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Kumar P, Chatterjee M, Gupta A. Variations in Recurrent Laryngeal Nerve in Thyroidectomy. Indian J Otolaryngol Head Neck Surg 2023; 75:2856-2861. [PMID: 37974693 PMCID: PMC10645854 DOI: 10.1007/s12070-023-03859-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/04/2023] [Indexed: 11/19/2023] Open
Abstract
The aim of this study was to identify and evaluate variations in anatomy and the course of Recurrent. Laryngeal nerve (RLN) with respect to various landmarks. A retrospective study was conducted in the department of ENT and head and neck surgery in our institute including 52 eu-thyroid cases who had undergone primary thyroid surgery over a period of 1 year. 48 cases underwent hemi-thyroidectomy and 4 had total thyroidectomy. During the surgery the anatomy and relationship to surrounding structures of the RLN that were observed were recorded and compiled among the 56 sides that were operated on, RLN was identified as a single trunk in 47 cases (83.9%). The nerve showed extra-laryngeal branches in 6 cases (10.7%) while 3 cases were found to have degenerated RLN. None of the cases were found with a non-recurrent laryngeal nerve. With respect to inferior thyroid artery (ITA), 82% cases had the nerve passing deep to it and in the rest 18% the nerve passed anterior to the artery. While in none of the cases the nerve passed in between the branches of the artery. With respect to the tracheo-esophageal groove, RLN was found within the groove in 44 cases, while in 12 cases RLN was located lateral to the trachea-oesophageal groove. In the current study, variations in the anatomy of RLN was found less frequently, owing to the comparatively small sample size. The ITA and trachea-esophageal groove were both found as reliable landmarks for tracking the RLN.
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Affiliation(s)
- Pankaj Kumar
- Dept. of ENT, Head and Neck surgery, Dr. Baba Saheb Ambedkar Medical College and Hospital, Bhagwan Mahavir Marg, Sector 6, Rohini, Delhi India
| | - Moudipa Chatterjee
- Dept. of ENT, Head and Neck surgery, Dr. Baba Saheb Ambedkar Medical College and Hospital, Bhagwan Mahavir Marg, Sector 6, Rohini, Delhi India
| | - Ajay Gupta
- Dept. of ENT, Head and Neck surgery, Dr. Baba Saheb Ambedkar Medical College and Hospital, Bhagwan Mahavir Marg, Sector 6, Rohini, Delhi India
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Caceres C, Parham K. Giant Parathyroid Adenoma Associated With Aberrant Subclavian Artery and Nonrecurrent Laryngeal Nerve. EAR, NOSE & THROAT JOURNAL 2023; 102:504-506. [PMID: 34044628 DOI: 10.1177/01455613211020959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Parathyroid adenomas are responsible for 80% to 85% of cases of primary hyperparathyroidism. Giant parathyroid adenomas are a rare type of parathyroid adenoma defined as weighing >3.5 grams. Although giant parathyroid adenomas are rare entities whose clinical presentation may not be atypical, their surgical management can be challenging, especially in the setting of anatomical variants. We present here a case of a 29-year-old female with a 37-gram giant adenoma which was diagnosed after presentation with recurrent severe headaches. The presentation was also unique in that it was associated with a right aberrant subclavian artery and nonrecurrent laryngeal nerve.
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Affiliation(s)
| | - Kourosh Parham
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, UConn Health, Outpatient Pavilion, Farmington, CT, USA
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Kihara M, Miyauchi A, Fujishima M, Ishizaka T, Matsunaga A, Kawano S, Yamamoto M, Sasaki T, Masuoka H, Higashiyama T, Ito Y, Onoda N, Miya A, Akamizu T. Recurrent laryngeal nerve's course running anteriorly to a thyroid tumor. Thyroid Res 2023; 16:30. [PMID: 37475049 DOI: 10.1186/s13044-023-00172-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 07/10/2023] [Indexed: 07/22/2023] Open
Abstract
The thyroid gland's neurovascular relationship is commonly portrayed as the recurrent laryngeal nerve (RLN) coursing posteriorly to the thyroid gland. We report a rare case with the RLN running anteriorly to a thyroid tumor. A 56-year-old Japanese woman underwent a thyroidectomy for a benign thyroid tumor. Preoperatively, computed tomography confirmed that part of the tumor had extended into the mediastinum and was descending posteriorly up to the brachiocephalic artery. Intraoperatively, when the sternothyroid muscle was incised to expose the thyroid gland, a cord (nerve)-like structure was observed directly anterior to the thyroid tumor. Although the course of this cord-like structure was clearly different from the "traditional" course of the right RLN, the possibility that the structure was the RLN could not be excluded. The structure was traced back in order to preserve it; we saw that it entered the larynx at the lower margin of the cricothyroid muscle and approximately at the level of the cricothyroid junction through the back of the normal thyroid tissue. With intraoperative neuromonitoring, the structure was identified as the RLN. As a result, the course of the RLN run anterior to the tumor but then posterior to the 'normal thyroid' i.e. into it normal anatomical position. Had we assumed that the RLN was behind the thyroid tumor, we would have damaged the RLN. It would not be possible to diagnose this abnormal running course of the RLN reliably before surgery, but extra care should be taken in similar cases, that is, when a large thyroid tumor is descending posteriorly up to the brachiocephalic artery on the right side.
