Penetrating Aortic Ulcer and Vocal Card Paralysis

A 75 year old chap went to his GP because his voice had changed. His GP referred him to an ENT surgeon who diagnosed left vocal cord paralysis. Who subsequently performed a CT scan of the chest, and referred him to a chest physician. The chest physician diagnosed a penetrating aortic ulcer with involvement of the recurrent laryngeal nerve, and referred him to an aortic surgeon. What would you do ?   Answer

Answer

The first step is to exclude lung cancer. He had already undergone upper aero digestive tract assessment by the ENT consultant who found no tumour. A bronchoscopy was also normal. 

Options include:

• Open operation to remove ulcer - Probably what not to do
• Stent across ulcer, not because of vocal cord palsy, but to prevent risk of rupture or dissection. It should be noted that his descending aorta is tortuous behind the heart making insertion of the stent potentially problematic. His femoral arteries and iliacs have also not been assessed. Retrograde insertion of stents has been described via the carotid artery!!!
• Just watch. Perform serial scans.