The branches provide both sensory and motor fibers. In 4 patients with recurrent laryngeal nerve paralysis, the left recurrent nerve was most commonly involved. Causes of recurrent laryngeal nerve paralysis jama. 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. The effects of immediate recurrent laryngeal nerve rln reconstruction during thyroid cancer surgery with or. The presence of an nrln significantly increases the risk of iatrogenic injury and operative complications. 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.
Recurrent laryngeal nerve injury in the neck is due to thyroid tumors or surgery, cervical spine surgery, esophageal tumors and deep penetrating wounds to the neck. Doctors help you with trusted information about nerve injury in nerve damage. Recurrent laryngeal nerve injury karolinska institutet. The incidence of nonrecurrent laryngeal rln nerve is around 0. Metaanalysis of recurrent laryngeal nerve injury in. Unrecognized transection of the rln or its motor branch can be a cause of unexpected permanent palsy of these nerves. Unilateral rln injury can cause varying degrees of hoarseness, microaspiration.
A 63yearold man presented with acute dysphonia immediately after insertion of a hickman line via the subclavian route. Our aim was to provide a comprehensive metaanalysis of the overall prevalence of the. Treatment depends on the cause and extent of the laryngeal nerve damage. Injury of the external branch of the superior laryngeal nerve in.
Surgical safety of total thyroidectomy in multinodular goitre and type of vocal cord paralysisstudied. Total lobectomy is currently recommended also in benign thyroid disease in order to reduce the risk of goitre recurrence, an approach claimed not to increase postoperative morbidity. A novel variation of the recurrent laryngeal nerve bmc. The nonrln nrln is a rare anatomical anomaly of the rln, with an incidence of 0. Pediatric ansa to recurrent laryngeal nerve reinnervation. To evaluate the effect of recurrent nerve dissection on the incidence of recurrent laryngeal nerve injury rlni and to analyze the performance of individual.
Recurrent laryngeal nerve an overview sciencedirect topics. Although recurrent laryngeal nerve injury has been described following central venous access via the jugular route, it has not previously been reported following access via the subclavian route. The most common cause is after surgery thyroid surgery, neck surgery or cardiac surgery. A branch of the vagus nerve curving upward, on the right side around the root of the subclavian artery, on the left side around the arch of the aorta, then passing superiorly, posterior to the common carotid artery between the trachea and the esophagus to the larynx. A 50yearold woman was presented to our department with a nodule in the right thyroid lobe, and she reported no voice changes. Positive identification of the rln is essential for preservation of nerve integrity and function. It may affect all, one or several of the intrinsic laryngeal muscles thyroarytenoid, lateral cricoarytenoid, posterior cricoarytenoid, interarytenoid except the cricothyroid. Pdf incidence of recurrent laryngeal nerve injury in.
This requires indirect laryngoscopy preoperatively, and, as soon as possible, postoperatively. Injury to both recurrent laryngeal nerves during thyroidectomy is a rare event, and its occurrence in endoscopic thyroidectomy has not yet been reported. Malignant neoplasms of the lung and pulmonary tuberculosis were the most frequent causes of the paralysis. Superior laryngeal nerve injury from thyroid surgery teitelbaum. The superior laryngeal nerve sln provides motor innervation to the cricothyroid muscle. It descends on the larynx, beneath the sternothyroid muscle, to supply the cricothyroid muscle. The importance of the recurrent laryngeal nerve in surgery on the anterior region of the neck has motivated many published papers on critical points of its pathway, relationship with the inferior thyroid artery, penetration in the larynx, division outside the larynx, and branches communicating with the internal branch of the superior laryngeal nerve. Original article prevention and treatment of recurrent laryngeal nerve injury in thyroid surgery yan jiang, bo gao, xiaohua zhang, jianjie zhao, jinping chen, shu zhang, donglin luo department of general surgery, institute of surgery research, daping hospital, third military medical university, chongqing 400042, china. Opsimos on recurrent laryngeal nerve injury treatment. The recurrent laryngeal nerves and the thoracic surgeon.
Also evaluated is the risk with corpectomy, reoperative procedures, and instrumentation. Laryngeal nerve damage can be caused by injury, tumors, surgery, or infection. The right recurrent laryngeal nerve the right rln makes a quick entry and exit at the top of the right chest. The external branch of the superior laryngeal nerve sln is probably the nerve most commonly injured in thyroid surgery, with an injury rate estimated at 025%. There are two recurrent laryngeal nerves right and left in the human body both arising from the vagus nerve but they follow slightly different courses on the left and right side. Injury to the left and right laryngeal nerves at the same time can cause a breathing problem. Anatomic considerations have been used as justification to determine the side of surgical approach.
