A 50yearold woman was presented to our department with a nodule in the right thyroid lobe, and she reported no voice changes. A novel variation of the recurrent laryngeal nerve bmc. Damage to a recurrent laryngeal nerve rln with resultant paralysis of the sole abducting muscle posterior cricoarytenoid of the vocal cords can cause symptoms ranging from almost undetectable hoarseness in unilateral lesions to stridor and acute airway. The second one is traction on the esophagus due to an unnatural position of the head and neck during. Anatomy of recurrent laryngeal nerve rln dent1 pbl 3. Our aim was to provide a comprehensive metaanalysis of the overall prevalence of the nrln, its origin, and its association with an aberrant subclavian artery. Normal position of the recurrent laryngeal nerve in the tracheoesophageal groove.
Most of the research and clinical interest in the field of neurolaryngology is focused on the recurrent laryngeal nerve rln. Recurrent laryngeal nerve injury produces an abductor laryngeal paralysis. Our experience of rln monitoring, even in this preliminary report, was convincing. Management of unilateral recurrent laryngeal nerve injury after. Recurrent laryngeal nerve request pdf researchgate. Because the nerve is so close to the outer lobes of the thyroid gland, it is extremely vulnerable. Injury to the recurrent laryngeal nerve is one of the main complications resulting from thyroid surgery. Transection injury to the recurrent laryngeal nerve rln leads to unilateral vocal cord paralysis uvcp with motor, sensory, and autonomic dysfunctions of the larynx such as various degrees of dysphonia, aspiration tendencies, or airway impairment 1, 2. In order to decrease the rates of rlnp and to determine clinical practice guidelines for. Vocal cord paralysis after openheart surgery european.
Pdf recurrent laryngeal nerve injury during thyroid surgery. Pdf incidence of recurrent laryngeal nerve injury in. Recurrent laryngeal and superior laryngeal nerve injuries recurrent laryngeal nerve injury may result in vocal cord paralysis and hoarseness. Given the function and location of the left rln, injury to the nerve can be suspected when a patient presents with vocal fold cord dysfunction vcd or. Recurrent laryngeal nerve injuries are not common with pneumonectomy or any pulmonary resection. The laryngeal nerve is a nerve branching down from the vagus nerve towards the larynx. Recurrent laryngeal nerve injury may result in vocal cord paralysis and hoarseness. The superior approach of the recurrent laryngeal nerve is a reliable alternative. The recurrent and superior laryngeal nerves springerlink. The recurrent laryngeal nerve receives sensory innervation from the trachea, esophagus and pyriform sinus before it enters the larynx deep to the inferior constrictor muscle and posterior to the cricothyroid articulation. Injury to the recurrent laryngeal nerve is one of the most severe complications of thyroid surgery.
Even for experienced surgeons, a number of patients will have temporary laryngeal paralysis or paresis, which for some will become permanent after 12 months. The left recurrent laryngeal nerve is more susceptible to injury than the right nerve being more superficial and longer running from the chest up through the neck. The overall risk of injury to this nerve in both surgeries combined was 2. This is likely because rln injury is clinically more important as well as easier to identify. Differential diagnosis includes recurrent laryngeal nerve injury rln, superior laryngeal nerve sln paresis, and muscle tension dysphonia patient has had multiple visits with kristine teets for voice therapy. The left nerve passes under the aortic arch and the right nerve passes under the right subclavian artery.
Positive identification of the rln is essential for preservation of nerve integrity and function. Department of medicine, montefiore medical center, bronx, new york 2. You have two, one on each side, as you do with other nerves. What causes injury to the vagus nerve or the recurrent. Injury may be caused by an endotracheal tube cuff that is situated too high or by a centrally positioned esophageal stethoscope or nasogastric tube that can compress the posterior branch of the recurrent laryngeal nerve. Anatomy of recurrent laryngeal nerveanatomy of recurrent. The nerves then exit the skull and travel down through the neck with the carotid arteries. The vocal cord assumes a median or paramedian position. Spontaneous laryngeal reinnervation following chronic. Recurrent laryngeal nerve rln damage because of thyroid and parathyroid surgery has been recognized for over a century. Intraoperative injury to the recurrent nerve can occur as a result of traction, stretch, or thermal injury from electrocautery. The recurrent laryngeal nerves may be injured as a result of trauma, during surgery, as a result of tumour spread, or due to other means 12 injury to the recurrent laryngeal nerves can result in a weakened voice or loss of voice and cause problems in the respiratory tract. The present study aimed to assess the incidence of transientpermanent postoperative rln injuries after thyroid and parathyroid surgery in the present cohort, to observe the timing of recovery, and to identify risk factors for permanent rln injury.
