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Xu MH, Dou JP, Guo MH, Yi WQ, Han ZY, Liu FY, Yu J, Cheng ZG, Yu XL, Wang H, Bai N, Wang SR, Yu MA, Liang P, Chen L. Risk factors for recurrent laryngeal nerve injury in microwave ablation of thyroid nodules: A multicenter study. Radiother Oncol 2024; 200:110516. [PMID: 39216824 DOI: 10.1016/j.radonc.2024.110516] [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] [Received: 01/29/2024] [Revised: 08/13/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND PURPOSE This study aimed to investigate the risk factors for recurrent laryngeal nerve (RLN) injury after microwave ablation (MWA) of thyroid nodules and to identify factors influencing the recovery time of post-procedure hoarseness. MATERIALS AND METHODS We retrospectively analyzed data from patients who underwent MWA for thyroid nodules at five hospitals between November 2018 and July 2022. Patients were divided into malignant and benign nodule groups. Variables analyzed included nodule size and location, the shortest distance from nodules to the thyroid capsule and tracheoesophageal groove (TEG-D), and ablation parameters. Univariate and multivariate analyses were performed to identify risk factors. Kaplan-Meier and Cox analyses were used to evaluate the recovery time of hoarseness after MWA. RESULTS The study included 1,216 patients (mean age 44 ± 12 [SD] years; 901 women) with 602 malignant nodules and 614 benign nodules. The posterior capsule distance (PCD) and TEG-D were identified as independent influencing factors for hoarseness in all patients (P = 0.014, OR = 0.068; P < 0.001, OR = 0.005; AUC = 0.869). TEG-D was a significant risk factor for hoarseness, with safe thresholds identified at 4.9 mm for malignant nodules and 2.2 mm for benign nodules. Among patients who developed hoarseness, those in the close-distance group (TEG-D≤2 mm) had a longer recovery time compared to the distant-distance group. TEG-D was an independent factor influencing recovery time (P = 0.008, HR = 11.204). CONCLUSION Clinicians should consider several factors, particularly TEG-D and PCD, when assessing the risk of RLN injury before MWA. TEG-D was a vital independent factor influencing recovery time. SUMMARY Clinicians should pay attention to several influencing factors for RLN injury before MWA and TEG-D was an independent influencing factor for recovery time of hoarseness after MWA.
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Affiliation(s)
- Ming-Hong Xu
- Senior Department of Otolaryngology-Head & Neck Surgery, the Sixth Medical Center of PLA General Hospital, Chinese PLA Medical School, No. 28 Fuxing Road, Haidian District, Beijing 100853, China; Chinese PLA Medical School, Beijing, China
| | - Jian-Ping Dou
- Department of Interventional Ultrasound, Chinese PLA Medical School & Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Mo-Han Guo
- Senior Department of Otolaryngology-Head & Neck Surgery, the Sixth Medical Center of PLA General Hospital, Chinese PLA Medical School, No. 28 Fuxing Road, Haidian District, Beijing 100853, China; Chinese PLA Medical School, Beijing, China
| | - Wen-Qi Yi
- Chinese PLA Medical School, Beijing, China; Department of Interventional Ultrasound, Chinese PLA Medical School & Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhi-Yu Han
- Department of Interventional Ultrasound, Chinese PLA Medical School & Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Fang-Yi Liu
- Department of Interventional Ultrasound, Chinese PLA Medical School & Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jie Yu
- Department of Interventional Ultrasound, Chinese PLA Medical School & Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhi-Gang Cheng
- Department of Interventional Ultrasound, Chinese PLA Medical School & Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiao-Ling Yu
- Department of Interventional Ultrasound, Chinese PLA Medical School & Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Hui Wang
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Nan Bai
- Department of Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Shu-Rong Wang
- Department of Medical Ultrasound, Yantai Hospital of Shandong Wendeng Orthopaedics & Traumatology, Yantai, China
| | - Ming-An Yu
- Department of Interventional Ultrasound Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Ping Liang
- Department of Interventional Ultrasound, Chinese PLA Medical School & Fifth Medical Center of Chinese PLA General Hospital, Beijing, China.
| | - Lei Chen
- Senior Department of Otolaryngology-Head & Neck Surgery, the Sixth Medical Center of PLA General Hospital, Chinese PLA Medical School, No. 28 Fuxing Road, Haidian District, Beijing 100853, China.
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Chao YK, Li Z, Jiang H, Wen YW, Chiu CH, Li B, Shang X, Fang TJ, Yang Y, Yue J, Zhang X, Zhang C, Liu YH. Multicentre randomized clinical trial on robot-assisted versus video-assisted thoracoscopic oesophagectomy (REVATE trial). Br J Surg 2024; 111:znae143. [PMID: 38960881 PMCID: PMC11221944 DOI: 10.1093/bjs/znae143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 04/15/2024] [Accepted: 05/24/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Surgery for oesophageal squamous cell carcinoma involves dissecting lymph nodes along the recurrent laryngeal nerve. This is technically challenging and injury to the recurrent laryngeal nerve may lead to vocal cord palsy, which increases the risk of pulmonary complications. The aim of this study was to compare the efficacy and safety of robot-assisted oesophagectomy (RAO) versus video-assisted thoracoscopic oesophagectomy (VAO) for dissection of lymph nodes along the left RLN. METHODS Patients with oesophageal squamous cell carcinoma who were scheduled for minimally invasive McKeown oesophagectomy were allocated randomly to RAO or VAO, stratified by centre. The primary endpoint was the success rate of left recurrent laryngeal nerve lymph node dissection. Success was defined as the removal of at least one lymph node without causing nerve damage lasting longer than 6 months. Secondary endpoints were perioperative and oncological outcomes. RESULTS From June 2018 to March 2022, 212 patients from 3 centres in Asia were randomized, and 203 were included in the analysis (RAO group 103; VAO group 100). Successful left recurrent laryngeal nerve lymph node dissection was achieved in 88.3% of the RAO group and 69% of the VAO group (P < 0.001). The rate of removal of at least one lymph node according to pathology was 94.2% for the RAO and 86% for the VAO group (P = 0.051). At 1 week after surgery, the RAO group had a lower incidence of left recurrent laryngeal nerve palsy than the VAO group (20.4 versus 34%; P = 0.029); permanent recurrent laryngeal nerve palsy rates at 6 months were 5.8 and 20% respectively (P = 0.003). More mediastinal lymph nodes were dissected in the RAO group (median 16 (i.q.r. 12-22) versus 14 (10-20); P = 0.035). Postoperative complication rates were comparable between the two groups and there were no in-hospital deaths. CONCLUSION In patients with oesophageal squamous cell carcinoma, RAO leads to more successful left recurrent laryngeal nerve lymph node dissection than VAO, including a lower rate of short- and long-term recurrent laryngeal nerve injury. Registration number: NCT03713749 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Zhigang Li
- Division of Thoracic Surgery, Shanghai Chest Hospital, Shanghai, China
| | - Hongjing Jiang
- Department of Minimally Invasive Oesophageal Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Centre of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Yu-Wen Wen
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
- Department of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Hung Chiu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Bin Li
- Division of Thoracic Surgery, Shanghai Chest Hospital, Shanghai, China
| | - Xiaobin Shang
- Department of Minimally Invasive Oesophageal Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Centre of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Tuan-Jen Fang
- Department of Otorhinolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Yang Yang
- Division of Thoracic Surgery, Shanghai Chest Hospital, Shanghai, China
| | - Jie Yue
- Department of Minimally Invasive Oesophageal Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Centre of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Xiaobin Zhang
- Division of Thoracic Surgery, Shanghai Chest Hospital, Shanghai, China
| | - Chen Zhang
- Department of Minimally Invasive Oesophageal Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Centre of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Yun-Hen Liu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
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Aygun N, Unlu MT, Caliskan O, Kostek M, Isgor A, Uludag M. The relation of recurrent laryngeal nerve to inferior thyroid artery and extralaryngeal nerve branching may increase the risk of vocal cord paralysis in thyroidectomy. Langenbecks Arch Surg 2024; 409:198. [PMID: 38935142 PMCID: PMC11211155 DOI: 10.1007/s00423-024-03392-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE The anatomical variations of the recurrent laryngeal nerve (RLN) are common during thyroidectomy. We aimed to evaluate the risk of RLN paralysis in case of its anatomical variations, retrospectively. METHODS The patients with primary thyroidectomy between January 2016 and December 2019 were enrolled. The effect of age, gender, surgical intervention, neuromonitorisation type, central neck dissection, postoperative diagnosis, neck side, extralaryngeal branching, non-RLN, relation of RLN to inferior thyroid artery (ITA), grade of Zuckerkandl tubercle on vocal cord paralysis (VCP) were investigated. RESULTS This study enrolled 1070 neck sides. The extralaryngeal branching rate was 35.5%. 45.9% of RLNs were anterior and 44.5% were posterior to the ITA, and 9.6% were crossing between the branches of the ITA. The rate of total VCP was 4.8% (transient:4.5%, permanent: 0.3%). The rates of total and transient VCP were significantly higher in extralaryngeal branching nerves compared to nonbranching nerves (6.8% vs. 3.6%, p = 0.018; 6.8% vs. 3.2%, p = 0.006, respectively). Total VCP rates were 7.2%, 2.5%, and 2.9% in case of the RLN crossing anterior, posterior and between the branches of ITA, respectively (p = 0.003). The difference was also significant regarding the transient VCP rates (p = 0.004). Anterior crossing pattern increased the total and transient VCP rates 2.8 and 2.9 times, respectively. CONCLUSION RLN crossing ITA anteriorly and RLN branching are frequent anatomical variations increasing the risk of VCP in thyroidectomy that cannot be predicted preoperatively. This study is the first one reporting that the relationship between RLN and ITA increased the risk of VCP.
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Affiliation(s)
- Nurcihan Aygun
- Department of General Surgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Huzur Avenue, Cumhuriyet Street, Sariyer, Istanbul, 34371, Turkey.
| | - Mehmet Taner Unlu
- Department of General Surgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Huzur Avenue, Cumhuriyet Street, Sariyer, Istanbul, 34371, Turkey
| | - Ozan Caliskan
- Department of General Surgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Huzur Avenue, Cumhuriyet Street, Sariyer, Istanbul, 34371, Turkey
| | - Mehmet Kostek
- Department of General Surgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Huzur Avenue, Cumhuriyet Street, Sariyer, Istanbul, 34371, Turkey
| | - Adnan Isgor
- Department of General Surgery, Sisli Memorial Hospital, Istanbul, Turkey
| | - Mehmet Uludag
- Department of General Surgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Huzur Avenue, Cumhuriyet Street, Sariyer, Istanbul, 34371, Turkey
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Dip F, Falco J, White K, Rosenthal R. Fluorescence imaging to visualize the recurrent laryngeal nerve during thyroidectomy procedures: analysis of 65 cases and 81 nerves. Surg Endosc 2024; 38:1406-1413. [PMID: 38168731 DOI: 10.1007/s00464-023-10627-4] [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] [Received: 06/05/2023] [Accepted: 11/29/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) injury after thyroidectomy is relatively common. Locating the RLN prior to thyroid dissection is paramount to avoid injury. We developed a fluorescence imaging system that permits nerve autofluorescence. We aimed to determine the sensitivity and specificity of fluorescence imaging at detecting the RLN relative to thyroid and other background tissue and compared it to white light. METHODS In this prospective study, 65 patients underwent thyroidectomy from January to April 2022 (16 bilateral thyroid resections) using white and fluorescent light. Fluorescence intensity [relative fluorescence units (RFU)] was recorded for RLN, thyroid, and background. RFU mean, minimum, and maximum values were calculated using Image J software. Thirty randomly selected pairs of white and fluorescent light images were independently reviewed by two examiners to compare RLN detection rate, number of branches, and length and minimum width of nerves visualized. Parametric and nonparametric statistical analysis was performed. RESULTS All 81 RNLs observed were visualized more clearly under fluorescence (mean intensity, µ = 134.3 RFU) than either thyroid (µ = 33.7, p < 0.001) or background (µ = 14.4, p < 0.001). Forest plots revealed no overlap between RLN intensity and that of either other tissue. Sensitivity and specificity for RLN were 100%. All 30 RLNs and all 45 nerve branches were clearly visualized under fluorescence, versus 17 and 22, respectively, with white light (both p < 0.001). Visible nerve length was 2.5 × as great with fluorescence as with white light (µ = 1.90 vs. 0.76 cm, p < 0.001). CONCLUSIONS In 65 patients and 81 nerves, RLN detection was markedly and consistently enhanced with autofluorescence neuro-imaging during thyroidectomy, with 100% sensitivity and specificity.