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Affiliation(s)
- Minoru Kihara
- Department of Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan.
| | - Akira Miyauchi
- Department of Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
| | - Makoto Fujishima
- Department of Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
| | - Tomo Ishizaka
- Department of Head and Neck Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
| | - Akihide Matsunaga
- Department of Head and Neck Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
| | - Shiori Kawano
- Department of Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
| | - Masashi Yamamoto
- Department of Head and Neck Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
| | - Takahiro Sasaki
- Department of Head and Neck Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
| | - Hiroo Masuoka
- Department of Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
| | - Takuya Higashiyama
- Department of Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
| | - Yasuhiro Ito
- Department of Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
| | - Naoyoshi Onoda
- Department of Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
| | - Akihiro Miya
- Department of Surgery Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
| | - Takashi Akamizu
- Department of Internal Medicine, Kuma Hospital, 8-2-35 Shimoyamate-Dori, Chuo-Ku, Kobe, Hyogo, 650-0011, Japan
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Valenzuela-Fuenzalida JJ, Baeza-Garrido V, Navia-Ramírez MF, Cariseo-Ávila C, Bruna-Mejías A, Becerra-Farfan Á, Lopez E, Orellana Donoso M, Loyola-Sepulveda W. Systematic Review and Meta-Analysis: Recurrent Laryngeal Nerve Variants and Their Implication in Surgery and Neck Pathologies, Using the Anatomical Quality Assurance (AQUA) Checklist. Life (Basel) 2023; 13:life13051077. [PMID: 37240722 DOI: 10.3390/life13051077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION The recurrent laryngeal nerve (RLN) is the structure responsible for sensory and motor innervation of the larynx, and it has been shown that its lesion due to a lack of surgical rigor led to alterations such as respiratory obstruction due to vocal cords paralysis and permanent phonation impairment. The objectives of this review were to know the variants of the RLN and its clinical relevance in the neck region. METHODS This review considered specific scientific articles that were written in Spanish or English and published between 1960 and 2022. A systematic search was carried out in the electronic databases MEDLINE, WOS, CINAHL, SCOPUS, SCIELO, and Latin American and Caribbean Center for Information on Health Sciences to compile the available literature on the subject to be treated and was enrolled in PROSPERO. The included articles were studies that had a sample of RLN dissections or imaging, intervention group to look for RLN variants, or the comparison of the non-recurrent laryngeal nerve (NRLN) variants, and finally, its clinical correlations. Review articles and letters to the editor were excluded. All included articles were evaluated through quality assessment and risk of bias analysis using the methodological quality assurance tool for anatomical studies (AQUA). The extracted data in the meta-analysis were interpreted to calculate the prevalence of the RLN variants and their comparison and the relationship between the RLN and NRLN. The heterogeneity degree between included studies was assessed. RESULTS The included studies that showed variants of the RLN included in this review were 41, a total of 29,218. For the statistical analysis of the prevalence of the RLN variant, a forest plot was performed with 15 studies that met the condition of having a prevalence of less than 100%. As a result, the prevalence was shown to be 12% (95% CI, SD 0.11 to 0.14). Limitations that were present in this review were the publication bias of the included studies, the probability of not having carried out the most sensitive and specific search, and finally, the authors' personal inclinations in selecting the articles. DISCUSSION This meta-analysis can be considered based on an update of the prevalence of RLN variants, in addition to considering that the results show some clinical correlations such as intra-surgical complications and with some pathologies and aspects function of the vocal cords, which could be a guideline in management prior to surgery or of interest for the diagnostic.
