Iatrogenic recurrent laryngeal nerve rln injury is a rare but well recognized and dreaded complication of thyroid or parathyroid surgery. Background the non recurrent laryngeal nerve nrln is a rare embryologicallyderived variant of the recurrent laryngeal nerve rln. The role of intraoperative neuromonitoring of recurrent laryngeal nerve during thyroidectomy. Laryngeal reinnervation for unilateral vocal fold paralysis using ansa cervicalis nerve to recurrent laryngeal nerve anastomosis. Tran sient postoperative hoarseness after openheart operation, previously assumed to be caused by intralaryngeal injury, may indeed be caused by injury to the right recurrent laryngeal nerve. The most common cause is after surgery thyroid surgery, neck surgery or cardiac surgery.
The various causes of recurrent laryngeal nerve paralysis that i have observed during the past 24 years are reported. Rov et at, laryngeal features of external superior laryngeal nerve denervation fi g 3. A 63yearold man presented with acute dysphonia immediately after insertion of a hickman line via the subclavian route. Therefore, preventing recurrent laryngeal nerve injury is an important goal in thyroid surgery. 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. Recurrent laryngeal nerve injury produces an abductor laryngeal paralysis. Recurrent laryngeal nerve the recurrent laryngeal nerve is a myelinated nerve. Lesions involving the recurrent laryngeal nerve rln are usually easy to recognize with indirect laryngoscopy or fibre optic examination, but injuries to the external branch of the superior laryngeal nerve are often underdiagnosed because of limited or absent clinical signs 915.
Relationship of the recurrent laryngeal nerve rln to the left and right inferior thyroid arteries. 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. Injury to the recurrent laryngeal nerve is accompanied by a poor functional recovery of the target organ, the larynx. Overall incidence of transient rlnp is reported to be 0. In 4 patients with recurrent laryngeal nerve paralysis, the left recurrent nerve was most commonly involved. A novel variation of the recurrent laryngeal nerve bmc surgery. The present study aimed to assess the incidence of transientpermanent postoperative rln injuries after.
Malignant neoplasms of the lung and pulmonary tuberculosis were the most frequent causes of the paralysis. Objectivesto study the incidence of recurrent laryngeal nerve rln palsy in total thyroidectomy done for multinodular goitre. What are the signs and symptoms of recurrent laryngeal. Studies looking at the recurrent laryngeal nerve from horses with rln have shown that there is ongoing, continual or intermittent damage of the nerve and repeated attempts at repair. Injury mechanisms and electromyographic changes after. Recurrent laryngeal nerve paralysis rlnp is a common and sometimes severe complication after esophagectomy. May 30, 2017 the vagus nerves, from which the recurrent laryngeal nerves branch, exit the skull at the jugular foramen and travel within the carotid sheath alongside the carotid arteries through the neck. Ducharme, jon cheetham, in equine sports medicine and surgery second edition, 2014. 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. The frequency of rln is reported as 1%11% in the literature. Improving voice outcomes after injury to the recurrent laryngeal.
Metaanalysis of recurrent laryngeal nerve injury in. The effects of immediate recurrent laryngeal nerve rln reconstruction during thyroid cancer surgery with or without uvfp before the surgery were evaluated with videostroboscopic, aerodynamic, and perceptual analyses. Pdf laryngeal features of external superior laryngeal. Recurrent laryngeal nerve injury following reoperative. Recurrent laryngeal nerve rln injury is a common severe complication in thyroid surgery, and unilateral rln injury is more common.
Prevention and treatment of recurrent laryngeal nerve injury. Management of unilateral recurrent laryngeal nerve injury. Objective gradual impairment of nerve conduction is expected to be tightly associated with simultaneous gradual loss of vocal cord contractility. Recurrent laryngeal nerve rln injury during surgery may reveal differences in electromyographic emg changes after sustained compression or traction. Original article prevention and treatment of recurrent laryngeal. 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. 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. Prevention and treatment of recurrent laryngeal nerve injury in. After the recurrent laryngeal nerve leaves the vagus nerve, it goes down into the chest and then loops back up, to supply nerves to the larynx the voice box. Laryngeal nerve injuries were classified into type 1 injury segmental and 2 diffuse. Recurrent laryngeal nerve rln injury is a feared complication after thyroid and parathyroid surgery. Laryngeal nerve palsy or paralysis anatomy, physiology. Our experience of rln monitoring, even in this preliminary report, was convincing.