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Affiliation(s)
- Fernando Dip
- Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Jorge Falco
- Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Kevin White
- ScienceRight Research Consulting Services, London, ON, Canada
| | - Raul Rosenthal
- Cleveland Clinic Florida, The Bariatric Institute, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Kuo CT, Chiu CH, Fang TJ, Chao YK. Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study. Ann Surg Oncol 2024; 31:1546-1552. [PMID: 37989958 DOI: 10.1245/s10434-023-14560-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/22/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) palsy is a serious complication of esophagectomy that affects the patient's phonation and the ability to prevent life-threatening aspiration events. The aim of this single-center, retrospective study was to investigate the clinical course of left RLN palsy and to identify the main prognostic factors for recovery. METHODS The study cohort consisted of 85 patients who had developed left RLN palsy after minimally invasive McKeown esophagectomy. Vocal cord function was assessed in all participants through laryngoscopic examinations, both in the immediate postoperative period and during follow-up. Permanent palsy was defined as no evidence of recovery after 6 months. Univariate and multivariable logistic regression analyses were applied to evaluate the associations between different variables and the outcome of palsy. RESULTS Twenty-two (25.8%) patients successfully recovered from left RLN palsy. On multivariable logistic regression analysis, active smoking (odds ratio [OR] 0.335, p = 0.038) and the use of thoracoscopic surgery (vs. robotic surgery; OR 0.264, p = 0.028) were identified as independent unfavorable predictors for recovery from palsy. The estimated rates of recovery derived from a logistic regression model for patients harboring two, one, or no risk factors were 13.16%, 31.15-34.75%, and 61.39%, respectively. CONCLUSION Only one-quarter of patients who had developed left RLN palsy after minimally invasive McKeown esophagectomy were able to fully recover. Smoking habits and the surgical approach were identified as key determinants of recovery. Patients harboring adverse prognostic factors are potential candidates for early intervention strategies.
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Affiliation(s)
- Chun-Ting Kuo
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Chiu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Tuan-Jen Fang
- Department of Otolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan.
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Dos Santos Menezes Siqueira GV, Dos Santos Rodrigues MH, Santos CNN, Gonçalves PE, Garção DC. Anatomical variations of recurrent laryngeal nerve: a systematic review and meta-analyses. Surg Radiol Anat 2024; 46:353-362. [PMID: 38329522 DOI: 10.1007/s00276-023-03293-7] [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] [Received: 10/26/2023] [Accepted: 12/27/2023] [Indexed: 02/09/2024]
Abstract
PURPOSE The aim of this systematic review and meta-analysis was to systematically review and perform a meta-analysis on the anatomical variations of the RLN. METHODS We performed online research for studies that addressed anatomical variations of the RLN and laterality, published between 2015 and 2021. We found 230 articles, and nine were included. RESULTS Eight variations were found, with Type I prevailing (41.17%; 95% CI 19.44-64.88), extra laryngeal divergence of the RLN. The other types were: II-fan shape; III-distance greater than 5 mm to the cricothyroid joint; IV-thickening and adipopexy in the elderly; V-non-recurrent laryngeal nerve; VI-intracranial branch; VII-tortuous ascending RLN; and VIII-combination between the inferior branch of the NV and the ascending trunk of the RLN. Types I (p = 0) and III (p < 0.01) prevailed on the left and types II (p < 0.01) and V (p < 0.01) on the right. CONCLUSIONS It was observed that variations occurred due to the path of the RLN to the entrance to the larynx, its shape, and the age of the evaluated individual. The most frequent variation and side were, respectively, Type I, extra laryngeal divergence and left.
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Affiliation(s)
| | | | - Caio Nemuel Nascimento Santos
- Department of Morphology, Federal University of Sergipe, Marechal Rondon Jardim Avenue, Rosa Elze, São Cristóvão, Sergipe, 49100-000, Brazil
| | - Paulo Eduardo Gonçalves
- Department of Morphology, Federal University of Sergipe, Marechal Rondon Jardim Avenue, Rosa Elze, São Cristóvão, Sergipe, 49100-000, Brazil
| | - Diogo Costa Garção
- Department of Morphology, Federal University of Sergipe, Marechal Rondon Jardim Avenue, Rosa Elze, São Cristóvão, Sergipe, 49100-000, Brazil
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Pandey AK, Varma A, Bansal C, Bhardwaj A. An Exposition on Surgical Experiences in Identification, Exposure, and Injuries of Recurrent Laryngeal Nerve (RLN) During Thyroid Operations: Gleanings, Narrative, and the Reflections. Indian J Otolaryngol Head Neck Surg 2023; 75:1363-1369. [PMID: 37636600 PMCID: PMC10447788 DOI: 10.1007/s12070-023-03541-7] [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: 01/18/2023] [Accepted: 01/26/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Identifying and preserving the recurrent laryngeal nerve (RLN) is of paramount importance during thyroid surgeries. Iatrogenic injuries to RLN (RLNI) are considered one of the most serious and feared complications of thyroidectomies. Surgically, there are four routes/approaches (lateral, inferior, superior, and medial) for localizing and identifying the RLN. This study aims to estimate the incidence of RLNI in the context of various approaches taken intra-operatively for nerve localization and identification. MATERIALS AND METHODS This retrospective analytical study included 54 cases of thyroidectomies operated for various benign and malignant thyroid disorders in a tertiary care center from January 2018 to December 2020. Intraoperative search, identification, and dissection of the nerve were done with superior, inferior, medial, and lateral approaches. The chi-square test and exact test were used to analyze the data and p-value < 0.05 was considered significant. Pre- and post-operative recurrent laryngeal nerve evaluation was done with 90 degrees Hopkins laryngoscope. RESULTS Overall in this series, the incidence of post-thyroidectomy RLNI was 3.7% and 3.7% for permanent and temporary nerve insults, respectively. Non-recurrent RLN on the right side was identified in one case and extra-laryngeal branching of RLN was identified in two cases. There was no statistically significant difference (p = 0.929) between the different approaches taken and the incidence of RLNI. The type of surgery and pathology also expressed no statistically significant relevance with the incidence of RLNI (p = 0.463 and p = 0.277, respectively). CONCLUSION Adoption of a particular surgical approach to localize and identify RLN during thyroid surgery carries no statistically significant difference between RLNI and approaches taken. Meticulous handling and dissection of the tissue in the correct surgical plane are crucial determinants in preventing RLNIs.
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Affiliation(s)
- Apoorva Kumar Pandey
- Department of ENT, Shri Guru Ram Rai Institute of Medical Sciences, Dehradun, Uttarakhand 248001 India
| | - Arvind Varma
- Department of ENT, Shri Guru Ram Rai Institute of Medical Sciences, Dehradun, Uttarakhand 248001 India
| | - Chetan Bansal
- Department of ENT, ONGC Hospital, 8979467716 Dehradun, India
| | - Aparna Bhardwaj
- Department of Pathology, Shri Guru Ram Rai Institute of Medical Sciences, 9411718270 Dehradun, Uttarakhand India
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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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Dash M, Deshmukh P, Gaurkar SS, Singh CV, Sandbhor A. Non-Recurrent Laryngeal Nerve: A Rare Anatomical Entity in a Patient Undergoing Hemithyroidectomy. Cureus 2022; 14:e29935. [PMID: 36348859 PMCID: PMC9634855 DOI: 10.7759/cureus.29935] [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: 08/31/2022] [Accepted: 10/04/2022] [Indexed: 11/07/2022] Open
Abstract
A non-recurrent laryngeal nerve (NRLN) is a common anatomical modification with an occurrence rate ranging from 0.5% to 0.7% in surgical procedures related to thyroid pathology [1]. In this condition cervical vagus nerve reaches the larynx directly, increasing the likelihood of vocal cord palsy. Non-RLN injury can be reduced by anticipating it and identifying it early. This case report describes how a non-recurrent inferior laryngeal nerve was discovered intraoperatively during systemic dissection, averting intra-operative nerve injury. A 40-year-old female reported to the department of Otorhinolaryngology and Head and Neck Surgery Outpatient Clinic for a nodular tumor in her neck that has been increasing for the previous five years. The colloid multi-nodular thyroid of the right lobe was confirmed by a fine needle aspiration cytology (FNAC). The patient was lined up for a surgical procedure requiring resection of the right lobe of the thyroid. A non-recurrent right inferior laryngeal nerve was discovered during surgery. The operation and recovery went smoothly, and there was no change in his voice in subsequent follow-ups. For those who are related to this professional line, this presentation provides a summary of what a non-recurrent laryngeal nerve looks like during surgery. This is critical for anyone undergoing diagnostic and surgical procedures which demand to be invasive in the region involving the neck and upper thorax, as it lowers the risk of iatrogenic nerve injury. A solitary trauma of this nerve can induce irreversible hoarseness, whereas a multilateral lesion might result in aphonia and potentially deadly dysphonia.
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Dip F, Rosenthal D, Socolovsky M, Falco J, De la Fuente M, White KP, Rosenthal RJ. Nerve autofluorescence under near-ultraviolet light: cutting-edge technology for intra-operative neural tissue visualization in 17 patients. Surg Endosc 2022; 36:4079-4089. [PMID: 34694489 DOI: 10.1007/s00464-021-08729-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 09/06/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Nerve visualization and the identification of other neural tissues during surgery is crucial for numerous reasons, including the prevention of iatrogenic nerve and neural structure injury and facilitation of nerve repair. However, current methods of intra-operative nerve detection are generally expensive, unproven, and/or technically challenging. Recently, we have documented, in both in vivo animal models and ex vivo human tissue, that nerves autofluorescence when viewed in near-ultraviolet light (NUV). In this paper, we describe our use of nerve autofluorescence to facilitate the visualization of nerves and other neural tissues intra-operatively in 17 patients undergoing a range of surgical procedures. METHODS Employing the same prototype axon imaging system previously documented to markedly enhance nerve visualization in both in vivo animal and ex vivo human models, surgical fields were observed in 17 patients under both white and NUV light during parotid tumor resection (n = 3), thyroid tumor resection (n = 7), and surgery for peripheral nerve and spinal tumors and injury (n = 7). RESULTS In all 17 patients, the intra-operative use of the imaging system both was feasible and markedly enhanced the localization of all neural tissues throughout their course within the surgical field. All 17 procedures were successful and devoid of any peri-operative complications or post-operative neurological deficits. CONCLUSIONS Intra-operatively visualizing auto-fluorescent peripheral nerves and other neural tissues under NUV light is feasible in human patients across a range of clinical scenarios and appears to appreciably enhance nerve and other neural tissue visualization. Controlled studies to explore this technology further are needed.
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Affiliation(s)
- Fernando Dip
- Florida Department of General Surgery, Cleveland Clnic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, 33331, USA.,Instituto Argentino de Diagnóstico y Tratamiento Buenos Aires Argentina, Av. Córdoba 2351, C1121ABJ CABA, Buenos Aires, Argentina
| | | | - Mariano Socolovsky
- Division of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Jorge Falco
- Instituto Argentino de Diagnóstico y Tratamiento Buenos Aires Argentina, Av. Córdoba 2351, C1121ABJ CABA, Buenos Aires, Argentina
| | - Martin De la Fuente
- Department of Surgery, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Kevin P White
- ScienceRight Research Consulting, 195 Dufferin Ave., #605, London, ON, N6A 1X7, Canada
| | - Raul J Rosenthal
- Florida Department of General Surgery, Cleveland Clnic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, 33331, USA.
