the context of general deterioration, we performed a cervico-thoracic CT scan (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), to rule out the eventuality of a neoplasm. The scan showed no mediastinal mass, enlarged lymph nodes, laryngeal mass, or suspicious lung nodules.The aorta was not dilated. However, CT revealed signs of left vocal cord paralysis, cardiomegaly, minimal cardiac effusion, and esophageal compression by the left atrium.\u003c/p\u003e\n\u003cp\u003eTherapeutically, the patient was placed on a low-sodium diet, oxygen therapy at 3 Litres/min, and volume depletion with injectable furosemide 40 mg three times daily, with potassium supplementation to prevent hypokalemia. Anticoagulation therapy with vitamin K antagonists (acenocoumarol 4 mg) was initiated, targeting an INR ( national index ratio ) between 2.5 and 3.5. Additionnaly, dapagliflozin 10 mg /day and spironolactone 50 mg/day, followed by bisoprolol 5 mg/day (after decongestion) were introduced.\u003c/p\u003e\n\u003cp\u003eThe evolution was marked by a clinical improvement in patient\u0026rsquo;s dyspnea, heart failure symptoms and regression of her BNP levels under intravenous diuretic treatment later transitioning to oral therapy. Her heart rate also slowed under beta-blocker treatment. For her severe mitral valve disease, mitral valve replacement surgery with left atrial reduction, left atrial appendage closure,and tricuspid repair were recommended. However, the patient refused any interventional procedure given the high surgical risk and the improvement in her symptoms opting to continue with medical treatment alone.\u003c/p\u003e\n\u003cp\u003eThe patient is currently monitored monthly for her anticoagulation therapy treatment with dose adjustments based on her INR. She also undergoes cardiology follow-up every three months and an echocardiographic assessment twice a year.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOrtner\u0026rsquo;s syndrome, first described by Norbert Ortner in 1897 in three patients with severe mitral stenosis, involves left atrial leading to left vocal cord paralysis and subsequent dysphonia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe left recurrent laryngeal nerve, a branch of the vagus nerve, innervates all intrinsic muscles of the larynx except the cricothyroid muscle. In general, lesions of the nerve on the left are more common than those on the right, probably because of its proximity to intrathoracic cardiovascular structures. Recurrent injury to the left recurrent laryngeal nerve can result in unilateral vocal cord paralysis and hoarseness [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Dysphagia megalatriensis, coined by Le Roux and Williams in 1969, described dysphagia caused by left atrial enlargement. The close anatomical relationship between left atrium dilatation and the esophagus causes compression and/or displacement of the esophagus leading to dysphagia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA recent systematic review, published in 2023, on the diagnostic and therapeutic management of Ortner\u0026rsquo;s syndrome, showed that the association of symptoms, dysphagia and dysphonia of cardiac origin, was found in only 11.97% of cases. Patients initially consulted either an Otorhinolaryngology specialist, gastroenterologist or cardiologist, either in scheduled consultations or in the emergency settings, due to the overlapping clinical signs across several specialties. Diagnostic tools such as chest X-ray, cervico-thoracic CT scan, echocardiography or endoscopic investigations like laryngoscopy or digestive fibroscopy were employed to confirm the diagnosis. Echocardiography remains the key tool for assessing atrial dilation and its involvement in laryngeal and esophageal compression syndromes. Given the wide range of differential diagnoses, several additional examinations were required in most cases before establishing a definitive diagnosis.There are four common mediastinal causes: dilatation of the thoracic aorta (aortic aneurysms), pulmonary artery dilatation, cardiomegaly with enlargement of the left atrium mainly or other cardiac chambers.\u003c/p\u003e \u003cp\u003eAmong the patients studied in the systematic review, only one-third underwent surgery for the underlying cause. This was primarly due to advanced age, various comorbidities, surgical risk or patient refusal. The remaining patients were treated medically. Both medically and surgically treated patients showed significant improvements in dysphonia and dysphagia compared to those who received no treatment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile rheumatic heart disease has become rare in developed countries, it remains dominant in developing nations. This is due to difficulties in managing acute rheumatic fever, compounded by a lack of information, financial resources, and delayed diagnosis [8].These factors sometimes lead to rare extracardiac complications, such as dysphonia (Ortner's syndrome) and dysphagia (dysphagia megalatriensis), as illustrated by our clinical case.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDysphonia and dysphagia are common reasons for consultation across various medical specialties.\u003c/p\u003e \u003cp\u003eAlthough these symptoms related to a cardiac pathology are extremely rare and there are few cases published in the literature.\u003c/p\u003e \u003cp\u003eThis case highlights the importance of prevention of acute rheumatic fever and early management of rheumatic heart disease to prevent complications such as left atrial enlargement leading to of Ortner\u0026rsquo;s syndrome and dysphagia megalatriensis.\u003c/p\u003e \u003cp\u003eThis case also underscores the need for a holistic patient evaluation, as extracardiac symptoms can sometimes reveal serious underlying cardiac conditions requiring appropriate treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval was exempted by the Ethical Committee at Ibn Rochd University Hospital for reporting this case.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of this case report and accompanying images.