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Affiliation(s)
- Juan José Valenzuela-Fuenzalida
- Department of Morphology and Function, Faculty of Health Sciences, Universidad de las Américas, Santiago 8370040, Chile
- Departamento de Morfología, Facultad de Medicina, Universidad Andrés Bello, Santiago 8370186, Chile
| | - Vicente Baeza-Garrido
- Departamento de Morfología, Facultad de Medicina, Universidad Andrés Bello, Santiago 8370186, Chile
| | | | - Carolina Cariseo-Ávila
- Departamento de Morfología, Facultad de Medicina, Universidad Andrés Bello, Santiago 8370186, Chile
| | - Alejandro Bruna-Mejías
- Departamento de Ciencias y Geografía, Facultad de Ciencias Naturales y Exactas, Universidad de Playa Ancha, Valparaíso 2360072, Chile
| | - Álvaro Becerra-Farfan
- Departamento de Ciencias Química y Biológicas, Facultad de Ciencias de la Salud, Universidad Bernardo O'Higgins, Santiago 8370874, Chile
| | - Esteban Lopez
- Department of Morphology and Function, Faculty of Health Sciences, Universidad de las Américas, Santiago 8370040, Chile
| | | | - Walter Loyola-Sepulveda
- Kinesiology School, Faculty of Health Sciences, Universidad de las Américas, Santiago 8370040, Chile
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Harsha MP, Padha K. A New Anatomical Variation and Course of RLN Described: A Rare Case Report of a Lateral and Superiorly Placed Bilateral RLN Over the Thyrohyoid Muscle. Indian J Otolaryngol Head Neck Surg 2022; 74:6216-6218. [PMID: 36742822 PMCID: PMC9895504 DOI: 10.1007/s12070-021-02917-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/02/2021] [Indexed: 02/07/2023] Open
Abstract
Ling XY described 3 variations of RLN in relation to Inferior thyroid artery (ITA), with the RLN either being anterior to ITA, in between the branches of ITA or posterior to ITA. We add to these variations and present a new anatomical variation and course of RLN in which it lies in a lateral position and descends from a superior position on the thyrohyoid muscle to enter the larynx medially.
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Left Nonrecurrent Laryngeal Nerve: A Very Unusual Finding during Thyroid Surgery. Case Rep Surg 2022; 2022:4632501. [PMID: 35341078 PMCID: PMC8942699 DOI: 10.1155/2022/4632501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 02/22/2022] [Indexed: 12/05/2022] Open
Abstract
Background Identifying the inferior laryngeal nerve is one of the main concerns in thyroid surgery. The typical recurrent position occurs due the relative position between the vagus nerve and the larynx during the last 3 branchial arches development. In rare cases, this nerve does not loop under the right subclavian artery or the aortic arch. This abnormality is present in 0.7% of patients and is associated with the presence of anatomical vascular anomalies. The left non-recurrent inferior laryngeal nerve is an even rarer abnormality, with only six cases described in the literature to date. Method A 46- years old female patient referred to total thyroidectomy for symptomatic multinodular benign goiter. Results A left non-recurrent inferior laryngeal nerve was found with difficulty and then a partial thyroidectomy was performed. CT scan showed dextroposition of the vessels of the base of the heart and an aberrant left subclavian artery. Conclusion An association of a right-sided aortic arch and aberrant left subclavian artery, or the presence of situs inversus, although rare anatomical variations, are associated to a non-recurrent inferior left laryngeal nerve. Proper identifying these abnormalities may help to properly identify and salvage this structure.
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Harcourt-Brown TR, Carter M. Implantable vagus nerve stimulator settings and short-term adverse effects in epileptic dogs. J Vet Intern Med 2021; 35:2350-2358. [PMID: 34472639 PMCID: PMC8478022 DOI: 10.1111/jvim.16226] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 07/02/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Implantable vagus nerve stimulation (VNS) devices can be used to treat epilepsy in dogs. Adverse effects and short-term complications associated with delivering suggested therapeutic electrical stimulation (>1.5 mA) are not well-described. OBJECTIVES To compare complications and adverse effects observed with standard and rapid protocols of current increase. ANIMALS Sixteen client-owned dogs with idiopathic epilepsy. METHODS Nonrandomized, nonblinded prospective cohort study. Surgical complications, stimulation-related adverse effects, modifications to stimulator settings, number of hospital visits, and time to reach 1.5 mA stimulation current without intolerable adverse effects were described in dogs receiving current increases every 1 to 3 weeks (slow ramping) and dogs receiving current increases every 8 to 12 hours (fast ramping). RESULTS Self-resolving surgery site seromas formed in 6 dogs. No other surgical complications were observed. Fourteen dogs reached 1.5 mA. Coughing (11/14 dogs; 5 slow, 6 fast ramping) was the most common adverse effect. Intolerable coughing that limited current increases despite changing other stimulus parameters occurred in 6/7 of the fast-ramping group and in none of the slow-ramping group. Median time to 1.5 mA was 72 days (range, 28-98) in the slow-ramping group and 77 days (range, 3-152) in the fast-ramping group. Median number of clinic visits was 6 for the slow-ramping group (range, 5-6) and 3 for the fast-ramping group (range, 1-7). CONCLUSIONS AND CLINICAL IMPORTANCE Coughing is a common adverse effect of VNS in dogs and generally is well tolerated, particularly if current is increased slowly and other stimulation parameters are adapted for effect.