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11
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Aygun N, Kostek M, Unlu MT, Isgor A, Uludag M. Clinical and Anatomical Factors Affecting Recurrent Laryngeal Nerve Paralysis During Thyroidectomy via Intraoperative Nerve Monitorization. Front Surg 2022; 9:867948. [PMID: 35574531 PMCID: PMC9095935 DOI: 10.3389/fsurg.2022.867948] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background Despite all the technical developments in thyroidectomy and the use of intraoperative nerve monitorization (IONM), recurrent laryngeal nerve (RLN) paralysis may still occur. We aimed to evaluate the effects of anatomical variations, clinical features, and intervention type on RLN paralysis. Method The RLNs identified till the laryngeal entry point, between January 2016 and September 2021 were included in the study. The effects of RLN anatomical features considering the International RLN Anatomical Classification System, intervention and monitoring types on RLN paralysis were evaluated. Results A total of 1,412 neck sides of 871 patients (672 F, 199 M) with a mean age of 49.17 + 13.42 years (range, 18–99) were evaluated. Eighty-three nerves (5.9%) including 78 nerves with transient (5.5%) and 5 (0.4%) with permanent vocal cord paralysis (VCP) were detected. The factors that may increase the risk of VCP were evaluated with binary logistic regression analysis. While the secondary thyroidectomy (OR: 2.809, 95%CI: 1.302–6.061, p = 0.008) and Berry entrapment of RLN (OR: 2.347, 95%CI: 1.425–3.876, p = 0.001) were detected as the independent risk factors for total VCP, the use of intermittent-IONM (OR: 2.217, 95% CI: 1.299–3.788, 0.004), secondary thyroidectomy (OR: 3.257, 95%CI: 1.340–7.937, p = 0.009), and nerve branching (OR: 1.739, 95%CI: 1.049–2.882, p = 0.032) were detected as independent risk factors for transient VCP. Conclusion Preference of continuous-IONM particularly in secondary thyroidectomies would reduce the risk of VCP. Anatomical variations of the RLN cannot be predicted preoperatively. Revealing anatomical features with careful dissection may contribute to risk reduction by minimizing actions causing traction trauma or compression on the nerve.
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Affiliation(s)
- Nurcihan Aygun
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
- *Correspondence: Nurcihan Aygun
| | - Mehmet Kostek
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Taner Unlu
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Adnan Isgor
- Department of General Surgery, Sisli Memorial Hospital, Istanbul, Turkey
| | - Mehmet Uludag
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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12
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Gurleyik E, Gurleyik G. Anatomy and motor function of extra-laryngeal branching patterns of the recurrent laryngeal nerve; an electrophysiological study of 1001 nerves at risk. Acta Chir Belg 2022:1-6. [PMID: 35361054 DOI: 10.1080/00015458.2022.2061119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Safe thyroid surgery depends on a deep knowledge of human neck anatomy, including the recurrent laryngeal nerve (RLN). Anatomic variations such as extra-laryngeal terminal branching (ETB) are common. PATIENTS AND METHODS We studied the ETB pattern of 1001 RLNs at risk in 596 patients. We identified and exposed the location of division points on the cervical part of bifid RLN. The function of nerve branches was assessed through intraoperative nerve monitoring (IONM). RESULTS Bifid RLNs was identified in 39.6% of patients. The nerve-based prevalence of ETB was 28.5%. The prevalence of ETB for the right and left RLN was 21.8% and 35.5%, respectively (p < 0.001). The location of the division point was found in the middle, distal, and proximal segments in 48.8%, 33.3%, and 18% of bifid RLNs, respectively. Electrophysiological monitoring revealed motor functions in all anterior and in 7% of posterior branches. The rate of injury was 0.4%, and 1.1% in single trunk and bifid nerves, respectively (p = 0.360), and 3.9% in nerves with proximal branching (p = 0.084). CONCLUSIONS The ETB prevalence is high and showing division points in different cervical segments of the RLN. All anterior branches and some posterior branches contain motor fibers. Knowledge and awareness of these anatomic and functional variations are mandatory for every thyroid surgeon to avoid misidentification and misinterpretation of human RLN anatomy.
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Affiliation(s)
- Emin Gurleyik
- Department of Surgery, Duzce University Medical Faculty, Duzce, Turkey
| | - Gunay Gurleyik
- Department of Surgery, Health Sciences University, Haydarpasa Numune Teaching Hospital, Istanbul, Turkey
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13
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Liu N, Chen B, Li L, Zeng Q, Sheng L, Zhang B, Liang W, Lv B. Recurrent Laryngeal Nerve Injury Near the Nerve Entry Point in Total Endoscopic Thyroidectomy: A Retrospective Cohort Study. Cancer Manag Res 2021; 13:8979-8987. [PMID: 34880678 PMCID: PMC8645946 DOI: 10.2147/cmar.s338551] [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: 09/09/2021] [Accepted: 11/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background Recurrent laryngeal nerve injury (RLNI) still occurs in total endoscopic thyroidectomy (TET) by using intraoperative neuromonitoring (IONM). As the region where most injuries occur, more attention should be paid to RLNI near the nerve entry point (NEP) in TET. Materials and Methods This cohort study collected retrospectively data from 415 patients who underwent TET between February 2012 and December 2019. The functions of the recurrent laryngeal nerve (RLN) in TET were recorded by IONM. The patients with RLNI near the NEP were followed up by laryngoscopies. The demographic and clinical characteristics, the mechanisms of RLNI, and the outcomes of RLNI were recorded and analyzed. Results There were a total of 444 at-risk nerves in 405 patients were analyzed. The incidence of RLNI near the NEP was 7.9%. RLNs with extralaryngeal branches were more likely to be injured near the NEP (P = 0.037). The incidences of different types of RLNI, in order of frequency, were 68.8% for thermal injury (n = 22), 28.1% for traction/compression injury (n = 9), and 3.1% for transverse injury (n = 1). A total of 93.8% (n = 30) of RLNI patients had complete recovery of vocal cord activity function. Conclusion The extralaryngeal branch was a risk factor for RLNI near the NEP in TET. Thermal injury caused by an ultrasonic scalpel was the most common cause of RLNI near the NEP. Most RLNIs near the NEP would eventually recover.
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Affiliation(s)
- Nan Liu
- Department of Thyroid Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China
| | - Bo Chen
- Department of Thyroid Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China
| | - Luchuan Li
- Department of Thyroid Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China
| | - Qingdong Zeng
- Department of Thyroid Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China
| | - Lei Sheng
- Department of Thyroid Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China
| | - Bin Zhang
- Department of Thyroid Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China
| | - Weili Liang
- Department of Thyroid Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China
| | - Bin Lv
- Department of Thyroid Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China
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Liddy W, Wu CW, Dionigi G, Donatini G, Giles Senyurek Y, Kamani D, Iwata A, Wang B, Okose O, Cheung A, Saito Y, Casella C, Aygun N, Uludag M, Brauckhoff K, Carnaille B, Tunca F, Barczyński M, Kim HY, Favero E, Innaro N, Vamvakidis K, Serpell J, Romanchishen AF, Takami H, Chiang FY, Schneider R, Dralle H, Shin JJ, Abdelhamid Ahmed AH, Randolph GW. Varied Recurrent Laryngeal Nerve Course Is Associated with Increased Risk of Nerve Dysfunction During Thyroidectomy: Results of the Surgical Anatomy of the Recurrent Laryngeal Nerve in Thyroid Surgery Study, an International Multicenter Prospective Anatomic and Electrophysiologic Study of 1000 Monitored Nerves at Risk from the International Neural Monitoring Study Group. Thyroid 2021; 31:1730-1740. [PMID: 34541890 DOI: 10.1089/thy.2021.0155] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: The recurrent laryngeal nerve (RLN) can be injured during thyroid surgery, which can negatively affect a patient's quality of life. The impact of intraoperative anatomic variations of the RLN on nerve injury remains unclear. Objectives of this study were to (1) better understand the detailed surgical anatomic variability of the RLN with a worldwide perspective; (2) establish potential correlates between intraoperative RLN anatomy and electrophysiologic responses; and (3) use the information to minimize complications and assure accurate and safe intraoperative neuromonitoring (IONM). Methods: A large international registry database study with prospectively collected data was conducted through the International Neural Monitoring Study Group (INMSG) evaluating 1000 RLNs at risk during thyroid surgery using a specially designed online data repository. Monitored thyroid surgeries following standardized IONM guidelines were included. Cases with bulky lymphadenopathy, IONM failure, and failed RLN visualization were excluded. Systematic evaluation of the surgical anatomy of the RLN was performed using the International RLN Anatomic Classification System. In cases of loss of signal (LOS), the mechanism of neural injury was identified, and functional evaluation of the vocal cord was performed. Results: A total of 1000 nerves at risk (NARs) were evaluated from 574 patients undergoing thyroid surgery at 17 centers from 12 countries and 5 continents. A higher than expected percentage of nerves followed an abnormal intraoperative trajectory (23%). LOS was identified in 3.5% of NARs, with 34% of LOS nerves following an abnormal intraoperative trajectory. LOS was more likely in cases of abnormal nerve trajectory, fixed splayed or entrapped nerves (including at the ligament of Berry), extensive neural dissection, cases of cancer invasion, or when lateral lymph node dissection was needed. Traction injury was found to be the most common form of RLN injury and to be less recoverable than previous reports. Conclusions: Multicenter international studies enrolling diverse patient populations can help reshape our understanding of surgical anatomy during thyroid surgery. There can be significant variability in the anatomic and intraoperative characteristics of the RLN, which can impact the risk of neural injury.
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Affiliation(s)
- Whitney Liddy
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Kaohsiung Medical University Hospital, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi," University Hospital G. Martino, University of Messina, Messina, Italy
| | - Gianluca Donatini
- Department of Visceral and Endocrine Surgery, CHU Poitiers-University of Poitiers, Poitiers, France
| | - Yasemin Giles Senyurek
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Ayaka Iwata
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California, USA
| | - Bo Wang
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
- Department of Thyroid and Parathyroid Surgery, Fujian Medical University Union Hospital, Fujian, China
| | - Okenwa Okose
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony Cheung
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Yoshiyuki Saito
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Keio University School of Medicine, Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Claudio Casella
- Department of Molecular and Translational Medicine, School of Medicine, University of Brescia Surgical Clinic, Spedali Civili Brescia, Brescia, Italy
| | - Nurcihan Aygun
- Department of General Surgery, University of Health Sciences Turkey, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Uludag
- Department of General Surgery, University of Health Sciences Turkey, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Katrin Brauckhoff
- Department of Breast and Endocrine Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Bruno Carnaille
- Department of General and Endocrine Surgery, Lille University Hospital, Lille University, Lille, France
| | - Fatih Tunca
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University, Medical College, Kraków, Poland
| | - Hoon Yub Kim
- Department of Surgery, Korea University Thyroid Center, Korea University College of Medicine, Seongbuk-gu, Seoul, Korea
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Emerson Favero
- Department of Head and Neck Surgery, School of Medicine, University of Mogi das Cruzes, São Paulo, Brazil
| | - Nadia Innaro
- Unit of Endocrine Surgery, AOU Mater Domini, Catanzaro, Italy
| | - Kyriakos Vamvakidis
- Department of Endocrine Surgery, "Henry Dunant" Hospital Center, Athens, Greece
| | - Jonathan Serpell
- Med, Breast, Endocrine and General Surgery Unit, Alfred Health, Monash University, Melbourne, Victoria, Australia
| | | | - Hiroshi Takami
- Department of Surgery, Ito Hospital, Shibuya-ku, Tokyo, Japan
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Rick Schneider
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle, Martin-Luther University, Halle (Saale), Germany
| | - Henning Dralle
- Division of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University of Duisburg Essen, Essen, Germany
| | - Jennifer J Shin
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amr H Abdelhamid Ahmed
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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The Most Common Anatomical Variation of Recurrent Laryngeal Nerve: Extralaryngeal Branching. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2021; 55:294-303. [PMID: 34712069 PMCID: PMC8526224 DOI: 10.14744/semb.2021.93609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 06/19/2021] [Indexed: 11/20/2022]
Abstract
Objective: Extralaryngeal branching of recurrent laryngeal nerve (RLN) is frequent. In various studies, detection rate of extralaryngeal nerve branching was increased by intraoperative neuromonitorization (IONM). Our aim was evaluation of the relationship between the features of extralaryngeal branching of RLN and other anatomic variations in thyroidectomy patients under the guidance of IONM. Methods: Patients underwent thyroidectomy using IONM between January 2016 and December 2019 and whose RLNs were fully explored till the nerve’s entry point to the larynx, were enrolled to the study. Extralaryngeal branching of RLN was accepted as branching of the nerve at a ≥5 mm distance from its laryngeal entry point and having its all branches entering the larynx. Entrapment of RLN at the region of ligament of Berry (BL) by a vascular structure or posterior BL and relationship between RLN and inferior thyroid artery (ITA) was evaluated. Results: Out of 696 patients meeting the inclusion criteria, 1127 neck sides (536F and 160M) were evaluated. Mean age was 49.1±13.4 (range; 18–89). Nerve branching ratio was 35.3% and was higher in females than males (38.2%vs.25.8%, p<0.0001, respectively). Extralaryngeal branching of RLN was detected in 398 (35.3%) out of 1127 nerves. A total of 368 (92.5%) RLNs had two, 27 (6.8%) nerves had three, and 3 (0.7%) had multiple branches. RLN crossed anterior to and between branches of ITA more frequently in branching nerves than non-branching nerves (47.7 vs. 44.4% and 12.8% vs. 7.6%, respectively) but crossed posterior to ITA less frequently in branching nerves (38.5% vs. 48%, respectively, p=0.001). Entrapment of RLN at the region of BL was higher in branched nerves (25.9% vs. 17.5%, respectively, p=0.001). Entrapment of RLN wasmore frequent at the right side than left side both in branching (31.5% vs.19.4%, respectively, p=0.008) and non-branching nerves (20.6% vs. 14.4%, respectively). Conclusion: Extralaryngeal branching of RLN is not rare and mostly divided into two branches. Branching ratio is higher in females than males. In branching nerves, rate of crossing anterior to and between branches of ITA was higher, in non-branching nerves, rate of crossing posterior to ITA was higher. In branching nerves, possibility of entrapment of RLN at the region of BL was higher. Both in branching and non-branching nerves, entrapment of RLN at the region of BL was higher at the right side. Extralaryngeal branching, relationship between RLN and ITA, and entrapment of RLN at the region of BL are frequently seen and variable anatomic variations and cannot be foreseen preoperatively. Most of the extralaryngeal branches and their relationship with other variations can be detected by finding RLN at the level of ITA and following RLN until its entry point to the larynx.