Anatomy of recurrent laryngeal nerveanatomy of recurrent. Recurrent laryngeal nerve injury after thyroid and. Dysfunctions of the recurrent laryngeal nerve rln manifested as nerve paralysis are among the most spectacular, cumbersome and quality of. Recurrent laryngeal nerve an overview sciencedirect topics. What causes injury to the vagus nerve or the recurrent.
This applica tion has great significance in prevention of bilateral vocal cord paralysis given the bilateral nature of the typical thyroid procedure. The recurrent laryngeal nerve exits the caudal brainstem as part of the vagus nerve cranial nerve x and descends along the trachea dorsal to the common carotid artery with a different course between the left and right recurrent laryngeal nerves. Recurrent laryngeal nerve rln injury remains a challenge due to the lack of effective treatments. Surgical safety of total thyroidectomy in multinodular goitre and type of vocal cord paralysisstudied. Pdf recurrent laryngeal nerve injury during thyroid surgery. Pdf incidence of recurrent laryngeal nerve injury in.
Recurrent laryngeal nerve injury in thyroid surgery. Injuries to the recurrent inferior laryngeal nerve riln remain one of the major post. Doctors help you with trusted information about nerve injury in nerve damage. Its peculiar route results from evolutionary lengthening of the neck. Cas e 3 brai n ste m arteriovenou s malfonnatio n an d hig h lef t vagu s nerv e injury. Routine preoperative and postoperative laryngoscopy has been advocated by some experts, but remains controversial. Metaanalysis of recurrent laryngeal nerve injury in thyroid. Intraoperative neuromonitoring versus visual nerve.
Recurrent laryngeal nerve radiology reference article. Unilateral recurrent laryngeal nerve neuropraxia following. Treatment of recurrent laryngeal nerve injury jama surgery. This nerve damage can occur as a result of the endotracheal tube cuff pressing the recurrent laryngeal nerve between the thyroid lamina and the arytenoid cartilage. Recurrent laryngeal nerve request pdf researchgate. Opsimos on recurrent laryngeal nerve injury treatment. Pdf recurrent laryngeal nerve injury secondary to blunt.
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. For the patient this means impairments of vocal fold mobility and various kinds of voice disorders. One of the branches of the vagus nerve, a long and important nerve that originates in the brain stem. Recurrent laryngeal nerve injury may result in vocal cord paralysis and hoarseness. Recurrent laryngeal nerve rln injury is an intractable complication of thyroidectomy. What you need to know about the recurrent laryngeal nerve. Bbivar vocal pathologies recurrent laryngeal nerve.
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. Recurrent laryngeal nerve injury rlni is a disabling complication of thyroid surgery. 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 1112 injury to the nerve may paralyze the posterior cricoarytenoid muscle on the same side. Recurrent nerveinjury should always alert one to the possibility of a thoracic aneurysm. The recurrent laryngeal nerves and the thoracic surgeon ctsnet. Vocal fold paresis, also known as recurrent laryngeal nerve paralysis or vocal fold paralysis, is an injury to one or both recurrent laryngeal nerves rlns, which control all muscles of the larynx except for the cricothyroid muscle. Patients with an injury to the recurrent laryngeal nerve were found to have voice alterations in all vocal. It could be caused by a tumor or mass affecting the nerve. 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. How is recurrent laryngeal nerve rln, injury following. The laryngeal nerve is a nerve branching down from the vagus nerve towards the larynx. Recurrent laryngeal nerve injury with anterior cervical spin.
The recurrent laryngeal nerve rln is vulnerable to injury in thyroid and parathyroid reoperations because of the presence of scar tissue and displacement of the nerve from its normal position. The recurrent laryngeal nerve is responsible for both abduction opening and. Functional regeneration of the transected recurrent. The rln is important for speaking, breathing and swallowing. Injury to the recurrent laryngeal nerve is one of the most severe complications of thyroid surgery. Symptoms of nerve injury include vocal cord paralysis. Anatomy of recurrent laryngeal nerve rln dent1 pbl 3.
The recurrent laryngeal nerve is susceptible to nerve injury after acdf surgery. Definition of recurrent laryngeal nerve medicinenet. Recurrent laryngeal nerve rln injury is one of the most frequent complications of anterior cervical discectomy and fusion acdf procedures. This requires indirect laryngoscopy preoperatively, and, as soon as. Also evaluated is the risk with corpectomy, reoperative procedures, and instrumentation. Any kind of neck injury can cause damage to the recurrent laryngeal nerve.