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Affiliation(s)
| | - Michael Carter
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Akiyama T, Tanaka S, Hitotsumatsu T. Carotid Endarterectomy for a Patient with a Right-sided Aortic Arch and Aberrant Left Subclavian Artery Predicting a Left Non-recurrent Inferior Laryngeal Nerve: A Case Report and Literature Review. NMC Case Rep J 2021; 8:45-50. [PMID: 34012748 PMCID: PMC8116918 DOI: 10.2176/nmccrj.cr.2019-0283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/01/2020] [Indexed: 11/20/2022] Open
Abstract
Cardiovascular malformations during embryogenesis can lead the inferior laryngeal nerve to branching directly from the cervical vagus nerve and entering the larynx. This rare anatomical variation is known as a non-recurrent inferior laryngeal nerve (NRILN), and increases the risk of accidental injury resulting in postoperative vocal cord paralysis during neck surgery. We report a case of an 83-year-old man who presented with left symptomatic internal carotid artery stenosis with a right-sided aortic arch and aberrant left subclavian artery (ALSCA). We performed carotid endarterectomy (CEA) using intraoperative neuromonitoring to avoid NRILN injury. To the best of our knowledge, this is the first report of searching for a left NRILN by electrophysiology during CEA. Neurovascular surgeons need to understand the variations of the NRILN associated with congenital cardiovascular anomalies and effective use of intraoperative nerve monitoring (IONM). We discuss the embryological origin, IONM, and surgical pitfalls of this case.
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Affiliation(s)
- Tomoaki Akiyama
- Department of Neurosurgery, Stroke and Neurological Center, Shin-Koga Hospital, Kurume, Fukuoka, Japan
| | - Shunya Tanaka
- Department of Neurosurgery, Stroke and Neurological Center, Shin-Koga Hospital, Kurume, Fukuoka, Japan
| | - Tsutomu Hitotsumatsu
- Department of Neurosurgery, Stroke and Neurological Center, Shin-Koga Hospital, Kurume, Fukuoka, Japan
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Gowd AK, Vahidi NA, Magdycz WP, Zollinger PL, Carmouche JJ. Correlation of Voice Hoarseness and Vocal Cord Palsy: A Prospective Assessment of Recurrent Laryngeal Nerve Injury Following Anterior Cervical Discectomy and Fusion. Int J Spine Surg 2021; 15:12-17. [PMID: 33900952 DOI: 10.14444/8001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Injury to the recurrent laryngeal nerve (RLN) has been implicated as a common complication following anterior cervical discectomy and fusion (ACDF) surgery. The purpose of this study is to determine the true incidence of voice hoarseness and RLN palsy following ACDF surgery, to determine the reliability of symptoms in the diagnosis of RLN injury, and to evaluate factors related to the development of these symptoms. METHODS All patients undergoing elective (primary or secondary) ACDF surgery at a single institution consented to and enrolled in the present study. All approaches were through the left side. Enrolled patients received both preoperative and postoperative (within 1 month following surgery) laryngoscopy by a fellowship-trained ENT physician for evaluation of RLN function. Patients also responded as to whether they were experiencing postoperative symptoms of dysphagia, aspiration, and voice changes. RESULTS In total, 108 patients were included in this study. Mean age of the population was 59.2 ± 10.7 years and mean body mass index was 31.2 ± 7.1 kg/m2. Three patients had previously undergone a thyroidectomy, whereas 20 patients had undergone a previous ACDF. Average intubation time for ACDF surgery was 121.6 ± 38.5 minutes. After surgery and excluding patients who were experiencing preoperative symptoms, 19 patients (20.4%) complained of dysphagia, 2 patients (1.9%) complained of aspiration symptoms, and 5 patients (4.6%) complained of voice hoarseness. There was no incidence of vocal cord palsy from postoperative laryngoscopy. From multivariate analysis, endotracheal cuff pressure after retractor placement was correlated to postoperative voice hoarseness, dysphagia, and aspiration symptoms. CONCLUSIONS From the results of this prospective study, the RLN remained functional even a month after surgery despite several cases of postoperative dysphagia, aspiration, and voice changes. Endotracheal cuff pressure, number of vertebral levels, body mass index, and intubation time were important variables related to postoperative symptoms. CLINICAL RELEVANCE Voice hoarseness does not necessarily indicate recurrent laryngeal nerve injury after ACDF but may be caused by compressive forces on laryngeal tissue during retraction or intubation. Laryngoscopy should be performed in cases with high clinical suspicion. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - Nima A Vahidi
- Department of Orthopaedic Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - William P Magdycz
- Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Pamela L Zollinger
- Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Jonathan J Carmouche
- Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
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Labuschagne JJ, Hammer N. Intra-Operative Detection of a Left-Sided Non-Recurrent Laryngeal Nerve during Vagus Nerve Stimulator Implantation. MEDICINA-LITHUANIA 2020; 56:medicina56100489. [PMID: 32977517 PMCID: PMC7598250 DOI: 10.3390/medicina56100489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 11/17/2022]
Abstract
Left sided non-recurrent laryngeal nerves (NRLN) are very rarely observed during surgery in the head and neck region. Arising directly from the cervical aspect of the vagus nerve, the NRLN lies in a vulnerable position distant from its normal location. NRLNs are normally associated with embryological branchial arch aberrations and subsequent vascular anomalies. The anomalous course of the NRLN makes it more susceptible to injury during surgery in the neck region. Knowledge of this anatomical variant will reduce the potential for injury and resultant vocal cord paralysis. During microsurgical dissection of the carotid sheath for the implantation of a vagus nerve stimulator in a 19-year-old female patient with refractory epilepsy, a moderate-sized branch of the main vagus nerve trunk was identified postero-medially within the carotid sheath. Intra-operative stimulation of this nerve resulted in a compound muscle evoked potential from the left vocal cord. Thus, this branch was confirmed to be a left-sided NRLN. The patient had no associated vascular anomalies. This is first reported case of a left-sided NRLN found during VNS insertion. Awareness of the possibility of an NRLN is imperative to prevent iatrogenic injury. A medial location of the vagus nerve within the carotid sheath should alert the surgeon to the possible presence of an NRLN. The absence of fourth branchial arch remnant anomalies is not a guarantee as to the absence of a left-sided NRLN. The addition of intra-operative nerve monitoring for vagus nerve stimulator (VNS) implantation procedures should be strongly considered to help avoid iatrogenic injury.