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Van Slycke S, Van Den Heede K, Magamadov K, Gillardin JP, Vermeersch H, Brusselaers N. Intra-operative vagal neuromonitoring predicts non-recurrent laryngeal nerves: technical notes and review of the recent literature. Acta Chir Belg 2021; 121:248-253. [PMID: 31986987 DOI: 10.1080/00015458.2020.1722931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND During thyroid surgery, extreme caution must be taken not to harm the recurrent laryngeal nerve to avoid vocal cord palsy. A non-recurrent laryngeal nerve (NRLN) is a rare anatomical variation that is extremely vulnerable during thyroid surgery. METHODS Description of two NRLN during thyroid surgery discovered early by using continuous intra-operative vagal nerve neuromonitoring and review of the literature. RESULTS During thyroid surgery, we use continuous intra-operative vagal nerve neuromonitoring starting with checking vagal nerve signals. It is essential to start stimulation in the most proximal portion of the carotid sheath. An absent pre-dissection signal on the right vagal nerve with a positive signal on the left vagal nerve indicates a non-recurrent course of the right laryngeal nerve. Post-operatively computed tomography scan (CT-scan) was performed and showed an associated extra-anatomical course of the subclavian artery also known as an arteria lusoria. CONCLUSION The NRLN is an important surgical challenge because unilateral palsy can lead to permanent hoarseness. This anomaly emphasizes the importance of a thorough surgical dissection and the use of intra-operative vagal nerve neuromonitoring. Our method of continuous intra-operative vagal nerve monitoring makes it possible to predict a non-recurrent laryngeal nerve in an early stage during surgery.
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Affiliation(s)
- S. Van Slycke
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Clinic Aalst, Aalst, Belgium
- Department of Head and Skin, University Hospital Ghent, Ghent, Belgium
- Department of General Surgery, AZ Damiaan, Ostend, Belgium
| | - K. Van Den Heede
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Clinic Aalst, Aalst, Belgium
| | - K. Magamadov
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Clinic Aalst, Aalst, Belgium
| | - J.-P. Gillardin
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Clinic Aalst, Aalst, Belgium
| | - H. Vermeersch
- Department of Head and Skin, University Hospital Ghent, Ghent, Belgium
- Department of Plastic and Reconstructive Surgery, University Hospital Ghent, Ghent, Belgium
| | - N. Brusselaers
- Department of Head and Skin, University Hospital Ghent, Ghent, Belgium
- Department of Microbiology, Tumour and Cell Biology, Centre for Translational Microbiome Research, Karolinkska Institutet, Karolinska Hospital, Stockholm, Sweden
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Gršić K, Bumber B, Curić Radivojević R, Leović D. Prophylactic Central Neck Dissection in Well-differentiated Thyroid Cancer. Acta Clin Croat 2021; 59:87-95. [PMID: 34219889 PMCID: PMC8212603 DOI: 10.20471/acc.2020.59.s1.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Well-differentiated cancers, both papillary and follicular, account for 90% of all diagnosed thyroid cancers. They have an indolent disease course with a 20-year disease-specific survival over 90%. According to current guidelines, the therapy of choice for well-differentiated thyroid carcinoma is total thyroidectomy or lobectomy. The indication for prophylactic central neck dissection is still a controversial issue and the subject of unfinished and ongoing debate. There is no indication for prophylactic central neck dissection in follicular thyroid carcinomas, which primarily metastasize hematogenously. In small solitary papillary thyroid carcinomas (T1 and T2), prophylactic central neck dissection is not indicated as it does not bring benefits in terms of improved patient survival and at the same time significantly increases the risk of temporary and permanent postoperative complications. Prophylactic central neck dissection is indicated in advanced papillary thyroid cancers (T3 and T4) and all other high-risk well-differentiated thyroid cancer, as well as in the presence of metastatic lymph nodes in the lateral neck.
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Affiliation(s)
| | - Boris Bumber
- 1Department of Otorhinolaryngology and head and neck surgery, Zagreb University Hospital Centre, Zagreb, Croatia; 2Department of Anaesthesiology, Resuscitation and Intensive Care, Zagreb University Hospital Centre, Zagreb, Croatia; 3Department of Otorhinolaryngology and Maxillofacial Surgery, Faculty of Medicine, J. J. Strossmayer University of Osijek, Osijek, Croatia; 4Department of Dental Medicine, Faculty of Dental Medicine and Health, J. J. Strossmayer University of Osijek, Osijek, Croatia
| | - Renata Curić Radivojević
- 1Department of Otorhinolaryngology and head and neck surgery, Zagreb University Hospital Centre, Zagreb, Croatia; 2Department of Anaesthesiology, Resuscitation and Intensive Care, Zagreb University Hospital Centre, Zagreb, Croatia; 3Department of Otorhinolaryngology and Maxillofacial Surgery, Faculty of Medicine, J. J. Strossmayer University of Osijek, Osijek, Croatia; 4Department of Dental Medicine, Faculty of Dental Medicine and Health, J. J. Strossmayer University of Osijek, Osijek, Croatia
| | - Dinko Leović
- 1Department of Otorhinolaryngology and head and neck surgery, Zagreb University Hospital Centre, Zagreb, Croatia; 2Department of Anaesthesiology, Resuscitation and Intensive Care, Zagreb University Hospital Centre, Zagreb, Croatia; 3Department of Otorhinolaryngology and Maxillofacial Surgery, Faculty of Medicine, J. J. Strossmayer University of Osijek, Osijek, Croatia; 4Department of Dental Medicine, Faculty of Dental Medicine and Health, J. J. Strossmayer University of Osijek, Osijek, Croatia
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18
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Gibson MM, Chen AY. Intermittent Neuromonitoring of the Recurrent Laryngeal and Vagus Nerves: the Ins and Outs. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00351-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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19
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Bonati E, Ivanova S, Loderer T, Cozzani F, Rossini M, Giuffrida M, Del Rio P. Intraoperative neuromonitoring (IONM) in thyroidectomy for carcinoma in an high volume academic Hospital. Minerva Surg 2021; 77:124-129. [PMID: 33890442 DOI: 10.23736/s2724-5691.21.08701-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The diagnosis of thyroid carcinoma has changed in last decades, as the surgical technique during thyroidectomy (endoscopic surgery, robotic surgery, new energy device, intraoperative neuromonitoring). METHODS We analyzed patients undergone to thyroidectomy or lobectomy for thyroid carcinoma from January 2010 to December 2019 at the General Surgery Unit of the Hospital - University of Parma. We divided patients into two groups, based on the use or not of IONM. RESULTS We analyzed data about 638 patients, 486 (76.2%) female and 152 (23.8%) male, with a mean age of 51.8 years. Totally, 574 patients underwent total thyroidectomy and lymphadenectomy was performed in 39 patients. The lobectomy rate was higher in interventions with neuromonitoring (13.93%) than in those without IONM (3.06%). Considering the incidence of postoperative complications and the presence of infiltration of perithyroid tissues or thyroiditis or lymph node metastasis at the histological report, a statistically significant percentage of dysphonia and paraesthesia was recorded only in patients with infiltration of perithyroid tissues (p <0.0001). There was no significant difference in postoperative blood calcium values. The use of intraoperative neuromonitoring has not significantly changed the incidence of postoperative complication. CONCLUSIONS Our study did not show a protective impact of the use of intraoperative neuromonitoring during thyroidectomy on the incidence of postoperative complications but confirmed that it increases the surgeon's feel safety during surgery and facilitates the identification of any undetected nerve lesion with visually intact nerve, inducing the interruption of the thyroidectomy after lobectomy alone, reducing the risk of bilateral recurrent paralysis.
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Affiliation(s)
- Elena Bonati
- Unit of General Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy -
| | - Sonya Ivanova
- Unit of General Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Tommaso Loderer
- Unit of General Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Federico Cozzani
- Unit of General Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Matteo Rossini
- Unit of General Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Mario Giuffrida
- Unit of General Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Paolo Del Rio
- Unit of General Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
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Microscopic Thyroidectomy: The Way We Do It. Indian J Otolaryngol Head Neck Surg 2020; 72:437-442. [PMID: 33088771 DOI: 10.1007/s12070-020-01853-6] [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: 03/26/2020] [Accepted: 04/02/2020] [Indexed: 10/24/2022] Open
Abstract
The present study was conducted with an intent to document the reduced morbidity in terms of postoperative hypocalcemia, injury to recurrent laryngeal and external branch of superior laryngeal nerve, in patients undergoing microscope assisted thyroidectomy. The present study enrolled a total of 878 patrients who underwent hemi, total and completion thyroidectomies, over a period of 3 years at Jain ENT Hospital, Jaipur. In the present study, out of 1118 RL nerves dissected temporary paresis was found in 1.52% and permanent palsy in only 0.36%. Temporary hypocalcemia was seen in 8.12% while permanent hypocalcemia in 0.6% patients. EBSLN could be identified in 1082 of the 1118 nerves dissected. We recommend the use microscope routinely for all thyroid surgeries, starting from the very first step in view of the reduced morbidity that it offers.
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Liu N, Chen B, Li L, Zeng Q, Sheng L, Zhang B, Liang W, Lv B. Mechanisms of recurrent laryngeal nerve injury near the nerve entry point during thyroid surgery: A retrospective cohort study. Int J Surg 2020; 83:125-130. [PMID: 32931979 DOI: 10.1016/j.ijsu.2020.08.058] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/22/2020] [Accepted: 08/26/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The use of intraoperative neuromonitoring (IONM) for visual identification of recurrent laryngeal nerve (RLN) has decreased the rates of RLN injury (RLNI) during thyroid surgery. However, little attention has been paid to RLNI near the nerve entry point (NEP), where most injuries occur. The aim of this study was to determine the mechanism of RLNI near the NEP and to describe the recovery of nerve function. METHODS Patients undergoing thyroid surgery were analyzed to identify true loss of signal (LOS) by IONM. Follow-up for vocal cord palsy (VCP) was confirmed by a postoperative laryngoscopy. The risk factors for RLNI, the type of RLNI, the prevalence of VCP and the time for VCP recovery were all recorded and analyzed. RESULTS We analyzed 3582 at-risk nerves in 2257 surgical patients. The overall rate of RLNI near the NEP in at-risk nerves was 3.2%. RLNI was more likely to occur in nerves with extralaryngeal bifurcation (p = 0.013). The distribution of RLNI types, in order of frequency, was traction (52.6%; n = 61), compression (38.8%; n = 45), thermal (7.8%; n = 9), and nerve transection (0.9%; n = 1). Complete recovery from VCP was documented in 93.1% (n = 108) of RLNI. CONCLUSION Patients with a bifurcated RLN were at a higher risk of RLNI near the NEP than those without bifurcation. Traction and compression injuries occurred most frequently, but would eventually recover. Excessive stretching of the thyroid lobe played a role in RLNIs near the NEP.
