Recurrent laryngeal nerve injury in thyroid surgery. 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. Aug 17, 2016 recurrent laryngeal nerve paralysis 1. The vocal cord assumes a median or paramedian position. Pdf recurrent laryngeal nerve injury during thyroid surgery. 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 radiology reference article. Pdf metaanalysis of recurrent laryngeal nerve injury in. Recurrent laryngeal nerve rln injury is a feared complication after thyroid and parathyroid surgery. 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. What causes injury to the vagus nerve or the recurrent. A novel variation of the recurrent laryngeal nerve bmc surgery. Recurrent laryngeal nerve rln injury during surgery may reveal differences in electromyographic emg changes after sustained compression or traction. Prevention and treatment of recurrent laryngeal nerve injury in. Positive identification of the rln is essential for preservation of nerve integrity and function. Recurrent laryngeal nerve injury produces an abductor laryngeal paralysis. Accurate diagnosis can be made only by visualizing the vocal cords while the patient is awake.
Anatomy of recurrent laryngeal nerveanatomy of recurrent. Recurrent laryngeal nerve paralysis after esophagectomy. Recurrent laryngeal nerve injury is a classic and feared complication of thyroid surgery. 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. Cas e 3 brai n ste m arteriovenou s malfonnatio n an d hig h lef t vagu s nerv e injury. The most common cause is after surgery thyroid surgery, neck surgery or cardiac surgery.
This applica tion has great significance in prevention of bilateral vocal cord paralysis given the bilateral nature of the typical thyroid procedure. Whiplash puts excessive stress on the neck and this can also lead to recurrent laryngeal nerve damage. The laryngeal nerve is a nerve branching down from the vagus nerve towards the larynx. We conducted a metaanalysis to assess the incidence of nerve injuries with or without ionm. 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. Iatrogenic injury of the recurrent laryngeal nerve is doubtless one of the main problems in thyroid surgery. Partial recurrent laryngeal nerve paralysis is a diagnosis inconsistent with the spectrum of vocal fold immobility disorders that have been proposed to date. Intraoperative neuromonitoring versus visual nerve. Recurrent laryngeal nerve request pdf researchgate. Recurrent laryngeal nerve paralysis rlnp is a common and sometimes severe complication after esophagectomy. Its peculiar route results from evolutionary lengthening of the neck. Recurrent laryngeal nerve the recurrent laryngeal nerve is a myelinated nerve. Studies published from january 1994 to february 2012 in english language on humans were identified. Routine preoperative and postoperative laryngoscopy has been advocated by some experts, but remains controversial. Surgical procedures of the head and neck can also lead to nerve injury. Any kind of neck injury can cause damage to the recurrent laryngeal nerve. 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.
Metaanalysis of recurrent laryngeal nerve injury in. Partial paralysis for most authors is identical to paresis, meaning that all muscles innervated by the iln are equally or almost affected. Improving voice outcomes after injury to the recurrent laryngeal. Ducharme, jon cheetham, in equine sports medicine and surgery second edition, 2014. Recurrent laryngeal nerve rln injury is an intractable complication of thyroidectomy. What you need to know about the recurrent laryngeal nerve. Recurrent nerveinjury should always alert one to the possibility of a thoracic aneurysm. 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. Right vocalcord paralysis after openheart operation.
Malignant neoplasms of the lung and pulmonary tuberculosis were the most frequent causes of the paralysis. Incidence and risk factors for injuries to the recurrent. The site, cause, and circumstance of nerve injury were elucidated with the application of lnm. Bbivar vocal pathologies recurrent laryngeal nerve. 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. Pdf incidence of recurrent laryngeal nerve injury in. This requires indirect laryngoscopy preoperatively, and, as soon as. Pdf recurrent laryngeal nerve injury secondary to blunt. Recurrent laryngeal nerve definition of recurrent laryngeal. Opsimos on recurrent laryngeal nerve injury treatment.
Relationship of the recurrent laryngeal nerve rln to the left and right inferior thyroid arteries. Whenever surgery is performed in the neck, there is always a possiblity of nerve damage. Recurrent laryngeal nerve injury in thyroid surgery ncbi. Metaanalysis of recurrent laryngeal nerve injury in thyroid. Original article prevention and treatment of recurrent laryngeal. Symptoms of nerve injury include vocal cord paralysis. Partial recurrent laryngeal nerve paralysis or paresis. 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. Recurrent laryngeal nerve injury with anterior cervical spin. 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. Intraoperative nerve monitoring ionm aimed at reducing the injuries of recurrent laryngeal nerve during thyroidectomy is controversial. Recurrent laryngeal and superior laryngeal nerve injuries. Overall incidence of transient rlnp is reported to be 0.