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Affiliation(s)
- Jason John Labuschagne
- Netcare Unitas Hospital, Centurion 0140, South Africa
- Department of Neurosurgery, University of Witwatersrand, Johannesburg 2193, South Africa
- Department of Pediatric Neurosurgery, Nelson Mandela Children’s Hospital, Johannesburg 2193, South Africa
- Correspondence: (J.J.L.); or (N.H.); Tel.: +43-316-38571100 (N.H.)
| | - Niels Hammer
- Department of Macroscopic and Clinical Anatomy, Medical University of Graz, 8010 Graz, Austria
- Department of Trauma, Orthopedic and Plastic Surgery, University Hospital of Leipzig, 04109 Leipzig, Germany
- Fraunhofer Institute for Machine Tools and Forming Technology, 01187 Dresden, Germany
- Correspondence: (J.J.L.); or (N.H.); Tel.: +43-316-38571100 (N.H.)
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Lower cranial nerve syndromes: a review. Neurosurg Rev 2020; 44:1345-1355. [PMID: 32638140 DOI: 10.1007/s10143-020-01344-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 06/09/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
The purpose of this paper is to provide a comprehensive review encompassing the syndromes associated with the lower cranial nerves (LCNs). We will discuss the anatomy of some of these syndromes and the historical contributors after whom they were named. The LCNs can be affected individually or in combination, since the cranial nerves at this level share their courses through the jugular foramen and hypoglossal canal and the extracranial spaces. Numerous alterations affecting them have been described in the literature, but much remains to be discovered on this topic. This paper will highlight some of the subtle differences among these syndromes. Symptoms and signs that have localization value for LCN lesions include impaired speech, deglutition, sensory functions, alterations in taste, autonomic dysfunction, neuralgic pain, dysphagia, head or neck pain, cardiac or gastrointestinal compromise, and weakness of the tongue, trapezius, or sternocleidomastoid muscles. To assess the manifestations of LCN lesions correctly, precise knowledge of the anatomy and physiology of the area is required. Treatments currently used for these conditions will also be addressed here. Effective treatments are available in several such cases, but a precondition for complete recovery is a correct and swift diagnosis.
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Lawlor CM, Zendejas B, Baird C, Munoz-San Julian C, Jennings RW, Choi SS. Intraoperative Recurrent Laryngeal Nerve Monitoring During Pediatric Cardiac and Thoracic Surgery: A Mini Review. Front Pediatr 2020; 8:587177. [PMID: 33330282 PMCID: PMC7728690 DOI: 10.3389/fped.2020.587177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/29/2020] [Indexed: 12/18/2022] Open
Abstract
Objective: Review techniques for intraoperative recurrent laryngeal nerve (RLN) monitoring during pediatric surgery for esophageal atresia, tracheoesophageal fistula, tracheobronchomalacia, and cardiac surgery. Summary Background Data: Literature was reviewed for reports of intraoperative recurrent laryngeal nerve monitoring in cervical, thoracic, and cardiac surgical procedures which place the RLNs at risk for injury. Methods: Review paper. Results: The RLN is at risk during pediatric surgery for esophageal atresia, tracheoesophageal fistula, tracheobronchomalacia, and cardiac surgery. Intraoperative nerve monitoring has decreased rates of RLN injury in thyroid surgery. Intraoperative RLN monitoring techniques appropriate for pediatric surgery are discussed, including endotracheal tubes with integrated surface electrodes, adhesive surface electrodes for smaller endotracheal tubes, endolaryngeal electrodes, and automatic periodic continuous intra-operative stimulation. Conclusions: Multiple techniques exist to monitor the RLN in children undergoing cervical, cardiac, and thoracic surgery. Monitoring the RLN during procedures that place the RLNs at risk may help decrease the rate of RLN injury.
