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We present a case of an 87-year-old female with new-onset hoarseness of unclear etiology. Imaging demonstrated a penetrating aortic ulcer (PAU) in the proximal descending thoracic aorta with an associated pseudoaneurysm that enlarged to a depth of 32 mm over 2 years. This patient was diagnosed with hoarseness being secondary to left recurrent laryngeal nerve (LRLN) palsy, a variant of Ortner syndrome. Patient was treated with endovascular stent-grafting successfully covering of the PAU and pseudoaneurysm with zone 3 proximal landing zone. The patient had moderate improvement in hoarseness after 1 year of follow-up. Endovascular repair is indicated for symptomatic patients with PAUs complicated by enlarging pseudoaneurysms or rupture. Endovascular treatment is effective with low procedural morbidity and mortality. In this case, the PAU and associated pseudoaneurysm at the level of the ligamentum arteriosum caused compression on the LRLN, resulting in a nerve palsy and hoarseness. This case highlights the importance of vascular imaging for patients presenting with unclear etiology of hoarseness or other signs of LRLN palsy. Therefore, aortic arch abnormalities, a variant of Ortner syndrome, even though rare, should be on the differential diagnosis of new onset hoarseness.