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Affiliation(s)
- Nan Liu
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, China.
| | - Bo Chen
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, China.
| | - Luchuan Li
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, China.
| | - Qingdong Zeng
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, China.
| | - Lei Sheng
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, China.
| | - Bin Zhang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, China.
| | - Weili Liang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, China.
| | - Bin Lv
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, China.
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Thomas AM, Fahim DK, Gemechu JM. Anatomical Variations of the Recurrent Laryngeal Nerve and Implications for Injury Prevention during Surgical Procedures of the Neck. Diagnostics (Basel) 2020; 10:diagnostics10090670. [PMID: 32899604 PMCID: PMC7555279 DOI: 10.3390/diagnostics10090670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 08/25/2020] [Accepted: 08/31/2020] [Indexed: 12/02/2022] Open
Abstract
Accurate knowledge of anatomical variations of the recurrent laryngeal nerve (RLN) provides information to prevent inadvertent intraoperative injury and ultimately guide best clinical and surgical practices. The present study aims to assess the potential anatomical variability of RLN pertaining to its course, branching pattern, and relationship to the inferior thyroid artery, which makes it vulnerable during surgical procedures of the neck. Fifty-five formalin-fixed cadavers were carefully dissected and examined, with the course of the RLN carefully evaluated and documented bilaterally. Our findings indicate that extra-laryngeal branches coming off the RLN on both the right and left side innervate the esophagus, trachea, and mainly intrinsic laryngeal muscles. On the right side, 89.1% of the cadavers demonstrated 2–5 extra-laryngeal branches. On the left, 74.6% of the cadavers demonstrated 2–3 extra-laryngeal branches. In relation to the inferior thyroid artery (ITA), 67.9% of right RLNs were located anteriorly, while 32.1% were located posteriorly. On the other hand, 32.1% of left RLNs were anterior to the ITA, while 67.9% were related posteriorly. On both sides, 3–5% of RLN crossed in between the branches of the ITA. Anatomical consideration of the variations in the course, branching pattern, and relationship of the RLNs is essential to minimize complications associated with surgical procedures of the neck, especially thyroidectomy and anterior cervical discectomy and fusion (ACDF) surgery. The information gained in this study emphasizes the need to preferentially utilize left-sided approaches for ACDF surgery whenever possible.
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Affiliation(s)
- Alison M. Thomas
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA; (A.M.T.); (D.K.F.)
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA
| | - Daniel K. Fahim
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA; (A.M.T.); (D.K.F.)
- Michigan Head & Spine Institute, Southfield, MI 48034, USA
| | - Jickssa M. Gemechu
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA
- Correspondence: ; Tel.: +1-248-370-3667
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Sitges-Serra A, Gallego-Otaegui L, Fontané J, Trillo L, Lorente-Poch L, Sancho J. Contralateral surgery in patients scheduled for total thyroidectomy with initial loss or absence of signal during neural monitoring. Br J Surg 2019; 106:404-411. [PMID: 30681138 DOI: 10.1002/bjs.11067] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/20/2018] [Accepted: 10/30/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Staged total thyroidectomy has been advised to prevent bilateral recurrent laryngeal nerve paralysis when loss of the signal from neural monitoring is observed after dissection of the initial thyroid lobe. This is supported by expert opinion but hard evidence is lacking. A lost signal can return during surgery or, even if it persists, its positive predictive value is only in the range 60-70 per cent. The aim of the present study was to investigate the clinical outcome of patients in whom total thyroidectomy was performed following loss of signal after dissection of the first thyroid lobe. METHODS This was a prospective observational study of adult patients scheduled for neural monitoring during total thyroidectomy. The prevalence of first-side absence or loss of signal was recorded. The contralateral thyroid lobe was approached routinely. The vagus and recurrent laryngeal nerves on the first side were retested during and at the end of the contralateral procedure. RESULTS Some 462 patients were included. Loss (32 patients) or initial absence (8) of signal at dissection of the first thyroid lobe was noted in 40 patients (8·7 per cent). Total thyroidectomy was completed in 29 patients, and a change of surgical strategy adopted in 11 patients with benign disease. At retesting, 15 of 37 initially silent nerves recovered electromyographic signal after a mean(s.d.) interval of 30(14) min. Postoperative vocal cord palsy/paresis was demonstrated in 24 of 40 patients. One patient developed a bilateral paresis that could be managed conservatively. CONCLUSION After an absence or loss of signal of the recurrent laryngeal nerve following dissection of the first thyroid lobe, contralateral thyroidectomy can be performed safely, avoiding the expense, psychological burden and potential complications of a second procedure.
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Affiliation(s)
- A Sitges-Serra
- Endocrine Surgery Unit, Hospital del Mar, Barcelona, Spain
| | | | - J Fontané
- Department of Otolaryngology, Hospital del Mar, Barcelona, Spain
| | - L Trillo
- Department of Anaesthesiology, Hospital del Mar, Barcelona, Spain
| | - L Lorente-Poch
- Endocrine Surgery Unit, Hospital del Mar, Barcelona, Spain
| | - J Sancho
- Endocrine Surgery Unit, Hospital del Mar, Barcelona, Spain
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MP S, S A, Jose J. Inferior Approach: a Safe Method for Identification of Recurrent Laryngeal Nerve During Thyroidectomy. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1848-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Usefulness of intraoperative neuromonitoring for preservation of an extralaryngeal bifurcation of the recurrent laryngeal nerve: A case report. Int J Surg Case Rep 2018; 53:330-332. [PMID: 30471624 PMCID: PMC6257905 DOI: 10.1016/j.ijscr.2018.11.009] [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: 11/03/2018] [Accepted: 11/08/2018] [Indexed: 11/22/2022] Open
Abstract
Recurrent laryngeal nerve injury is a major complication of thyroid surgery. Use of an electromyography endotracheal tube can prevent this injury. We describe a case of extralaryngeal bifurcation of the recurrent laryngeal nerve. Intraoperative neuromonitoring could identify and preserve this bifurcation.
Introduction: Recurrent laryngeal nerve injury is a major complication of thyroid surgery. An endotracheal tube with electromyography electrodes attached to it was recently developed for intraoperative neuromonitoring during thyroid surgery. Here we describe the successful identification and preservation of an extralaryngeal bifurcation of the recurrent laryngeal nerve by intraoperative neuromonitoring in a patient undergoing thyroid surgery. Presentation of case: A 56-year-old woman presented for evaluation of a neck swelling found during a medical examination. Computed tomography (CT) revealed a tumor with a 5-cm diameter in the left thyroid lobe. Fine needle aspiration cytology revealed a Bethesda category III finding. Left thyroid lobe resection was scheduled. During surgery, the left recurrent laryngeal nerve was found to be adhered to the tumor. Careful exploration and intraoperative neuromonitoring allowed us to identify and preserve an extralaryngeal bifurcation of the recurrent laryngeal nerve. Discussion: The recurrent laryngeal nerve can demonstrate various anomalies and bifurcations. Failure to notice and correctly identify extralaryngeal bifurcation leads to recurrent laryngeal nerve injury. Motor branch injury has a particularly large effect. Intraoperative neuromonitoring has been reported to be useful for identifying and preserving the recurrent laryngeal nerve and its aberrations as well as the external branch of the superior laryngeal nerve during thyroid surgery. Conclusion: The findings from this case suggest that an extralaryngeal bifurcation of the recurrent laryngeal nerve can be identified and safely preserved by intraoperative neuromonitoring.
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A Review of Methods for the Preservation of Laryngeal Nerves During Thyroidectomy. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2018; 52:79-91. [PMID: 32595378 PMCID: PMC7315061 DOI: 10.14744/semb.2018.37928] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 06/11/2018] [Indexed: 11/20/2022]
Abstract
The recurrent laryngeal nerve (RLN) provides motor innervation to the abductor and adductor muscles of the vocal cord, whereas the external branch of the superior laryngeal nerve (EBSLN) provides motor innervation to the cricothyroid muscle, which is the tensor muscle of the vocal cord. Both the RLN and the EBSLN are anatomically close to the thyroid and are therefore at risk of injury during thyroidectomy. These 2 laryngeal nerves must be carefully preserved during surgery to ensure that the function of the vocal cord is not impaired. Currently, complete exposure of the RLN during thyroidectomy is accepted as the gold standard method for the preservation of RLN. Sufficient knowledge of surgical anatomy, clinical experience, and meticulous surgical techniques are key factors in the identification and safe dissection of the RLN. During a thyroidectomy, the RLN can be identified using four different approaches, depending on the type of thyroid growth and choice of the surgeon: There are lateral, inferior, superior, and medial approaches. The lateral approach is the most commonly used technique in primary thyroid surgery. The RLN is usually found by dissection around the inferior thyroid artery at the level of the middle lobe of the thyroid. RLN is generally found at the site of its entry into the neck region devoid of scar formation when the inferior approach is used especially in cases with secondary surgery. The superior approach is recommended for patients with an huge goiter or large substernal goiter. In this approach, the upper pole of the thyroid is first released and then pulled forward and laterally, and the RLN is exposed on the nerve’s entry point (NEP), into the larynx, under the cricopharyngeus muscle. The medial approach is preferred for patients with substernally or retropharyngeally enlarged goiters. In this approach, the isthmus is first dissected and divided, and then the isthmus and the medial part of the lobe are dissected away from the trachea to reveal the anterolateral part of the trachea. The fibers between the lateral aspect of the second or third tracheal rings and the thyroid, and the fibers of the Berry ligament are gradually dissected cranially, to allow RLN to enter into the field of view lateral to the trachea. The preservation of the anatomical integrity of the RLN does not indicate that its functional integrity is also preserved. IONM is a tool for the functional assessment of RLN, and so this method is an addition to visually identifying RLN, which is the gold standard. IONM significantly contributes to visual identification of the RLN, determination of its anatomical variations, intraoperative recognition of RLN injury, prevention of bilateral vocal cord paralysis, and detection and preservation of electrical activity in the nerve in patients with preoperative vocal cord paralysis. Although there is no standardized method for the preservation of the EBSLN, 3 methods have been defined during the release of the upper pole of the thyroid. These methods involve dividing the branches of the superior thyroidal artery one by one on the capsule without visually identifying the EBSLN, searching and visually identifying the EBSLN before the dissection of the upper pole vessels, or detecting the EBSLN and dissecting the upper pole under the guidance of IONM. IONM also significantly contributes to the detection and confirmation of the EBSLN and dissection and preservation of the upper pole of the thyroid gland.
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Bilateral patterns and motor function of the extralaryngeal branching of the recurrent laryngeal nerve. Surg Radiol Anat 2018; 40:1077-1083. [PMID: 29468266 DOI: 10.1007/s00276-018-1989-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 02/15/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the bilateral patterns and motor function of the extralaryngeal branches (ELB) of the recurrent laryngeal nerve(RLN). METHODS This study included 500 consecutive patients who underwent total thyroidectomy. Intraoperative nerve monitoring (IONM) was used in 230 patients. Demographic data, indications for surgery, the bilateral patterns of ELB of the RLN, electromyographic activity of the ELB, distance between the branching point to the entrance into the larynx, and the rate of postoperative morbidity were analyzed. RESULTS The overall rate of ELB was 27.6% (276/1000). A single trunk of the RLN on both sides was found in 269 (54%) patients, whereas ELB on both sides was observed in 45 (9%) patients. The rates of ELB on the left and right sides were 26.6 and 28.6%, respectively. Of the 89 branched nerves which were dissected using IONM, an evoked motor response was present in 100% of the anterior branches and 5.6% of the posterior branches. The mean branching distance of the RLN was significantly greater in female patients than in male patients on the left side (p = 0.031). The patterns of ELB showed no significant difference in male and female patients. The rates of postoperative transient and permanent hypoparathyroidism and unilateral RLN palsy were 21.6 and 2.8%, and 3.2 and 0.8%, respectively. The rate of RLN palsy was higher in branched nerves compared to those with a single trunk (0.75 vs 0.3%; p = 0.2). CONCLUSION Unilateral ELB of the RLN might be observed in approximately 1/4 of the patients, while bilateral branching is rare. A few number of posterior branches of the RLN can have motor function. The RLN's with ELB might have a higher risk of injury compared to those with a single trunk.