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Affiliation(s)
- Claire M Lawlor
- Department of Otolaryngology, Children's National Health System, Washington, DC, United States
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Christopher Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Carlos Munoz-San Julian
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Sukgi S Choi
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, United States
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Pediatric glossopharyngeal neuralgia: a comprehensive review. Childs Nerv Syst 2019; 35:395-402. [PMID: 30361762 DOI: 10.1007/s00381-018-3995-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/10/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Debilitating facial pain can seriously affect an individual's daily living. Given that the pathophysiology behind neuropathic and myofascial pain is not fully understood, when chronic facial pain goes undiagnosed, it has been proposed that one of the two is the likely cause. Since their discovery, glossopharyngeal neuralgia (GN) and Eagle's syndrome have been considered mostly conditions afflicting the adult population. However, when pediatric patients present with symptoms resembling GN or Eagle's syndrome, physicians are less apt to include these as a differential diagnosis simply due to the low prevalence and incidence in the pediatric population. MATERIALS AND METHODS A literature review was performed with the aim to better understand the history of reported cases and to provide a comprehensive report of the anatomical variations that lead to these two conditions as well as the way these variations dictated medical and surgical management. Articles were obtained through Google Scholar and PubMed. Search criteria included key phrases such as pediatric glossopharyngeal neuralgia and pediatric Eagle syndrome. These key phrases were searched independently. PubMed was searched primarily then cross-referenced articles were found via Google Scholar. Results from non-English articles were excluded. RESULTS A total of 58 articles were reviewed. Most of the articles focused on adult glossopharyngeal neuralgia, and the majority was comprised of case reports. When searched via PubMed, a total of 16 articles and 2 articles returned for glossopharyngeal neuralgia and Eagle's syndrome, respectively. After criteria selection and cross-referencing, a total of seven articles were found with respect to pediatric glossopharyngeal neuralgia. CONCLUSIONS While they are rare conditions, there are multiple etiologies that lead to the debilitating symptoms of GN and Eagle's syndrome. The clinical anatomy proved notable as multiple causes of GN and Eagle's syndrome are due to variation in the anatomy of the neurovascular structures surrounding the glossopharyngeal nerve, an elongated styloid process, a calcified stylohyoid ligament as well as a calcified stylomandibular ligament. Due to the success of different treatment modalities, the treatment of choice is dependent on clinical judgment.
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Staartjes VE, de Wispelaere MP, Schröder ML. Recurrent Laryngeal Nerve Palsy Is More Frequent After Secondary than After Primary Anterior Cervical Discectomy and Fusion: Insights from a Registry of 525 Patients. World Neurosurg 2018; 116:e1047-e1053. [PMID: 29864565 DOI: 10.1016/j.wneu.2018.05.162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/21/2018] [Accepted: 05/23/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) palsy is a common complication after anterior cervical discectomy and fusion (ACDF) and usually manifests with dysphagia, hoarseness, and respiratory difficulties. Next to proven risk factors, such as age and multilevel procedures, RLN palsy has been speculated to occur more frequently after secondary ACDF procedures. METHODS We analyzed a prospective registry of all consecutive patients undergoing zero-profile ACDF for disc herniation, myelopathy, or stenosis. RLN palsy was defined as persistent patient self-reported dysphagia, hoarseness, or respiratory problems without other identifiable causes. RLN palsy was assessed at scheduled 6-week telephone interviews. RESULTS Among 525 included patients, 511 primary and 40 secondary ACDF procedures were performed. Hoarseness was present in 12 (2.2%) cases, whereas dysphagia and respiratory difficulties both occurred in 3 (0.5%) cases. Overall incidence of RLN palsy was 2% after primary procedures and 8% after secondary procedures (P = 0.017). These rates are in line with the peer-reviewed literature, and the difference remained significant after controlling for confounders in a multivariate model (P = 0.033). Other reported risk factors, such as age, sex, surgical time, and multilevel procedures, had no relevant effect (P > 0.05). CONCLUSIONS Based on our data and other published series in the literature, RLN palsy may occur more frequently after secondary ACDF procedures with a clinically relevant effect size. There is a striking lack of uniformity in methods and reporting in research on RLN injury.