However, the two rlns are different from other nerves in that their courses are not symmetrical. Recurrent laryngeal nerve palsy rlnp is an important and potentially catastrophic complication of thyroid surgery. Recurrent laryngeal nerve injury rlni in thyroid surgery. Partial recurrent laryngeal nerve paralysis or paresis. Thyroid surgery, recurrent laryngeal rln injury, prevention, treatment introduction recurrent laryngeal nerve rln injury is a com mon severe complication in thyroid surgery 1, and unilateral rln injury is more common. The superior laryngeal nerve injury of a famous soprano. We conducted a metaanalysis to assess the incidence of nerve injuries with or without ionm. Feb 27, 2020 potential major complications of thyroid surgery include bleeding, injury to the recurrent laryngeal nerve see the first image below, hypoparathyroidism, hypothyroidism, thyrotoxic storm, injury to the superior laryngeal nerve see the second image below, and infection. The superior laryngeal nerve consists of two branches. Following the acute event, the most common presentation is hoarseness of voice. Recurrent laryngeal nerve injury is a classic and feared complication of thyroid surgery. Positive identification of the rln is essential for preservation of nerve integrity and function. Flexible laryngoscopy revealed a left vocal fold palsy. There are many causes of laryngeal nerve paresis palsy.
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. Laryngeal nerve palsy usually refers to the palsy of the recurrent largyngeal nerve. The recurrent laryngeal nerve related to thyroid surgery. The left recurrent laryngeal nerve is rela tively fixed, and contusion probablyoccurred during the time when theoverturned truck remained across. 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.
Right vocalcord paralysis after openheart operation. Causes of recurrent laryngeal nerve paralysis jama. We carried out an intraoperative study aimed to define anatomical relationships between the recurrent laryngeal nerve and the adjacent structures the inferior thyroid artery in particular, intraoperative identification of which may allow prevention of iatrogenic injuries of the laryngeal nerve. Recurrent laryngeal nerve injury in the chest is due to cardiac surgery, lung cancer, pulmonary tuberculosis. There are two recurrent laryngeal nerves, right and left. 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. The dissection of cervical paraesophageal and thoracic paratracheal lymph nodes, especially along the recurrent laryngeal nerve rln, raises the risk of injury to the rln. Because of the close anatomical relation between thyroid gland and laryngeal nerves, impairment of laryngeal function is a well known possible complication of thyroid surgery. Laryngeal reinnervation for unilateral vocal fold paralysis using ansa. Pdf metaanalysis of recurrent laryngeal nerve injury in. Partial recurrent laryngeal nerve paralysis is a diagnosis inconsistent with the spectrum of vocal fold immobility disorders that have been proposed to date. Quite a number of atheopaths have recently been using the mammalian recurrent laryngeal nerve as an argument against design. Whenever surgery is performed in the neck, there is always a possiblity of nerve damage. The presence of an nrln significantly increases the risk of iatrogenic injury and operative complications.
Studies published from january 1994 to february 2012 in english language on humans were identified. Damage to this nerve can result in a temporary or permanent palsy, which is associated with vocal. Thyroid surgery and recurrent laryngeal nerve monitoring. Anatomic considerations have been used as justification to determine the side of surgical approach. Vocal cord paresis or paralysis due to iatrogenic injury of the recurrent laryngeal nerve rlni is one of the main problems in thyroid surgery. Apr 01, 2005 read unilateral recurrent laryngeal nerve neuropraxia following placement of a proseal laryngeal mask airway in a patient with crest syndrome, acta anaesthesiologica scandinavica on deepdyve, the largest online rental service for scholarly research with thousands of academic publications available at your fingertips. You have two, one on each side, as you do with other nerves. Sep 19, 2017 introduction many thoracic surgeons are terrified to come anywhere near the recurrent laryngeal nerve rln, especially on the left side. Recurrent laryngeal nerve rln injury is a com mon severe complication in thyroid surgery 1, and unilateral rln injury is more common. Aug 17, 2016 recurrent laryngeal nerve paralysis 1. Recurrent laryngeal nerve injury in thyroid surgery ncbi. Vocal fold paralysis may be bilateral or unilateral and is typically caused by nerve involvement of the recurrent laryngeal nerve and, less commonly, the superior laryngeal nerve. Aug 29, 2019 for patients with bilateral vocal fold paralysis bvfp due to iatrogenic injury in which the recurrent laryngeal nerve rln or vagus nerve is injured neurapraxia but not severed, permanent surgical treatment should be postponed for at least 9 months after injury to allow spontaneous recovery.