Iatrogenic recurrent laryngeal nerve rln injury is a rare but well recognized and dreaded complication of thyroid or parathyroid surgery. Flexible laryngoscopy revealed a left vocal fold palsy. The frequency of rln is reported as 1%11% in the literature. 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. Also evaluated is the risk with corpectomy, reoperative procedures, and instrumentation. 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. Bilateral injuries can cause dyspnea and even suffocation. Recurrent laryngeal nerve injury causes and surgery lecturio. 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. The superior laryngeal nerve injury of a famous soprano. With the increase of awareness and the improvement of surgical techniques, the incidence of rln injury has declined about 0. The presence or absence of dysphonia is not a reliable predictor of vocalcord function in the preoperative setting. Laryngeal reinnervation for unilateral vocal fold paralysis using ansa cervicalis nerve to recurrent laryngeal nerve anastomosis.
Recovery of laryngeal function after intraoperative injury to. 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 rln injury is rarely seen following trauma. The present study aimed to assess the incidence of transientpermanent postoperative rln injuries after. 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. The reason for this fear is the dreaded complication of damaging the nerve and causing loss of voice, among other serious complications. Injury can be due to surgery, trauma, bacterial or viral infection, neurotoxic drugs, and tumors.
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. Following the acute event, the most common presentation is hoarseness of voice. 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. Anatomy of recurrent laryngeal nerve rln dent1 pbl 3. Injury to the recurrent laryngeal nerve is one of the most severe complications of thyroid surgery. Recurrent laryngeal nerve injury causes and surgery. Treatment of recurrent laryngeal nerve injury jama. 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. The recurrent laryngeal nerve is susceptible to nerve injury after acdf 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. All other intrinsic laryngeal muscles are innervated by the recurrent laryngeal nerve. 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. 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.
The recurrent laryngeal nerve rln branches off the vagus nerve and supplies function to some muscles of the larynx voice box. 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. You have two, one on each side, as you do with other nerves. Vocal cord function during recurrent laryngeal nerve injury assessed. Risk factors for recurrent laryngeal nerve rln lesions after thyroid gland surgery were evaluated retrospectively in 1026 patients. 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. 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. However, the two rlns are different from other nerves in that their courses are not symmetrical.
Vocalcord paralysis following blunttrauma to the chest may be temporary or permanent, depending upon the severity of the neural injury. Our experience of rln monitoring, even in this preliminary report, was convincing. Laryngeal nerve injuries were classified into type 1 injury segmental and 2 diffuse. Electrophysiologic recurrent laryngeal nerve monitoring.
Original article prevention and treatment of recurrent. Recurrent laryngeal nerve injury rlni in thyroid surgery. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. 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. Injury rates have been slowly decreasing in this period while effective treatment strategies have been increasing. Routine exposure of recurrent laryngeal nerve in thyroid surgery can. Recurrent laryngeal nerve rln injury is considered to be the most severe complication in thyroid surgery. Laryngeal reinnervation for unilateral vocal fold paralysis using ansa. Quite a number of atheopaths have recently been using the mammalian recurrent laryngeal nerve as an argument against design. All subjects experienced postoperative improvements in voice quality. The postulated mechanism of injury in the present case was compression of the tracheal bifurcation, mediastinal vasculature, and recurrent laryngeal nerve between the flexible anterior wall and the fixed posterior wall of the chest at the time of the accident. Protective effects of intraoperative nerve monitoring. Recurrent laryngeal nerve injury may result in vocal cord paralysis and hoarseness. Patients with an injury to the recurrent laryngeal nerve were found to have voice alterations in all vocal.
The left recurrent laryngeal nerve is rela tively fixed, and contusion probablyoccurred during the time when theoverturned truck remained across. 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. How is recurrent laryngeal nerve rln, injury following. The superior laryngeal nerve consists of two branches. Recurrent laryngeal nerve palsy after thyroid gland. 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. 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. 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. 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. There are two recurrent laryngeal nerves, right and left. Isolated vocalcord paralysis following blunt trauma to. Thyroid surgery and recurrent laryngeal nerve monitoring. 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.