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Affiliation(s)
- Victor E Staartjes
- Department of Neurosurgery, Bergman Clinics, Amsterdam, The Netherlands; Faculty of Medicine, University of Zurich, Zurich, Switzerland.
| | | | - Marc L Schröder
- Department of Neurosurgery, Bergman Clinics, Amsterdam, The Netherlands
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Johal J, Iwanaga J, Tubbs K, Loukas M, Oskouian RJ, Tubbs RS. The Accessory Nerve: A Comprehensive Review of its Anatomy, Development, Variations, Landmarks and Clinical Considerations. Anat Rec (Hoboken) 2018; 302:620-629. [DOI: 10.1002/ar.23823] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/11/2017] [Accepted: 05/14/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Jaspreet Johal
- Department of Anatomical SciencesSt. George's UniversitySt. George's Grenada
- Seattle Science FoundationSeattle Washington
| | - Joe Iwanaga
- Seattle Science FoundationSeattle Washington
| | - Kevin Tubbs
- Seattle Science FoundationSeattle Washington
| | - Marios Loukas
- Department of Anatomical SciencesSt. George's UniversitySt. George's Grenada
| | | | - R. Shane Tubbs
- Department of Anatomical SciencesSt. George's UniversitySt. George's Grenada
- Seattle Science FoundationSeattle Washington
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Haidar YM, Sahyouni R, Moshtaghi O, Wang BY, Djalilian HR, Middlebrooks JC, Verma SP, Lin HW. Selective recurrent laryngeal nerve stimulation using a penetrating electrode array in the feline model. Laryngoscope 2017; 128:1606-1614. [PMID: 29086427 DOI: 10.1002/lary.26969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 08/21/2017] [Accepted: 09/21/2017] [Indexed: 01/13/2023]
Abstract
OBJECTIVES/HYPOTHESIS Laryngeal muscles (LMs) are controlled by the recurrent laryngeal nerve (RLN), injury of which can result in vocal fold (VF) paralysis (VFP). We aimed to introduce a bioelectric approach to selective stimulation of LMs and graded muscle contraction responses. STUDY DESIGN Acute experiments in cats. METHODS The study included six anesthetized cats. In four cats, a multichannel penetrating microelectrode array (MEA) was placed into an uninjured RLN. For RLN injury experiments, one cat received a standardized hemostat-crush injury, and one cat received a transection-reapproximation injury 4 months prior to testing. In each experiment, three LMs (thyroarytenoid, posterior cricoarytenoid, and cricothyroid muscles) were monitored with an electromyographic (EMG) nerve integrity monitoring system. Electrical current pulses were delivered to each stimulating channel individually. Elicited EMG voltage outputs were recorded for each muscle. Direct videolaryngoscopy was performed for visualization of VF movement. RESULTS Stimulation through individual channels led to selective activation of restricted nerve populations, resulting in selective contraction of individual LMs. Increasing current levels resulted in rising EMG voltage responses. Typically, activation of individual muscles was successfully achieved via single placement of the MEA by selection of appropriate stimulation channels. VF abduction was predominantly observed on videolaryngoscopy. Nerve histology confirmed injury in cases of RLN crush and transection experiments. CONCLUSIONS We demonstrated the ability of a penetrating MEA to selectively stimulate restricted fiber populations within the feline RLN and selectively elicit contractions of discrete LMs in both acute and injury-model experiments, suggesting a potential role for intraneural MEA implantation in VFP management. LEVEL OF EVIDENCE NA. Laryngoscope, 128:1606-1614, 2018.
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Affiliation(s)
- Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A
| | - Ronald Sahyouni
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A
| | - Omid Moshtaghi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A
| | - Beverly Y Wang
- Department of Pathology, University of California, Irvine, Irvine, California
| | - Hamid R Djalilian
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A
| | - John C Middlebrooks
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A
| | - Sunil P Verma
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A.,University Voice and Swallowing Center, University of California Irvine School of Medicine, Irvine, California, U.S.A
| | - Harrison W Lin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, U.S.A
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Constable JD, Bathala S, Ahmed JJ, McGlashan JA. Non-recurrent laryngeal nerve with a coexisting contralateral nerve demonstrating extralaryngeal branching. BMJ Case Rep 2017; 2017:bcr-2016-218280. [PMID: 28314807 DOI: 10.1136/bcr-2016-218280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Non-recurrence and extralaryngeal branching are 2 of the more frequently encountered anomalies of the recurrent laryngeal nerve. If not anticipated intraoperatively, these abnormalities can put the nerve at risk, with subsequent vocal cord palsy. It is therefore important to report on and understand these abnormalities. We present a unique case of a non-recurrent laryngeal nerve with a coexisting contralateral nerve demonstrating extralaryngeal branching. This case allows us to demonstrate the importance of arteria lusoria in head and neck surgery, and to conclude that non-recurrence and extralaryngeal branching can occur separately within individual nerves in the same patient. The case also highlights the importance of a systematic intraoperative approach to the identification of every recurrent laryngeal nerve, especially in bilateral procedures having already exposed an anomalous nerve on one side.