Recurrent laryngeal nerve injury is an important postthyroidectomy complication for which different modalities of treatment were practiced to lower its incidence. The nonrecurrent laryngeal nerve a rare phenomenon. Original article prevention and treatment of recurrent. The latter originates from cell bodies in the nucleus ambiguus, the dorsal motor nucleus, and the inferior ganglion in the brain. There are many causes of laryngeal nerve paresis palsy. Recurrent laryngeal nerve injury causes and surgery. The right and left nerves are not symmetrical, with the left nerve looping under the aortic arch, and the right nerve looping under.
The incidence of nonrecurrent laryngeal nerve is 0. Recovery of laryngeal function after intraoperative injury. The superior laryngeal nerve consists of two branches. Injury to the recurrent laryngeal nerve is accompanied by a poor functional recovery of the target organ, the larynx. Treatment of recurrent laryngeal nerve injury jama.
The ebsln is the sole motor nerve to the cricothyroid muscle ctm and its dysfunction results in lowered voice fundamental frequency, lowered. Recurrent laryngeal nerve request pdf researchgate. Treatment of bilateral vocal cord paralysis following. Pdf recurrent laryngeal nerve injury in thyroid surgery. The risk of nerve injury increases in patients with an anomalous rln. Background the nonrecurrent laryngeal nerve nrln is a rare embryologicallyderived variant of the recurrent laryngeal nerve rln. Recurrent laryngeal nerve rln injury is a com mon severe complication in thyroid surgery 1, and unilateral rln injury is more common. Prevention and treatment of recurrent laryngeal nerve. Trauma to the nerve results in an inability to lengthen a vocal fold and, thus, inability to create a highpitched sound.
Injury to the recurrent laryngeal nerve is one of the most severe complications of thyroid surgery. Recurrent laryngeal nerve radiology reference article. Accurate diagnosis can be made only by visualizing the vocal cords while the patient is awake. Incidence and risk factors for injuries to the recurrent. She had no history of surgery or radiation to the head or neck. Recurrent laryngeal nerve injury produces an abductor laryngeal paralysis. However, the functions of this muscle and the anatomic variations of the. This file is licensed under the creative commons attributionshare alike 3. Careful dissection of the rln during surgery reduces the risk of damage.
Laryngeal recurrent nerve injury in surgery for benign thyroid. 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. It could be caused by a tumor or mass affecting the nerve. Optimal management of acute recurrent laryngeal nerve. Case report nonrecurrent laryngeal nerve and aberrant. Unilateral vocal fold paralysis uvfp occurs from a dysfunction of the recurrent laryngeal or vagus nerve innervating the larynx. Loss of function in the recurrent laryngeal nerve rln during thyroidparathyroid surgery, despite a macroscopically intact nerve, is a challenge which highlights the sensitivity and complexity of laryngeal innervation. Original contributions treatment of bilateral vocal cord paralysis following permanent recurrent laryngeal nerve injury. The ansa to recurrent laryngeal nerve reinnervation procedure has shown promise in restoring vocal fold closure for these children.
Recurrent laryngeal nerve injury in the chest is due to cardiac surgery, lung cancer, pulmonary tuberculosis, oesophageal cancer, mitral stenosis, and thoracic aortic aneurysm. Recurrent laryngeal nerve injury with anterior cervical. Flexible laryngoscopy revealed a left vocal fold palsy. Ta the terminal branch of the recurrent laryngeal nerve as the latter passes deep to the inferior pharyngeal constrictor. The recurrent laryngeal nerve is a branch of the vagus nerve that supplies all the intrinsic muscles of the larynx, with the exception of the cricothyroid muscles. Recurrent laryngeal nerve paralysis linkedin slideshare. Recurrent laryngeal nerve rln injury is a common severe complication in thyroid surgery, and unilateral rln injury is more common. It is important to note that the procedure helps to restore tone, bulk, and position of the vocal fold. To understand the course of the right rln one has to understand the course of the right vagus nerve first. The incidence of recurrent laryngeal nerve injury during. The nonrecurrent laryngeal nerve nrln is a rare embryologicallyderived variant of the recurrent laryngeal nerve rln.
The vocal cord assumes a median or paramedian position. Vocal cord paresis or paralysis due to iatrogenic injury of the recurrent laryngeal nerve rlni is one of the main problems in thyroid surgery. Unilateral vocal fold paralysis uvfp is one of the most serious problems in conducting surgery for thyroid cancer. The recurrent laryngeal nerve rln innervates all the important laryngeal muscles except the cricothyroid. Original article prevention and treatment of recurrent laryngeal. For the patient this means impairments of vocal fold. Damage to the nerves of the larynx can cause hoarseness, difficulty in swallowing or breathing, or the loss of voice. Laryngeal nerve damage multimedia encyclopedia health.
