Neuronal Survival and Glial Reactions after Recurrent Laryngeal Nerve Resection in the Rat

Recurrent laryngeal nerve transection in mice results in translational upper airway dysfunction

The recurrent laryngeal nerve (RLN) is responsible for normal vocal-fold (VF) movement, and is at risk for iatrogenic injury during anterior neck surgical procedures in human patients. Injury, resulting in VF paralysis, may contribute to subsequent swallowing, voice, and respiratory dysfunction. Unfortunately, treatment for RLN injury does little to restore physiologic function of the VFs. Thus, we sought to create a mouse model with translational functional outcomes to further investigate RLN regeneration and potential therapeutic interventions. To do so, we performed ventral neck surgery in 21 C57BL/6J male mice, divided into two groups: Unilateral RLN Transection (n = 11) and Sham Injury (n = 10). Mice underwent behavioral assays to determine upper airway function at multiple time points prior to and following surgery. Transoral endoscopy, videofluoroscopy, ultrasonic vocalizations, and whole-body plethysmography were used to assess VF motion, swallow function, vocal function, and respiratory function, respectively. Affected outcome metrics, such as VF motion correlation, intervocalization interval, and peak inspiratory flow were identified to increase the translational potential of this model. Additionally, immunohistochemistry was used to investigate neuronal cell death in the nucleus ambiguus. Results revealed that RLN transection created ipsilateral VF paralysis that did not recover by 13 weeks postsurgery. Furthermore, there was evidence of significant vocal and respiratory dysfunction in the RLN transection group, but not the sham injury group. No significant differences in swallow function or neuronal cell death were found between the two groups. In conclusion, our mouse model of RLN injury provides several novel functional outcome measures to increase the translational potential of findings in preclinical animal studies. We will use this model and behavioral assays to assess various treatment options in future studies.

Nimodipine Improves Reinnervation and Neuromuscular Function after Injury to the Recurrent Laryngeal Nerve in the Rat

Objectives:

Injury of the recurrent laryngeal nerve (RLN) is associated with a high degree of neuronal survival, but leads to various levels of vocal fold motion impairment or laryngeal synkinesis, which has been attributed to misdirected reinnervation of the target muscles in the larynx or aberrant, competing reinnervation from adjacent nerve fibers. The aim of the present study was to evaluate the impact of the regeneration-promoting agent nimodipine on reinnervation and neuromuscular function following RLN crush injury.

Methods:

Sixty adult rats were randomized into nimodipine-treated or untreated groups and then underwent RLN crush injury. Reinnervation of the posterior cricoarytenoid muscle (PCA) was assessed by electrophysiological examination, retrograde tracing of lower motor neurons before and after injury, and quantification of neuromuscular junctions in the PCA muscle.

Results:

At 6 weeks after injury, the nimodipine-treated animals showed significantly enhanced neuromuscular function and also demonstrated a higher number of motor neurons in the brain stem that had reinnervated the PCA, compared to the untreated animals. The somatotopic organization of ambiguus motor neurons innervating the larynx was similar before injury and after reinnervation.

Conclusions:

Nimodipine improves regeneration and neuromuscular function following RLN injury in the adult rat, and could be of use in future strategies following RLN injury.

Recovery of laryngeal function after intraoperative injury to the recurrent laryngeal nerve

Loss of function in the recurrent laryngeal nerve (RLN) during thyroid/parathyroid surgery, despite a macroscopically intact nerve, is a challenge which highlights the sensitivity and complexity of laryngeal innervation. Furthermore, the uncertain prognosis stresses a lack of capability to diagnose the reason behind the impaired function. There is a great deal of literature considering risk factors, surgical technique and mechanisms outside the nerve affecting the incidence of RLN paresis during surgery. To be able to prognosticate recovery in cases of laryngeal dysfunction and voice changes after thyroid surgery, the surgeon would first need to define the presence, location, and type of laryngeal nerve injury. There is little data describing the events within the nerve and the neurobiological reasons for the impaired function related to potential recovery and prognosis. In addition, very little data has been presented in order to clarify any differences between the transient and permanent injury of the RLN. This review aims, from an anatomical and neurobiological perspective, to provide an update on the current understandings of surgically-induced injury to the laryngeal nerves.