The rln is important for speaking, breathing and swallowing. One of the branches of the vagus nerve, a long and important nerve that originates in the brain stem. Sep 19, 2017 introduction many thoracic surgeons are terrified to come anywhere near the recurrent laryngeal nerve rln, especially on the left side. Background the non recurrent laryngeal nerve nrln is a rare embryologicallyderived variant of the recurrent laryngeal nerve rln. Recurrent laryngeal nerve rln damage because of thyroid and parathyroid surgery has been recognized for over a century. The recurrent laryngeal nerves and the thoracic surgeon ctsnet. Incidence of injury has been reported to be between 0. Management of unilateral recurrent laryngeal nerve injury. Laryngeal nerve palsy or paralysis anatomy, physiology. Recurrent laryngeal and superior laryngeal nerve injuries recurrent laryngeal nerve injury may result in vocal cord paralysis and hoarseness. Recurrent laryngeal nerve injury treatment answers on healthtap. The recurrent laryngeal nerve related to thyroid surgery. 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.
Recurrent laryngeal nerve injury following reoperative. Treatment of recurrent laryngeal nerve injury jama surgery. Intraoperative nerve monitoring ionm was designed to prevent rln injury. Rov et at, laryngeal features of external superior laryngeal nerve denervation fi g 3. The location and type of the injury along the nerve pathway will determine the type of paralysis and the resultant voice quality. Injury mechanisms and electromyographic changes after. 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. 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.
Recurrent laryngeal nerve an overview sciencedirect topics. Doctors help you with trusted information about nerve injury in nerve damage. It could be caused by a tumor or mass affecting the nerve. Objectivesto study the incidence of recurrent laryngeal nerve rln palsy in total thyroidectomy done for multinodular goitre. Because anatomic information useful to the surgeon is dif. 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 palsy complicating subclavian line. Recurrent laryngeal nerve injury after thyroid and. 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. 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. 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.
Surgical safety of total thyroidectomy in multinodular goitre and type of vocal cord paralysisstudied. What are the signs and symptoms of recurrent laryngeal. 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. 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. Surgeonperformed laryngeal ultrasound can be used to screen. Functional regeneration of the transected recurrent. Why does the recurrent laryngeal nerve on both sides present. Unilateral recurrent laryngeal nerve neuropraxia following. Anatomic considerations have been used as justification to determine the side of surgical approach.
Recurrent laryngeal nerve injury in the chest is due to cardiac surgery, lung cancer, pulmonary tuberculosis. Injury to the recurrent laryngeal nerve is accompanied by a poor functional recovery of the target organ, the larynx. Recurrent laryngeal nerve rln injury is one of the most frequent complications of anterior cervical discectomy and fusion acdf procedures. Injuries to the recurrent inferior laryngeal nerve riln remain one of the major post. 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. 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 rln injury is a common severe complication in thyroid surgery 1, and unilateral rln injury is more common. Recurrent laryngeal nerve injury rlni is a disabling complication of thyroid surgery. The various causes of recurrent laryngeal nerve paralysis that i have observed during the past 24 years are reported. Dysfunctions of the recurrent laryngeal nerve rln manifested as nerve paralysis are among the most spectacular, cumbersome and quality of.
Furthermore, the uncertain prognosis stresses a lack of capability to diagnose the reason behind the impaired function. A 63yearold man presented with acute dysphonia immediately after insertion of a hickman line via the subclavian route. 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. Definition of recurrent laryngeal nerve medicinenet. The presence of an nrln significantly increases the risk of iatrogenic injury and operative complications. Recurrent laryngeal nerve rln injury remains a challenge due to the lack of effective treatments. Damage to this nerve can result in a temporary or permanent palsy, which is associated with vocal.
Therefore, preventing recurrent laryngeal nerve injury is an important goal in thyroid surgery. The role of intraoperative neuromonitoring of recurrent laryngeal nerve during thyroidectomy. For the patient this means impairments of vocal fold mobility and various kinds of voice disorders. The recurrent laryngeal nerve is responsible for both abduction opening and. Vocal cord paresis or paralysis due to iatrogenic injury of the recurrent laryngeal nerve rlni is one of the main problems in thyroid surgery. In 4 patients with recurrent laryngeal nerve paralysis, the left recurrent nerve was most commonly involved. Recurrent laryngeal nerve rln injury is a com mon severe complication in thyroid surgery 1, and unilateral rln injury is more common. Causes of recurrent laryngeal nerve paralysis jama. 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. Pdf laryngeal features of external superior laryngeal. In this study, we established a new drug delivery system consisting of a tube of healall oral. There are many causes of laryngeal nerve paresis palsy.
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