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. EY conducted the literature review, designed, and wrote the manuscript. Dr ES, BM, DA and HR revised the literature review. Dr BG, EN wrote the radiological part. All authors have read and accepted the fnal version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCoen M, Leuchter I, Sussetto M, Banfi C, Giraud R, Bendjelid K. Progressive dysphonia: Ortner syndrome. Am J Med. 2018; 131:e494-e495. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.amjmed.2018.08.004\u003c/span\u003e\u003cspan address=\"10.1016/j.amjmed.2018.08.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFasseas P, Lee-Dorn R, Sokil AB, VanDecker W. Giant left atrium. Tex Heart Inst J. 2001;28(2):158\u0026ndash;9. PMID: 11453134; PMCID: PMC101162\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDutra BL, Campos Lda C, Marques Hde C, Vilela VM, Carvalho RE, Duque AG. Ortner's syndrome: Acase report and literature review. Radiol Bras. 2015; 48:260\u0026ndash;262. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/0100-3984.2013.1836\u003c/span\u003e\u003cspan address=\"10.1590/0100-3984.2013.1836\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoughran S, Alves C, MacGregor FB. Current aetiology of unilateral vocal fold paralysis in a teaching hospital in the West of Scotland. J Laryngol Otol. 2002; 116:907\u0026ndash;910. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1258/00222150260369426\u003c/span\u003e\u003cspan address=\"10.1258/00222150260369426\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eB. T. Le Roux, M. A. Williams. Dysphagia megalatriensis. Thorax (1969), 24, 603. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/thx.24.5.603\u003c/span\u003e\u003cspan address=\"10.1136/thx.24.5.603\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerma S, Talwar A, Talwar A, Khan S, Krishnasastry KV, Talwar A. Ortner's syndrome: A systematic review of presentation, diagnosis and management. Intractable Rare Dis Res. 2023;12(3):141\u0026ndash;147. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5582/irdr.2023.01047\u003c/span\u003e\u003cspan address=\"10.5582/irdr.2023.01047\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 37662622; PMCID: PMC10468413. https://doi.org/10.5582/irdr.2023.01047\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRemenyi, Boglarka et al. Valvular aspects of rheumatic heart disease. The Lancet, Volume 387, Issue 10025, 1335\u0026ndash;1346. March 26, 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0140-6736(16)00547-x\u003c/span\u003e\u003cspan address=\"10.1016/s0140-6736(16)00547-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-heart-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tehj","sideBox":"Learn more about [The Egyptian Heart Journal](https://tehj.springeropen.com)","snPcode":"43044","submissionUrl":"https://submission.springernature.com/new-submission/43044/3","title":"The Egyptian Heart Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ortner’s syndrome, Dysphagia megalatriensis, left atrial enlargement, mitral stenosis","lastPublishedDoi":"10.21203/rs.3.rs-5427711/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5427711/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOrtner\u0026rsquo;s syndrome, or cardiovocal syndrome, involves paralysis of the recurrent laryngeal nerve due to cardiac causes, while Dysphagia Megalatriensis, also known as cardiac or cardiogenic dysphagia, results from esophageal compression caused by left atrial enlargement. The coexistence of these entities is very rare and typically linked to significant left atrial dilation. The aim of this case report is to highlight the clinical progression and management considerations for such complex unusual cases.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eWe report the case of a 79-year-old woman who was diagnosed late with a severe rheumatic mitral stenosis leading to massive left atrial enlargement, causing compression of both the recurrent laryngeal nerve (Ortner\u0026rsquo;s syndrome) and the esophagus (dysphagia megalatriensis). She was treated with anticoagulation and heart failure drugs as she refused any surgical intervention with improvement in her clinical condition.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis case emphasizes the importance of early managing of rheumatic heart disease to avoid complications like left atrial enlargement, which can lead to Ortner\u0026rsquo;s syndrome and dysphagia megalatriensis. This case also highlights the need for a holistic patient evaluation, as extracardiac symptoms can sometimes reveal serious underlying cardiac conditions requiring appropriate treatment.\u003c/p\u003e","manuscriptTitle":"When your heart takes your voice and your swallowing away: Massive Left Atrial Dilation Leading to Ortner's Syndrome and Dysphagia Megalatriensis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-17 07:01:46","doi":"10.21203/rs.3.rs-5427711/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-18T06:45:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-16T05:35:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163015634351047049086305298157647491830","date":"2026-02-04T02:00:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-24T22:43:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"41016678280872224357221110378507780179","date":"2025-05-18T20:35:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-15T20:52:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-13T04:08:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-13T04:08:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Heart Journal","date":"2024-11-10T21:41:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-heart-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tehj","sideBox":"Learn more about [The Egyptian Heart Journal](https://tehj.springeropen.com)","snPcode":"43044","submissionUrl":"https://submission.springernature.com/new-submission/43044/3","title":"The Egyptian Heart Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e3c4f109-01c9-498d-85ca-a476a7e15a32","owner":[],"postedDate":"December 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-02-18T06:56:28+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-17 07:01:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5427711","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5427711","identity":"rs-5427711","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}