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Uludağ M, Yetkin G, Oran EŞ, Aygün N, Celayir F, İşgör A. Extralaryngeal division of the recurrent laryngeal nerve: A common and asymmetric anatomical variant. Turk J Surg 2017; 33:164-168. [PMID: 28944327 DOI: 10.5152/ucd.2016.3321] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/19/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Recognition of extralaryngeal branching of the recurrent laryngeal nerve is crucial because prevention of vocal cord paralysis requires preservation of all branches of the recurrent laryngeal nerve. We assessed the prevalence of extralaryngeal branching of the recurrent laryngeal nerve and the median branching distance from the point of bifurcation to the entry point of the nerve into the larynx. MATERIAL AND METHODS Prospective operative data on recurrent laryngeal nerve branching were collected from 94 patients who underwent thyroid or parathyroid surgery between September 2011 and May 2012. RESULTS A total of 161 recurrent laryngeal nerves were examined (82 right, 79 left). Overall, 77 (47.8%) of 161 recurrent laryngeal nerves were bifurcated before entering the larynx. There were 36 (43.9%) branching nerves on the right and 41 (51.9%) branching nerves on the left, and there was no significant difference between the sides in terms of branching (p=0.471). Among 67 patients who underwent bilateral exploration, 28.4% were found to have bilateral branching, 40.3% had unilateral branching, and the remaining 31.3% had no branching. The median branching distance was 15 mm (5-60mm). CONCLUSION Extralaryngeal division of recurrent laryngeal nerve is a common and asymmetric anatomical variant. These variations can be easily recognized if the recurrent laryngeal nerve is identified at the level of the inferior thyroid artery and then dissected totally to the entry point of the larynx. Inadvertent division of a branch may lead to vocal cord palsy postoperatively, even when the surgeon believes the integrity of the nerve has been preserved.
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Affiliation(s)
- Mehmet Uludağ
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Gürkan Yetkin
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Ebru Şen Oran
- Clinic of General Surgery, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Nurcihan Aygün
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Fevzi Celayir
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Adnan İşgör
- Department of General Surgery, Bahçeşehir University School of Medicine, İstanbul, Turkey
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Elsheikh E. Superior parathyroid gland approach to the recurrent laryngeal nerve. Head Neck 2017; 39:1287-1290. [PMID: 28493593 DOI: 10.1002/hed.24690] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 05/26/2016] [Accepted: 11/29/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The superior parathyroid gland is known to be almost constant in its location under the false thyroid capsule. Could it be a landmark to point to the site of incision of the false thyroid capsule and find the plane of the recurrent laryngeal nerve (RLN) during thyroidectomy? METHODS The study included 48 patients with benign goiter scheduled for hemithyroidectomy or total thyroidectomy; there were 16 cases of solitary thyroid nodules, 27 cases of multinodular goiter, and 5 cases of toxic goiter. RESULTS This study included 80 lobectomies. All patients showed no evidence of postoperative RLN palsy, bleeding, or hypoparathyroidism. The superior parathyroid gland was consistently found within the false capsule in all cases, whereas the inferior parathyroid was found within the same layer in 64 sides (80%). CONCLUSION The described approach can accurately guide dissection between true and false capsules of the thyroid to reach and preserve both the RLN and the superior parathyroid gland. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1287-1290, 2017.
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Affiliation(s)
- Ezzeddin Elsheikh
- Department of Otorhinolaryngology - Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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30
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Agrawal N, Evasovich MR, Kandil E, Noureldine SI, Felger EA, Tufano RP, Kraus DH, Orloff LA, Grogan R, Angelos P, Stack BC, McIver B, Randolph GW. Indications and extent of central neck dissection for papillary thyroid cancer: An American Head and Neck Society Consensus Statement. Head Neck 2017; 39:1269-1279. [PMID: 28449244 DOI: 10.1002/hed.24715] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The primary purposes of this interdisciplinary consensus statement were to review the relevant indications for central neck dissection (CND) in patients with papillary thyroid cancer (PTC) and to outline the appropriate extent and relevant techniques required to accomplish a safe and effective CND. METHODS A writing group convened by the American Head and Neck Society (AHNS) Endocrine Committee was tasked with identifying the important clinical elements to consider when managing the central neck compartment in patients with PTC based on available evidence in the literature, and the group's collective experience. The position statement paper was then submitted to the full Endocrine Committee, Education Committee, and AHNS Council. RESULTS This consensus statement was developed to inform the clinical decision-making process when managing the central neck compartment in patients with PTC from the AHNS. This document is intended to provide clarity through definitions as well as a basic guideline from which to manage the central neck. It is our hope that this improves the quality and reduces variation in management of the central neck, facilitates communication, and furthers research for patients with thyroid cancer. CONCLUSION This represents, in our opinion, contemporary optimal surgical care for this patient population and is endorsed by the American Head and Neck Society. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1269-1279, 2017.
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Affiliation(s)
- Nishant Agrawal
- Department of Surgery, Section of Otolaryngology - Head and Neck Surgery, University of Chicago, Chicago, Illinois
| | - Maria R Evasovich
- Department of Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Salem I Noureldine
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Erin A Felger
- Department of Surgery, Washington Hospital Center, Washington, DC
| | - Ralph P Tufano
- Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dennis H Kraus
- Center for Head and Neck Oncology, New York Head and Neck Institute, Northwell Health Cancer Institute, New York, New York
| | - Lisa A Orloff
- Department of Otolaryngology, Stanford University Medical Center, Stanford, California
| | - Raymon Grogan
- Department of Surgery, Section of Endocrine Surgery, University of Chicago, Chicago, Illinois
| | - Peter Angelos
- Department of Surgery, Section of Endocrine Surgery, University of Chicago, Chicago, Illinois
| | - Brendan C Stack
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Bryan McIver
- Department of Head and Neck Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Gregory W Randolph
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
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Cho I, Jo MG, Choi SW, Jang JY, Wang SG, Cha W. Some posterior branches of extralaryngeal recurrent laryngeal nerves have motor fibers. Laryngoscope 2017; 127:2678-2685. [PMID: 28425617 DOI: 10.1002/lary.26595] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 02/01/2017] [Accepted: 02/16/2017] [Indexed: 12/29/2022]
Abstract
OBJECTIVES/HYPOTHESIS Anatomical variations of the recurrent laryngeal nerve (RLN), such as extralaryngeal branching, are a well-known risk factor for RLN injury during thyroid surgery. This study aimed to analyze the surgical anatomy and to investigate the existence of posterior branch motor fibers of extralaryngeal RLNs. STUDY DESIGN Prospective consecutive observational study. METHODS This was a prospective cohort study of 366 patients between January 2014 and February 2016. Operative data included the type of operation, incidence of nerve bifurcation, the distances among anatomical landmarks. The motor fibers were evaluated using neurostimulation with laryngeal palpation. RESULTS A total of 667 RLNs at risk were analyzed in this study, and of these 103 (14.5%) nerves were bifurcated or trifurcated before the laryngeal entry point (LEP). More extralaryngeal branched RLNs were observed on the right side than on the left (17.5% vs. 13.3%, P = .294). The mean distance of the LEP point of division was longer on the left side (16.2 ± 6.7 mm) than on the right (14.7 ± 5.9 mm, P = .132). All branched RLNs had a palpable laryngeal twitch when stimulating anterior branches. When stimulating posterior branches, 28.2%(29/103) of branched RLNs showed palpable laryngeal twitch. Overall incidence of posterior motor branch in total RLNs was 4.3% (29/667). CONCLUSIONS The motor fibers of the RLN are all located in the anterior branch, whereas some posterior branches have motor function. Identification of all of the branches of the RLN may be mandatory to decrease the risk of postoperative nerve injury. LEVEL OF EVIDENCE 4. Laryngoscope, 127:2678-2685, 2017.
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Affiliation(s)
- Ilyoung Cho
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Min-Gyu Jo
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Sung-Won Choi
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Jeon Yeob Jang
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Soo-Geun Wang
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, Pusan National University School of Medicine, Yangsan, South Korea
| | - Wonjae Cha
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, Pusan National University School of Medicine, Yangsan, South Korea
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Keseroglu K, Bayir O, Umay EK, Saylam G, Tatar EC, Ozdek A, Korkmaz MH. Laryngeal electromyographic changes in postthyroidectomy patients with normal vocal cord mobility. Eur Arch Otorhinolaryngol 2017; 274:1925-1931. [PMID: 28132134 DOI: 10.1007/s00405-016-4442-2] [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] [Received: 10/30/2016] [Accepted: 12/22/2016] [Indexed: 11/27/2022]
Abstract
Thyroidectomy has been used for the treatment of thyroid disease for more than 100 years. In spite of the advancement of surgical techniques, there is still a risk of laryngeal nerve injury. The risk of partial or complete injury still depends on some surgical and disease-related factors. The aim of this study is to show the partial injury and to establish these risk factors via laryngeal electromyographic analysis (LEMG) in postthyroidectomy patients with normal vocal cord motion and mucosal anatomy. Patients who had undergone thyroid surgery were enrolled in this prospective study. LEMG analysis was performed to all patients with normal vocal cord mobility preoperatively and was repeated after the first and the third months of surgery. Thyroarytenoid (TA) and cricothyroid (CT) muscles were used to evaluate recurrent and external branch of superior laryngeal nerves, respectively. Four of the 32 patients had mild-to-moderate degrees of partial LEMG changes during preoperative LEMG analysis of TA and CT muscles on each side. After 3 months of surgery, there was a statistically significant worsening of LEMG findings in the right and left external branches of superior and left recurrent laryngeal nerves. Disease and surgery-related risk factors were analyzed. However, there was no significant relationship on the progression of LEMG findings according to these parameters. This is the first prospective study which supports the risk of progression of LEMG changes in patients with normal laryngoscopic examination after thyroid surgery. No reliable significant risk factor was found influencing the LEMG progression.
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Affiliation(s)
- Kemal Keseroglu
- Otolaryngology Department, Diskapi Yildirim Beyazit Training and Research Hospital, 1426 Street No: 28/11 Cukurambar, 06510, Ankara, Turkey.
| | - Omer Bayir
- Otolaryngology Department, Diskapi Yildirim Beyazit Training and Research Hospital, 1426 Street No: 28/11 Cukurambar, 06510, Ankara, Turkey
| | - Ebru Karaca Umay
- Physical Medicine and Rehabilitation Department, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Guleser Saylam
- Otolaryngology Department, Diskapi Yildirim Beyazit Training and Research Hospital, 1426 Street No: 28/11 Cukurambar, 06510, Ankara, Turkey
| | - Emel Cadalli Tatar
- Otolaryngology Department, Diskapi Yildirim Beyazit Training and Research Hospital, 1426 Street No: 28/11 Cukurambar, 06510, Ankara, Turkey
| | | | - Mehmet Hakan Korkmaz
- Faculty of Medicine Otolaryngology Department, Yildirim Beyazit University, Ankara, Turkey
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Barczyński M, Stopa M, Konturek A, Nowak W. The Overwhelming Majority but not All Motor Fibers of the Bifid Recurrent Laryngeal Nerve are Located in the Anterior Extralaryngeal Branch. World J Surg 2016; 40:629-35. [PMID: 26438241 PMCID: PMC4746211 DOI: 10.1007/s00268-015-3257-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Few small studies reported that motor fibers are located exclusively in the anterior branch of the bifid recurrent laryngeal nerve (RLN). The aim of this study was to investigate the location of the motor fibers to the intrinsic muscles of the larynx among the bifid RLNs, and assess the prevalence of RLN injury with respect to nerve branching in a pragmatic trial. METHODS This was a prospective cohort study of 1250 patients who underwent total thyroidectomy with intraoperative neural monitoring. The primary outcome was the position of the motor fibers in the bifid nerves. Adduction of the vocal folds was detected by the endotracheal tube electromyography and abduction by finger palpation of muscle contraction in the posterior cricoarytenoid. The secondary outcomes were the prevalence of the RLN branching and the prevalence of RLN injury in bifid versus non-bifid nerves. RESULTS The bifid RLNs were identified in 613/2500 (24.5%) nerves at risk, including 92 (7.4%) patients with bilateral bifurcations. The motor fibers were present exclusively in the anterior branch in 605/613 (98.7%) bifid nerves, and in both the RLN branches in 8/613 (1.3%) bifid nerves. Prevalence of RLN injury was 5.2 versus 1.6% for the bifid versus non-bifid nerves (p < 0.001), odds ratio 2.98 (95% confidence interval 1.79-4.95; p < 0.001). CONCLUSIONS The motor fibers of the RLN are located in the anterior extralaryngeal branch in the vast majority of but not in all patients. In rare cases, the motor fibers for adduction or abduction are located in the posterior branch of the RLN. As the bifid nerves are more prone to injury than non-branched nerves, meticulous dissection is recommended to assure preservation of all the branches of the RLN during thyroidectomy.