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Affiliation(s)
- James D Constable
- Department of Ear, Nose & Throat, Queen's Medical Centre, Nottingham, UK
| | | | - Jacob J Ahmed
- Department of Ear, Nose & Throat, Queen's Medical Centre, Nottingham, UK
| | - Julian A McGlashan
- Department of Ear, Nose & Throat, Queen's Medical Centre, Nottingham, UK
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Polednak AP. Relationship of the recurrent laryngeal nerve to the inferior thyroid artery: A comparison of findings from two systematic reviews. Clin Anat 2017; 30:318-321. [PMID: 28196399 DOI: 10.1002/ca.22851] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 02/01/2017] [Indexed: 12/14/2022]
Abstract
Systematic reviews (SRs) of anatomical studies may include a meta-analysis (MA) that provides weighted averages as pooled estimates of prevalence. The relationship of the recurrent laryngeal nerve (RLN) to the inferior thyroid artery (ITA) or its branches has been assessed in two published SRs, one without MA of 32 studies (SR1) and the other with MA of 79 studies (SR2). Both SRs reported differences in RLN-ITA patterns (in three categories) by side of the body, but the anterior pattern was less frequent in SR1 vs. SR2. The aim of this review was to explain the differences. The unweighted data from SR1 were found to be more affected (vs. SR2) by a single study with the largest number of RLNs and a low proportion anterior. In a MA using data from SR1, the pooled prevalence estimate for the anterior pattern was substantial (35%) on the right side (vs. 15% on the left) and close to the findings published in SR2. These consistent findings should be relevant to surgeons in attempting to avoid iatrogenic injury to RLNs. Comparison of methods and results from two or more SRs on the same anatomical relationships may be useful in evidence-based anatomy. Clin. Anat. 30:318-321, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Anthony P Polednak
- Retired, Connecticut Tumor Registry, Connecticut Department of Public Health, Hartford, Connecticut
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Morphology and Functional Anatomy of the Recurrent Laryngeal Nerve with Extralaryngeal Terminal Bifurcation. ANATOMY RESEARCH INTERNATIONAL 2016; 2016:9503170. [PMID: 27493803 PMCID: PMC4963538 DOI: 10.1155/2016/9503170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/20/2016] [Indexed: 11/20/2022]
Abstract
Anatomical variations of the recurrent laryngeal nerve (RLN), such as an extralaryngeal terminal bifurcation (ETB), threaten the safety of thyroid surgery. Besides the morphology of the nerve branches, intraoperative evaluation of their functional anatomy may be useful to preserve motor activity. We exposed 67 RLNs in 36 patients. The main trunk, bifurcation point, and terminal branches of bifid nerves were macroscopically determined and exposed during thyroid surgery. The functional anatomy of the nerve branches was evaluated by intraoperative nerve monitoring (IONM). Forty-six RLNs with an ETB were intraoperatively exposed. The bifurcation point was located along the prearterial, arterial, and postarterial segments in 11%, 39%, and 50% of bifid RLNs, respectively. Motor activity was determined in all anterior branches. The functional anatomy of terminal branches detected motor activity in 4 (8.7%) posterior branches of 46 bifid RLNs. The motor activity in posterior branches created a wave amplitude at 25–69% of that in the corresponding anterior branches. The functional anatomy of bifid RLNs demonstrated that anterior branches always contained motor fibres while posterior branches seldom contained motor fibres. The motor activity of the posterior branch was weaker than that of the anterior branch. IONM may help to differentiate between motor and sensory functions of nerve branches. The morphology and functional anatomy of all nerve branches must be preserved to ensure a safer surgery.
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Nonrecurrent Laryngeal Nerve in the Era of Intraoperative Nerve Monitoring. Adv Med 2016; 2016:1606029. [PMID: 27819021 PMCID: PMC5081457 DOI: 10.1155/2016/1606029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/27/2016] [Accepted: 09/21/2016] [Indexed: 12/02/2022] Open
Abstract
Nonrecurrent laryngeal nerve (non-RLN) is an anatomical variation increasing the risk of vocal cord palsy. Prediction and early identification of non-RLN may minimize such a risk of injury. This study assessed the effect of intraoperative neuromonitoring (IONM) on the detection of non-RLN. A total of 462 (236 right) nerves in 272 patients were identified and totally exposed, and all intraoperative steps of IONM were sequentially applied on the vagus nerve (VN) and RLN. Right predissection VN stimulation at a distal point did not create a sound signal in three cases (3/236; 1.27%). Proximal dissection of the right VN under IONM guidance established a proximal point, creating a positive signal. The separation point of non-RLN from VN was discovered in all three patients. Non-RLNs were exposed from separation to laryngeal entry. Positive IONM signals were obtained after resection of thyroid lobes, and postoperative period was uneventful in patients with non-RLN. Absence of distal VN signal is a precise predictor of the non-RLN. IONM-guided proximal dissection of the right VN leads to identification of the non-RLN. The prediction of non-RLN by the absence of the VN signal at an early stage of surgery may prevent or minimize the risk of nerve injury.
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