Recurrent laryngeal nerve rln injury has considerable clinical implications, including voice and swallowing dysfunction, which may. Intraoperative nerve monitoring ionm aimed at reducing the injuries of recurrent laryngeal nerve during thyroidectomy is controversial. Recurrent laryngeal nerve injury in thyroid surgery. Recurrent laryngeal nerve rln injury is a feared complication after thyroid and parathyroid surgery. Treatment of recurrent laryngeal nerve injury jama. The purpose of this study was to evaluate the usefulness of an asymmetrically porous polycaprolactone pclpluronic f127 nerve guide conduit ngc for functional regeneration in a rln injury animal model. We conducted a metaanalysis to assess the incidence of nerve injuries with or without ionm. But it can often be posterior or anterior to this position or may even be surrounded by thyroid parenchyma. Injury to the vagus nerve or the recurrent laryngeal nerve can be caused by retractors or by direct trauma from the use of forceps, electrocauterization, or the application of arterial clamps. Recovery of voice after reconstruction of the recurrent. There is no significant difference in the risk of recurrent laryngeal nerve damage in patients undergoing total versus subtotal thyroidectomy.
Laryngeal complications after thyroidectomy are a common problem. Recurrent laryngeal nerve rln injury is the most severe complication of thyroid surgery, leading to transient or permanent voice changes, which is one of the most common causes for medical. Iatrogenic injury of the recurrent laryngeal nerve is doubtless one of the main problems in thyroid surgery. The recurrent laryngeal nerve rln, also known as the inferior laryngeal nerve, is a branch of the vagus nerve cn x which has a characteristic loop around the right subclavian artery on the right and the aortic arch on the left before returning up to achieve the tracheoesophageal groove and then the larynx summary. Value of intraoperative neuromonitoring of the recurrent. Recurrent laryngeal nerve paralysis otolaryngologic clinics.
Role of intraoperative nerve monitoring during parathyroidectomy to prevent recurrent laryngeal nerve injury muhammad usman ghani, salman assad, shuja a. Treatment of recurrent laryngeal nerve injury jama surgery. Differential diagnosis includes recurrent laryngeal nerve injury rln, superior laryngeal nerve sln paresis, and muscle tension dysphonia patient has had multiple visits with kristine teets for voice therapy 10102014 3. Protective effects of intraoperative nerve monitoring. Although the left recurrent laryngeal nerve rln is only one element of this physiology, it is a structure that is at uniquely high risk of damage during neonatal aortic arch reconstruction. Recurrent laryngeal nerve the recurrent laryngeal nerve is a myelinated nerve. The left rln courses around the distal aortic arch and the patent ductus arteriosus close to the area of dissection needed to reconstruct the distal arch. Stretching or squashing of the recurrent laryngeal nerve that supplies nerves to the larynx as it has a very long, tortuous pathway to the larynx 2. They can be intentional sacrificing the nerve for a. Recurrent laryngeal nerve injury is a classic and feared complication of thyroid surgery. For the patient this means impairments of vocal fold.
Recurrent laryngeal nerve injury an overview sciencedirect topics. Vocal cord paralysis vcp caused by recurrent laryngeal nerve rln damage during thyroidectomy commonly results in serious medicolegal problems. Several mechanisms of injury to the recurrent laryngeal nerve have been suggested. While everyone would agree that visualization of the recurrent laryngeal nerve rln is the gold standard in thyroidectomy surgery, visual identification and preservation of the rln alone does not guarantee normal postoperative vocal cord function. Vocal cord paresis or paralysis due to iatrogenic injury of the recurrent laryngeal nerve rlni is one of the main problems in thyroid surgery. Although many procedures have been introduced to prevent the nerve injury, still the incidence of recurrent laryngeal nerve palsy varies between 1. Injury to the recurrent laryngeal nerve is accompanied by a poor functional recovery of the target organ, the larynx. Recurrent laryngeal nerve injury after thyroid and. Thyroid surgery and recurrent laryngeal nerve monitoring. The recurrent laryngeal nerve rln shows some anatomical variations that can potentially compromise the safety of thyroid surgery. Make it vulnerable to injury if it is not visualized during thyroidectomy. There are two recurrent laryngeal nerves and they branch of the vagus nerve which is the 10th cranial nerve.