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Affiliation(s)
- Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, 37 Prądnicka Street, 31-202, Kraków, Poland.
| | - Małgorzata Stopa
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, 37 Prądnicka Street, 31-202, Kraków, Poland
| | - Aleksander Konturek
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, 37 Prądnicka Street, 31-202, Kraków, Poland
| | - Wojciech Nowak
- Third Chair and Department of General Surgery, Jagiellonian University Medical College, 37 Prądnicka Street, 31-202, Kraków, Poland
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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: 4] [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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Shao T, Qiu W, Yang W. Confirmation of an anatomic variation of the recurrent laryngeal nerve at site of entry into the larynx in Chinese population. Am J Otolaryngol 2016; 37:351-5. [PMID: 26725328 DOI: 10.1016/j.amjoto.2015.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 10/21/2015] [Accepted: 10/31/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study was aimed at analyzing the frequency of the newly reported variation and the frequency of postoperative palsy associated with three different kinds of known variations. METHODS We conducted a retrospective study on the data of 2068 consecutive Chinese patients who underwent thyroidectomy. The study included 1362 left and 1507 right (2869 in total) RLNs. RESULTS Among all the RLNs, 548 were found to have variations at the laryngeal entry of the RLN. The most frequent variation was extralaryngeal branching (n=322), followed by the fan-shaped branching (n=201). Our newly identified variation was also noted in 25 of our patients. In these cases, the RLN entered the larynx from sites that were distant from the posterior cricothyroid joint. The distance from the entry of the RLN to the back of cricothyroid joints was over 5mm. Compared to the rates reported from other countries, the rate of the first type of variation is lower, while that of the second type is higher. The frequency of the new variation has not been reported in other populations, but it is consistent with our previous finding. The incidence of postoperative palsy was greater for RLNs with the first and third types of variations than in the normal RLNs. CONCLUSION We confirmed that the incidence of patients with the new type of variation of the RLN at the entry of the larynx was about 1% in Chinese. Awareness among surgeons regarding this variation is important to avoid postoperative palsy.
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Affiliation(s)
- Tanglei Shao
- Department of Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weihua Qiu
- Department of Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weiping Yang
- Department of Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Akil F, Yollu U, Ayral M, Turgut F, Yener M. The Anatomical Relationship Between Recurrent Laryngeal Nerve and First Tracheal Ring in Males and Females. Clin Exp Otorhinolaryngol 2016; 10:104-108. [PMID: 27337947 PMCID: PMC5327592 DOI: 10.21053/ceo.2015.01746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 01/26/2016] [Accepted: 03/01/2016] [Indexed: 11/30/2022] Open
Abstract
Objectives Despite the modern advances in thyroid surgery, recurrent laryngeal nerve (rln) paralysis is still a critical problem. In order to decrease the rate of this complication, rln anatomy has been studied intensively. In our study, we aimed to recognize the relationship of rln and landmarks of the first tracheal ring. Methods Eighty-six female and 18 male patients who were undergone total thyroidectomy were included in this study. Trachea vertical height (tvh), right recurrent laryngeal nerve height (rrh), left recurrent laryngeal nerve height (lrh), right recurrent laryngeal nerve to trachea anterior face median raphe distance (rrd), left recurrent laryngeal nerve to trachea anterior face median raphe distance (lrd), right recurrent laryngeal nerve respect to trachea ratio (rrtr), and left recurrent laryngeal nerve respect to trachea ratio (lrtr) parameters of all patients were measured and compared in males and females using independent t-test and measurements on both right and left sides were compared statistically without sex discrimination. Results There were no significant differences between groups in tvh, rrh, rrd, lrd, rrtr, and lrtr parameters. Lrh parameter was significantly higher in males than in females (P<0.04). Comparison of right and left sides revealed that lrh was significantly higher than rrh (P<0.001), lrd was significantly higher than rrd (P<0.001), and rrtr was significantly higher than lrtr (P<0.001). Conclusion In this study, we have shown that in all cases the rln was located around the lower half of trachea vertical length and at this level left rln was located significantly deeper than the right side.
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Affiliation(s)
- Ferit Akil
- Otolaryngology Department, Diyarbakir Selahaddin Eyyubi Public Hospital, Diyarbakir, Turkey
| | - Umur Yollu
- Otolaryngology Clinic, Gumushane Public Hospital, Gumushane, Turkey
| | - Muhammed Ayral
- Otolaryngology Department, Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Faith Turgut
- Otolaryngology Department, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Murat Yener
- Otolaryngology Department, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
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Uludag M, Yazici P, Aygun N, Citgez B, Yetkin G, Mihmanli M, Isgor A. A Closer Look at the Recurrent Laryngeal Nerve Focusing on Branches & Diameters: A Prospective Cohort Study. J INVEST SURG 2016; 29:383-388. [PMID: 27159534 DOI: 10.1080/08941939.2016.1176279] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM We aimed to investigate the anatomical characteristics of the recurrent laryngeal nerve (RLN) highlighting on its diameter and branching pattern. MATERIALS AND METHODS We prospectively collected 215 patients (178 female, 37 male) who underwent thyroid/parathyroid surgery during over a 2-year period. Apart from demographic features and surgical data, diameter of RLNs, and their branches and as well as branching distance (distance between the point of bifurcation and the laryngeal entry of RLN) were recorded. RESULTS In 215 patients, 378 RLNs were assessed and 42% (n = 159) bifurcated RLNs were observed. The bifurcation rate was similar on the right and left side(s) of the neck (40% and 44%, respectively; p = 0.47). In those, who underwent bilateral exploration, in the case of bifurcation on the first side of the neck, the possibility of contralateral bifurcation was approximately 50%, whereas this rate was found to be only 30% in those with nonbranching RLNs. Mean branching distance was 18 ± 9 mm, and it was similar on the right and left sides (17 and 19 mm, respectively). Approximately 80% of bifurcations were observed within 5-24 mm of the RLN. Mean diameter of the anterior branches was found to be significantly larger compared to posterior branches (1.09 ± 0.35 and 0.82 ± 0.36 mm, respectively; p < 0.01). CONCLUSIONS There is great variability in RLN branching. We observed that approximately two out of three bifurcations were unilateral and anterior branches were thicker compared to posterior branches. These findings should be taken into consideration to avoid any damage to the RLN during thyroid and parathyroid surgery.
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Affiliation(s)
- Mehmet Uludag
- a Sisli Hamidiye Etfal Training and Research Hospital , Sisli , Istanbul , Turkey
| | - Pinar Yazici
- a Sisli Hamidiye Etfal Training and Research Hospital , Sisli , Istanbul , Turkey
| | - Nurcihan Aygun
- a Sisli Hamidiye Etfal Training and Research Hospital , Sisli , Istanbul , Turkey
| | - Bulent Citgez
- a Sisli Hamidiye Etfal Training and Research Hospital , Sisli , Istanbul , Turkey
| | - Gurkan Yetkin
- a Sisli Hamidiye Etfal Training and Research Hospital , Sisli , Istanbul , Turkey
| | - Mehmet Mihmanli
- a Sisli Hamidiye Etfal Training and Research Hospital , Sisli , Istanbul , Turkey
| | - Adnan Isgor
- b School of Medicine , Department of General Surgery , Bahcesehir Universitesi , Istanbul , Turkey
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Uludag M, Aygun N, Isgor A. Motor function of the recurrent laryngeal nerve: Sometimes motor fibers are also located in the posterior branch. Surgery 2016; 160:153-160. [PMID: 26972775 DOI: 10.1016/j.surg.2016.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 12/22/2015] [Accepted: 02/03/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The function of the extralaryngeal branches of the recurrent laryngeal nerve (RLN) has yet to be described precisely. The goal of this study was to evaluate the incidence and motor function of the extralaryngeal branches of the RLN. METHODS Our study group consisted of 335 consecutive patients undergoing thyroid and parathyroid operations in whom the branches of the RLNs (n = 200) were evaluated with intraoperative nerve monitoring and by measuring the distance from the point of branching of the RLN into anterior and posterior branches and the entry of the individual branches into the larynx-defined as the branching distance. Anterior and posterior branches of the RLN were assessed separately by electromyography (using a standard electromyography endotracheal tube) for adduction and by finger palpation for abduction. The RLNs were classified as having motor function only in the anterior branches (Group 1) or function both in the anterior and posterior branches (Group 2). RESULTS There were 185 RLNs in Group 1 and 15 RLNs in Group 2, assessed by intraoperative nerve monitoring. Motor function was detected in all anterior branches of the RLN (100%) and in 8% of the posterior branches. The mean branching distance was greater in Group 2 compared with Group 1 (24.1 ± 13.6 mm, 17.3 ± 8.5 mm, respectively, P = .045). CONCLUSION Although the anterior branch of RLN always has motor function, the posterior branch also has motor function in about 8% of patients. The probability of detecting motor function in the posterior branch was greater among early branching RLNs, which have a greater branching distance. The surgeon should remember that posterior branches may contain motor fibers and protect these branches to avoid postoperative vocal cord dysfunction.
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Affiliation(s)
- Mehmet Uludag
- General Surgery, Sisli Hamidiye Etfal Education & Research Hospital, Istanbul, Turkey.
| | - Nurcihan Aygun
- General Surgery, Sisli Hamidiye Etfal Education & Research Hospital, Istanbul, Turkey
| | - Adnan Isgor
- General Surgery, Bahcesehir University, Istanbul, Turkey
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Gurleyik E. Location of motor fibers within branches of the recurrent laryngeal nerve with extralaryngeal terminal bifurcation; Functional identification by intraoperative neuromonitoring. Surgery 2015; 158:1339-44. [PMID: 26054316 DOI: 10.1016/j.surg.2015.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 03/28/2015] [Accepted: 04/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Extralaryngeal terminal bifurcation (ETB) of the recurrent laryngeal nerve (RLN) is an anatomic variation that threatens the safety of thyroid operation. Therefore, it is important to identify motor function in nerve branches to preserve appropriate motor activity. Intraoperative neuromonitoring (IONM) is an accepted procedure to identify motor function of the RLN. METHODS We established the operative anatomy of RLNs with ETB in 47 patients. The main trunk, bifurcation point, and the branches were identified and exposed completely during thyroid operation. The location of motor fibers within nerve branches was investigated by identifying motor function via IONM. Wave amplitudes were recorded after electrophysiologic stimulation. RESULTS A total of 61 RLNs had ETBs with anterior and posterior branches. Bifurcation occurred early along the pre-arterial (proximal) segment in 13% of bifid RLNs. IONM showed motor function in all anterior branches. IONM identified motor activity in 4 (18%) posterior branches of 22 right, 3 (8%) posterior branches of 39 left, and 7 (12%) posterior branches of all 61 RLNs with ETB. The rate of recorded wave amplitudes of motor function in seven posterior branches was between 14 and 78% of those of corresponding anterior branches. CONCLUSION In the RLN, the anterior branch always and the posterior branch uncommonly contain motor fibers. Wave amplitude analysis showed that motor function in the posterior branch is weaker than that in the anterior branch. On the basis of the location of motor fibers in both branches, total exposure and preservation of anatomy and function of all branches of the RLN is mandatory for complication-free thyroid surgery. Electrophysiologic testing may be as an important adjunct to visualization of the nerve with anatomic variation.
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Affiliation(s)
- Emin Gurleyik
- Department of Surgery, Duzce University, Medical Faculty, Duzce, Turkey.