The surgcial procedure is typically performed via a left thoracotomy and cardiopulmonary bypass is not necessary. Injury to the nerve results in significant morbidity. There are two recurrent laryngeal nerves, right and left, in the human body. Overall incidence of transient rlnp is reported to be 0. External laryngeal nerve an overview sciencedirect topics. This anomaly is called nonrecurrent laryngeal nerve. The recurrent laryngeal nerve rln is a branch of the vagus nerve cranial nerve x that supplies all the intrinsic muscles of the larynx, with the exception of the cricothyroid muscles. You may do so in any reasonable manner, but not in. Care must be taken during surgical dissection, however, because the left vagus nerve travels close to the region of interest, giving off the recurrent laryngeal branch in front of the aortic arch. A case of a 63year old lady with a nonrln and an aberrant subclavian artery was described. Recurrent laryngeal nerve injury treatment answers on. Recurrent laryngeal nerve palsy complicating subclavian.
The superior laryngeal nerve descends, by the side of the pharynx, behind the internal carotid artery, and divides into two branches the external laryngeal nerve and the internal laryngeal nerve the external laryngeal nerve is the smaller, external branch. Anatomical variations of recurrent laryngeal nerve during. The symposium will bring together clinicians and researchers from all over the world who are dedicated to the many aspects of laryngeal nerve injuries. Recurrent laryngeal nerve injury in thyroid surgery article pdf available in oman medical journal 261. A metaanalysis and clinical considerations article pdf available in peerj 53 march 2017 with 1,089 reads how we measure reads. Improving voice outcomes after injury to the recurrent laryngeal. 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. Current concepts in the prevention and management of unilateral and bilateral laryngeal nerve injury. Different treatments are available for the management of uvfp including intracordal injection, type i thyroplasty, arytenoid adduction, and laryngeal reinnervations. This syndrome results from an injury to the recurrent laryngeal nerve. During thyroidectomy, the external branch of the superior laryngeal nerve is at risk for injury, because it descends in. Recurrent laryngeal nerve injury in thyroid surgery core. Recurrent laryngeal nerve rln injury is commonly encountered by thyroid surgeons and may carry with it great morbidity. The paths of the left and right recurrent laryngeal nerves vary slightly with the left recurrent laryngeal nerve dividing from the main vagus nerve at the level of the aortic arch.
Very rarely, the inferior laryngeal nerve exits the vagal nerve in the cervical region and enters the larynx with a short and straight course from its origin. With the increase of awareness and the improvement of surgical techniques, the incidence of rln injury has declined about 0. Indeed, the main benefit of ionm is its ability to guide the surgeon in the event of variations in the expected anatomic course of the inferior laryngeal nerve 9, or in case of a nonrecurrent inferior laryngeal nerve revealed by short latency, as recently demonstrated 30. A complication of neck or chest surgery especially thyroid, lung, heart surgery, or cervical spine surgery.
Furthermore, the uncertain prognosis stresses a lack of capability to diagnose the reason behind the impaired function. Injury to the recurrent laryngeal nerve is accompanied by a poor functional recovery of the target. Several anatomic variations of the nerve increase the likelihood of iatrogenic damage. Laryngeal nerve damage is injury to one or both of the nerves that are attached to the voice box. Laryngeal nerve damage uf health, university of florida.
Otorinolaringoiatriaazienda sanitaria provinciale agrigento ospedale san giovanni di dio, agrigento, italy. The aim of the study was to analyse risk factors for recurrent laryngeal nerve rln palsy during neck surgery, with particular interest in complications after total lobectomy and subtotal resection, respectively. Nonrecurrent laryngeal nerve nrln is a rare anomaly which is reported in 0. The various causes of recurrent laryngeal nerve paralysis that i have observed during the past 24 years are reported. It causes a characteristic breathy voice often accompanied by swallowing disabilty, a weak cough, and the sensation of shortness of breath. The recurrent laryngeal nerve provides motor innervation to the intrinsic muscles of the larynx, which provide the majority of movement of the vocal cords see fig. This study was designed to document the incidence of injury to the superior laryngeal nerve in a series of patients who underwent thyroidectomy. Anatomy of recurrent laryngeal nerveanatomy of recurrent. Whether the injury is accidental or due to deliberate resection for oncologic soundness, the surgeon must be prepared to offer the best available treatment to patients, either at the time of injury or early in the recovery process.
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