Injury to the recurrent laryngeal nerve rln is a feared complication with associated morbidity 1 and is the most common source of litigation in patients who have undergone endocrine surgery 2. Dysfunctions of the recurrent laryngeal nerve rln manifested as nerve paralysis are among the most spectacular, cumbersome and quality of. The recurrent laryngeal nerve rln branches off the vagus nerve and supplies function to some muscles of the larynx voice box. The first mechanism is following central venous catheterization, either through direct trauma from the puncture site or secondary to thrombosis, fibrosis or hematoma formation. Current concepts in the management of unilateral recurrent. These demyelination injuries spontaneously heal within a few months, at least in peripheral nerves other than the recurrent laryngeal nerve rln. Damage to the recurrent laryngeal nerve rln consequent to thyroid surgery is a complication that has been recognized for over a century.
The degree of dysfunction is variable, but it may cause inadequate cough, inability to clear secretions, or aspiration in the postoperative setting. Studies performed on large groups of patients show a prevalence for permanent palsy of the recurrent nerve ranging from 0% after primary surgery to 20% after revision surgery. Pdf vocal cord paresis or paralysis due to iatrogenic injury of the recurrent laryngeal nerve rlni is one of the main problems in thyroid surgery find, read. The presence of an nrln significantly increases the risk of iatrogenic injury and operative complications. It then branches into the superior and recurrent laryngeal nerves rln, of which the latter is remarkably interesting from the point of view of evolutionary biology. Overall incidence of transient rlnp is reported to be 0. This injury, in turn, can contribute to vcd, inadequate airway protection, swallowing dysfunction, and glottic incompetence. Injury to recurrent laryngeal nerve leads to unilateral vocal cord paralysis. Gene therapy for recurrent laryngeal nerve injury ncbi. This requires indirect laryngoscopy preoperatively, and, as soon as possible, postoperatively.
Recurrent laryngeal nerve palsy rlnp is a long recognized and potentially catastrophic complication of thyroid surgery. Following chronic recurrent laryngeal nerve injury in the rat, laryngeal innervation is demonstrated through the superior laryngeal nerve from cells both within and outside of the normal cluster of cells that supply the superior laryngeal nerve. Endotracheal intubation is one of the most common procedures performed in the operating theatre, intensive care unit or wards, either on an elective or emergency basis. Anatomical variations of the recurrent laryngeal nerve in. Several anatomic variations of the nerve increase the likelihood of iatrogenic damage. Recurrent laryngeal nerve injury causes and surgery. Unilateral recurrent laryngeal nerve paralysis urlnp is a known complication of thyroid surgery. This approach is insensitive to variations induced by thyroid pathology. Value of intraoperative neuromonitoring of the recurrent laryngeal nerve in total thyroidectomy for benign goitre volume 129 issue 6 c page, p cuvelier, a biet, v strunski. Pdf metaanalysis of recurrent laryngeal nerve injury in. She had no history of surgery or radiation to the head or neck. Objectivesto study the incidence of recurrent laryngeal nerve rln palsy in total thyroidectomy done for multinodular goitre. Functional regeneration of recurrent laryngeal nerve. Injury can be due to surgery, trauma, bacterial or viral infection, neurotoxic drugs, and tumors.
Complete and incomplete recurrent laryngeal nerve injury. Background the nonrecurrent laryngeal nerve nrln is a rare embryologicallyderived variant of the recurrent laryngeal nerve rln. Intraoperative nerve monitoring ionm provides dynamic neural information and is recommended for high. The nerve can be cut or bruised which could result in temporary or permanent damage. Damage or disruption of the recurrent laryngeal nerve may result from a variety of causes and can occur anywhere along its course. Injury to both recurrent laryngeal nerves during thyroidectomy is a rare event, and its occurrence in endoscopic thyroidectomy has not yet been reported. However, the two rlns are different from other nerves in that their courses are not symmetrical. What you need to know about the recurrent laryngeal nerve. Relationship of the recurrent nerve to the inferior thyroid artery. Surgical safety of total thyroidectomy in multinodular goitre and type of vocal cord paralysisstudied. Injury of the recurrent laryngeal nerve and consequent disorder of vocal fold movement is a typical complication in thyroid and.
Management of unilateral recurrent laryngeal nerve injury. Recurrent laryngeal nerve injury during parathyroidectomy. Recurrent laryngeal nerve localization and protection in. Recurrent laryngeal nerve an overview sciencedirect topics. The identification of the recurrent nerve is a must for any ent and general surgeons. Pdf recurrent laryngeal nerve injury in thyroid surgery. Accurate diagnosis can be made only by visualizing the vocal cords while the patient is awake. Recurrent laryngeal nerve radiology reference article. Recurrent laryngeal nerve injury leading to vocal cord paralysis is a lesser known but important complication of intubation.
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