Recurrent laryngeal nerve definition of recurrent laryngeal. Why does the recurrent laryngeal nerve on both sides present. Protective effects of intraoperative nerve monitoring. Vocalcord paralysis following blunttrauma to the chest may be temporary or permanent, depending upon the severity of the neural injury. Vocal cord function during recurrent laryngeal nerve injury assessed. Recurrent laryngeal nerve injury causes and surgery.
The presence or absence of dysphonia is not a reliable predictor of vocalcord function in the preoperative setting. Incidence and risk factors for injuries to the recurrent. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. All subjects experienced postoperative improvements in voice quality. Whiplash puts excessive stress on the neck and this can also lead to recurrent laryngeal nerve damage. Routine exposure of recurrent laryngeal nerve in thyroid surgery can. 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. Recurrent laryngeal nerve rln injury is a common severe complication in thyroid surgery 1, and unilateral rln injury is more common. 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.
Recurrent laryngeal and superior laryngeal nerve injuries. Partial paralysis for most authors is identical to paresis, meaning that all muscles innervated by the iln are equally or almost affected. Recurrent laryngeal nerve injury causes and surgery lecturio. Recurrent laryngeal and superior laryngeal nerve injuries recurrent laryngeal nerve injury may result in vocal cord paralysis and hoarseness.
Injury to the recurrent laryngeal nerve rln is an unwelcome and not unfrequent complication of operations on or near the upper thoracic or cervical esophagus. Recurrent laryngeal nerve paralysis after esophagectomy. Recovery of laryngeal function after intraoperative injury. The reason for this fear is the dreaded complication of damaging the nerve and causing loss of voice, among other serious complications. Recurrent laryngeal nerve rln injury is rarely seen following trauma. Injury rates have been slowly decreasing in this period while effective treatment strategies have been increasing. Bilateral injuries can cause dyspnea and even suffocation.
Intraoperative nerve monitoring ionm was designed to prevent rln injury. The site, cause, and circumstance of nerve injury were elucidated with the application of lnm. Incidence of injury has been reported to be between 0. Risk factors for recurrent laryngeal nerve rln lesions after thyroid gland surgery were evaluated retrospectively in 1026 patients.
Identification and preservation of the recurrent laryngeal nerve rln is of major concern in surgery of the thyroid gland. Laryngeal nerve damage is injury to one or both of the nerves that are attached to the voice box. Furthermore, the uncertain prognosis stresses a lack of capability to diagnose the reason behind the impaired function. Iatrogenic injury of the recurrent laryngeal nerve is doubtless one of the main problems in thyroid surgery. Electrophysiologic recurrent laryngeal nerve monitoring. Recurrent laryngeal nerve rln damage because of thyroid and parathyroid surgery has been recognized for over a century. Recovery of laryngeal function after intraoperative injury to. English italian metaanalysis of recurrent laryngeal nerve injury in thyroid surgery with or without intraoperative nerve monitoring metaanalisi del danno dei nervi ricorrenti nella chirurgia tiroidea con o senza monitoraggio nervoso intraoperatorio. Injury can be due to surgery, trauma, bacterial or viral infection, neurotoxic drugs, and tumors. The vocal cord assumes a median or paramedian position. Injuries such as breaks, fractures and twisted necks will put strain on the area which can, in turn, affect bones, muscles, soft tissue and nerves. In this study, we established a new drug delivery system consisting of a tube of healall oral. 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 palsy complicating subclavian line.
Recurrent laryngeal nerve palsy after thyroid gland. 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 recurrent laryngeal nerve rln branches off the vagus nerve and supplies function to some muscles of the larynx voice box. Jul 12, 2019 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. Recurrent laryngeal nerve rln injury is considered to be the most severe complication in thyroid surgery. Because anatomic information useful to the surgeon is dif. Intraoperative nerve monitoring ionm aimed at reducing the injuries of recurrent laryngeal nerve during thyroidectomy is controversial. Isolated vocalcord paralysis following blunt trauma to. Recovery of laryngeal function after intraoperative injury to the recurrent laryngeal nerve 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. 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 returnin. The location and type of the injury along the nerve pathway will determine the type of paralysis and the resultant voice quality. Original article prevention and treatment of recurrent.
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