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Serpell JW, Lee JC, Yeung MJ, Grodski S, Johnson W, Bailey M. Differential recurrent laryngeal nerve palsy rates after thyroidectomy. Surgery 2014; 156:1157-66. [DOI: 10.1016/j.surg.2014.07.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 07/17/2014] [Indexed: 11/24/2022]
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Gurleyik E. Surgical anatomy of bilateral extralaryngeal bifurcation of the recurrent laryngeal nerve: similarities and differences between both sides. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2014; 6:445-9. [PMID: 25317388 PMCID: PMC4193150 DOI: 10.4103/1947-2714.141630] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background: Anatomical variations of the recurrent laryngeal nerve (RLN) such as extralaryngeal terminal bifurcation is an important risk for its motor function. Aims: The objective is to study surgical anatomy of bilateral bifurcation of the RLNs in order to decrease risk of vocal cord palsy in patients with bifurcated nerves. Materials and Methods: Surgical anatomy including terminal bifurcation was established in 292 RLNs of 146 patients. We included patients with bilateral bifurcation of RLN in this study. Based on two anatomical landmarks (nerve-artery crossing and laryngeal entry), the cervical course of RLN was classified in four segments: Pre-arterial, arterial, post-arterial and pre-laryngeal. According to these segments, bifurcation point locations along the cervical course of RLNs were compared between both sides in bilateral cases. Results: RLNs were exposed throughout their entire courses. Seventy (48%) patients had bifurcated RLNs. We identified terminal bifurcation in 90 (31%) of 292 RLNs along the cervical course. Bilateral bifurcation was observed in 20 (28.6%) patients with bifurcated RLNs. Bifurcation points were located on arterial and post-arterial segments in 37.5% and 32.5% of cases, respectively. Pre-arterial and pre-laryngeal segments contained bifurcations in 15% of cases. Comparison of both sides indicated that bifurcation points were similar in 5 (25%) and different in 15 (75%) patients with bilateral bifurcation. Permanent nerve injury did not occur in this series. Conclusion: Bilateral bifurcation of both RLNs was observed in approximately 30% of patients with extralaryngeal bifurcation which is a common anatomical variation. Bifurcation occurred in different segments along cervical course of RLN. Bifurcation point locations differed between both sides in the majority of bilateral cases. Increasing surgeons’ awareness of this variation may lead to safely exposing bifurcated nerves and prevent the injury to extralaryngeal terminal branches of RLN.
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Affiliation(s)
- Emin Gurleyik
- Department of Surgery, Duzce University, Medical Faculty, Duzce, Turkey
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Clinical relevance and surgical anatomy of non-recurrent laryngeal nerve: 7 year experience. Surg Radiol Anat 2014; 37:321-5. [DOI: 10.1007/s00276-014-1369-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 08/30/2014] [Indexed: 11/26/2022]
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Results of Intraoperative Neuromonitoring in Thyroid Surgery and Preoperative Vocal Cord Paralysis. World J Surg 2013; 38:582-91. [DOI: 10.1007/s00268-013-2402-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Extralaryngeal terminal division of the inferior laryngeal nerve: anatomical classification by a surgical point of view. J Thyroid Res 2013; 2013:731250. [PMID: 23819101 PMCID: PMC3683490 DOI: 10.1155/2013/731250] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 05/20/2013] [Indexed: 11/17/2022] Open
Abstract
Background. Complete anatomic knowledge including all variations of the inferior laryngeal nerve (ILN) is mandatory for thyroid surgeon. Extralaryngeal terminal division (ETD) of the ILN has significant importance for the safety of thyroidectomy. Material and Methods. Surgical dissection of 200 ILNs was performed on 100 cases. The presence of ETD of the nerve was determined intraoperatively. We propose by a surgical point of view a regional (segmental) classification of ETD of the ILN along its cervical course. Results. ETD has been observed in 54/200 nerves (27%). Great majority are bifurcated nerves (trifurcation 2%). Four types of ETD are classified. In type 1 (arterial; 46.3%), ETD has occurred near inferior thyroid artery (ITA). In type 2 (postarterial; 31.5%), division has been found on postarterial segment. In type 3 (prelaryngeal; 11%), division has been located very close to laryngeal entry point. In type 4 (prearterial; 11%), ETD has occurred before the nerve crossing the ITA. Conclusions. ETD of the ILN is a common anatomical variation. The bifurcation occurs in the ILN at various distances from laryngeal entry point. The classification increasing surgeons' awareness may help to simplify identification and exposure of terminal branches. Preservation of both extralaryngeal terminal branches of the ILN has paramount importance for the safety of thyroid operations.
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Tamaki T, Node Y, Saitou N, Saigusa H. Observation of Vocal Fold and Pharyngeal Paralysis After Carotid Endarterectomy Using a Magnifying Laryngoscope. World J Surg 2013; 37:911-4. [DOI: 10.1007/s00268-013-1920-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sitges-Serra A, Fontané J, Dueñas JP, Duque CS, Lorente L, Trillo L, Sancho JJ. Prospective study on loss of signal on the first side during neuromonitoring of the recurrent laryngeal nerve in total thyroidectomy. Br J Surg 2013; 100:662-6. [DOI: 10.1002/bjs.9044] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2012] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Staged thyroidectomy has been recommended when loss of the signal from intraoperative nerve monitoring is observed after first-side dissection of the recurrent laryngeal nerve. There is no high-quality evidence supporting this recommendation. In addition, it is not clear whether signal loss predicts postoperative vocal cord paralysis.
Methods
This was a prospective observational study of consecutive adult patients undergoing neuromonitored total thyroidectomy for either malignancy or multinodular goitre. The prevalence of first-side loss of signal was recorded. Surgery was completed, and vagus and laryngeal nerves on the first side were rechecked at the end of the procedure.
Results
Two-hundred and ninety patients were included. Loss of signal on the first side was noted in 16 procedures (5·5 per cent). Thyroidectomy was completed and, at retesting, 15 of 16 initially silent nerves recovered an electromyographic signal with a mean(s.d.) amplitude of 132(26) mcV. Mean time to recovery was 20·2 (range 10–35) min. In no patient was the signal lost on the opposite side. Only three of 15 nerves with a recovered signal were associated with transient vocal cord dysfunction.
Conclusion
After loss of signal of the recurrent laryngeal nerve dissected initially, there was a 90 per cent chance of intraoperative signal recovery. In this setting, judicious bilateral thyroidectomy can be performed without risk of bilateral recurrent nerve paresis.
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Affiliation(s)
- A Sitges-Serra
- Endocrine Surgery Unit, Hospital del Mar, Barcelona, Spain
| | - J Fontané
- Department of Otolaryngology, Hospital del Mar, Barcelona, Spain
| | - J P Dueñas
- Department of Anaesthesiology, Hospital del Mar, Barcelona, Spain
| | - C S Duque
- Department of Anaesthesiology, Hospital del Mar, Barcelona, Spain
| | - L Lorente
- Endocrine Surgery Unit, Hospital del Mar, Barcelona, Spain
| | - L Trillo
- Endocrine Surgery Unit, Hospital Pablo Tobóon Uribe e Instituto de Cancerología, Medellín, Colombia
| | - J J Sancho
- Endocrine Surgery Unit, Hospital del Mar, Barcelona, Spain
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Hayward NJ, Grodski S, Yeung M, Johnson WR, Serpell J. Recurrent laryngeal nerve injury in thyroid surgery: a review. ANZ J Surg 2012; 83:15-21. [DOI: 10.1111/j.1445-2197.2012.06247.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2012] [Indexed: 11/26/2022]
Affiliation(s)
- Nathan James Hayward
- Department of Breast, Endocrine and General Surgery; The Alfred; Melbourne; Victoria; Australia
| | - Simon Grodski
- Department of Breast, Endocrine and General Surgery; The Alfred; Melbourne; Victoria; Australia
| | - Meei Yeung
- Department of Breast, Endocrine and General Surgery; The Alfred; Melbourne; Victoria; Australia
| | - William R. Johnson
- Department of Breast, Endocrine and General Surgery; The Alfred; Melbourne; Victoria; Australia
| | - Jonathan Serpell
- Department of Breast, Endocrine and General Surgery; The Alfred; Melbourne; Victoria; Australia
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John A, Etienne D, Klaassen Z, Shoja MM, Tubbs RS, Loukas M. Variations in the Locations of the Recurrent Laryngeal Nerve in Relation to the Ligament of Berry. Am Surg 2012. [DOI: 10.1177/000313481207800933] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Injury to the recurrent laryngeal nerve (RLN) is one of the most common iatrogenic complications of thyroid surgery. The anatomical course of the nerve also increases its susceptibility to injury and many variations have been documented in the literature. The topographical relationship of the RLN to the ligament of Berry has been extensively studied over the past decades. The consensus in the literature is divided with several authors reporting the nerve to be embedded within the ligament and others reporting a constant finding of the nerve being posterolateral to the ligament. A new operative concept has been recently introduced as a possible resolution for the conflicting reports among authors. Further investigations are needed, however, to assess its reliability and overall effects on clinical outcomes.
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Affiliation(s)
- Alana John
- Department of Anatomical Sciences, St. George's University, School of Medicine, Grenada, West Indies
| | - Denzil Etienne
- Department of Anatomical Sciences, St. George's University, School of Medicine, Grenada, West Indies
| | - Zachary Klaassen
- Department of Anatomical Sciences, St. George's University, School of Medicine, Grenada, West Indies
| | | | - R. Shane Tubbs
- Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, School of Medicine, Grenada, West Indies
- Department of Surgery, Medical Faculty, University of Varmia and Masuria, Olsztyn, Poland
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Altorjay A, Rüll M, Paál B, Csáti G, Szilágyi A. "Mystic" transient recurrent nerve palsy after thyroid surgery. Head Neck 2012; 35:934-41. [PMID: 22847962 DOI: 10.1002/hed.23048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2012] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The mechanism of transient recurrent laryngeal nerve (RLN) palsy remains unclear. METHODS Samples were harvested from the RLN adjacent thyroid capsule and perineural fascia during 223 lobectomies and 89 RLNs from cadavers were used for histologic and immunohistologic evaluation. Intraoperative chromoendoscopic features of the RLN were compared with postoperative ear, nose, and throat examinations. RESULTS Those nerves that macroscopically seem to be single-branched (35 of 89 = 39.3%), microscopically consist of multiple fascicles in most of the cases (23 of 35 = 65.7%), resembling a plexus more than a single cord. Chronic lymphocytic infiltration of the thyroid capsule adjacent to the RLN was present in 29% (65 of 223) of the cases. The perineural fascia showed lymphocytic (18 of 223 = 8.1%) or granulocytic (7 of 223 = 3.1%) infiltration. CONCLUSIONS The origin of transient RLN palsy is multifactorial: plexus shaped microscopic nerve structure with or without branches, frame-like adventitial tissue, variable epineurium, inflammatory changes that involve not only the thyroid capsule but the perineural fascia, resultant nerve edema, and diffuse microhemorrhages by injury of fragile capillaries.
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Affiliation(s)
- Aron Altorjay
- Department of Surgery, St. George University Teaching Hospital, H-8000 Székesfehérvár, Seregélyesi út 3., Hungary.
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A Closer Look at Laryngeal Nerves during Thyroid Surgery: A Descriptive Study of 584 Nerves. ANATOMY RESEARCH INTERNATIONAL 2012; 2012:490390. [PMID: 22737584 PMCID: PMC3378964 DOI: 10.1155/2012/490390] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 03/19/2012] [Accepted: 04/09/2012] [Indexed: 11/18/2022]
Abstract
Morbidity after thyroidectomy is related to injuries to the parathyroids, recurrent laryngeal (RLN) and external branch of superior laryngeal nerves (EBSLN). Mostly these are due to variations in the surgical anatomy. In this study we analyse the surgical anatomy of the laryngeal nerves in Indian patients undergoing thyroidectomy. Materials and Methods. Retrospective study (February 2008 to February 2010). Patients undergoing surgery for benign goitres, T1, T2 thyroid cancers without lymph node involvement were included. Data on EBSLN types, RLN course and its relation to the TZ & LOB were recorded. Results. 404 thyroid surgeries (180 total & 224 hemithyroidectomy) were performed. Data related to 584 EBSLN and RLN were included (324 right sided & 260 left sided). EBSLN patterns were Type 1 in 71.4%, Type IIA in 12.3%, and Type IIB in 7.36%. The nerve was not seen in 4.3% cases. RLN had one branch in 69.34%, two branches in 29.11% and three branches in 1.36%. 25% of the RLN was superficial to the inferior thyroid artery, 65% deep to it and 8.2% between the branches. TZ was Grade 1 in 65.2%, Grade II in 25.1% and Grade III in 9.5%. 31.16% of the RLN passes through the LOB. Conclusions. A thorough knowledge of the laryngeal nerves and anatomical variations is necessary for safe thyroid surgery.
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