Migration and differentiation of neural progenitor cells after recurrent laryngeal nerve avulsion in rats

To investigate migration and differentiation of neural progenitor cells (NPCs) from the ependymal layer to the nucleus ambiguus (NA) after recurrent laryngeal nerve (RLN) avulsion. All of the animals received a CM-DiI injection in the left lateral ventricle. Forty-five adult rats were subjected to a left RLN avulsion injury, and nine rats were used as controls. 5-Bromo-2-deoxyuridine (BrdU) was injected intraperitoneally. Immunohistochemical analyses were performed in the brain stems at different time points after RLN injury. After RLN avulsion, the CM-DiI+ NPCs from the ependymal layer migrated to the lesioned NA. CM-DiI+/GFAP+ astrocytes, CM-DiI+/DCX+ neuroblasts and CM-DiI+/NeuN+ neurons were observed in the migratory stream. However, the ipsilateral NA included only CM-DiI+ astrocytes, not newborn neurons. After RLN avulsion, the NPCs in the ependymal layer of the 4th ventricle or central canal attempt to restore the damaged NA. We first confirm that the migratory stream includes both neurons and glia differentiated from the NPCs. However, only differentiated astrocytes are successfully incorporated into the NA. The presence of both cell types in the migratory process may play a role in repairing RLN injuries.

GFAP immunoreactivity within the rat nucleus ambiguus after laryngeal nerve injury

Changes that occur in astroglial populations of the nucleus ambiguus after recurrent (RLN) or superior (SLN) laryngeal nerve injury have hitherto not been fully characterised. In the present study, rat RLN and SLN were lesioned. After 3, 7, 14, 28 or 56 days of survival, the nucleus ambiguus was investigated by means of glial fibrillary acidic protein (GFAP) immunofluorescence or a combination of GFAP immunofluorescence and the application of retrograde tracers. GFAP immunoreactivity was significantly increased 3 days after RLN resection and it remained significantly elevated until after 28 days post injury (dpi). By 56 dpi it had returned to basal levels. In contrast, following RLN transection with repair, GFAP immunoreactivity was significantly elevated at 7 dpi and remained significantly elevated until 14 dpi. It had returned to basal levels by 28 dpi. Topographical analysis of the distribution of GFAP immunoreactivity revealed that after RLN injury, GFAP immunoreactivity was increased beyond the area of the nucleus ambiguus within which RLN motor neuron somata were located. GFAP immunoreactivity was also observed in the vicinity of neuronal somata that project into the uninjured SLN. Similarly, lesion of the SLN resulted in increased GFAP immunoreactivity around the neuronal somata projecting into it and also in the vicinity of the motor neuron somata projecting into the RLN. The increase in GFAP immunoreactivity outside of the region containing the motor neurons projecting into the injured nerve, may reflect the onset of a regenerative process attempting to compensate for impairment of one of the laryngeal nerves and may occur because of the dual innervation of the posterior cricoarytenoid muscle. This dual innervation of a very specialised muscle could provide a useful model system for studying the molecular mechanisms underlying axonal regeneration process and the results of the current study could provide the basis for studies into functional regeneration following laryngeal nerve injury, with subsequent application to humans.

Neuroregeneration in the nucleus ambiguus after recurrent laryngeal nerve avulsion in rats

OBJECTIVES

The objective was to investigate neuroregeneration, the origins of newborn cells and the proliferation of neuronal and glial cells in the nucleus ambiguus (NA) after ipsilateral recurrent laryngeal nerve (RLN) avulsion.

METHODS

All of the animals received a CM-Dil injection in the left lateral ventricle. Forty-five adult rats were subjected to a left RLN avulsion injury, while 9 rats were used as controls. 5-Bromo-2-deoxyuridine (BrdU) was injected intraperitoneally. Neuron quantification and immunohistochemical analysis were performed in the brain stems at different time points after RLN injury.

RESULTS

After RLN avulsion, CM-Dil labeled neural progenitor cells (NPCs) migrated to the ipsilateral NA and differentiated into astrocytes but not into neurons. In the NA, the neuronal cells re-expressed nestin. Only a small number of neuronal and glial cells in the NA showed BrdU immunoreactivity.

CONCLUSIONS

After RLN avulsion, the NPCs in the ependymal layer of the fourth ventricle or central canal are activated, migrate to the lesion in the NA and differentiate exclusively into astrocytes. The newborn neural stem cells in the NA may arise from the mature region neurons. The presence of both cell types in the NA may play a role in repairing RLN injuries.

Development of the rat larynx: a histological study

OBJECTIVES/HYPOTHESIS

To evaluate and describe the cartilaginous and muscular development of the rat larynx.

STUDY DESIGN

Histologic evaluation.

METHODS

The larynges of Sprague Dawley rats of embryonic day (E) 13, 15, 17, 19, 21, postnatal day 0, 14, and adult of 250 gm were collected. Four larynges of each age were harvested, cut into 15-μm serial sections, stained with hematoxylin and eosin, and evaluated under light microscopy. Representative digital images were recorded and evaluated at the preglottic (supraglottic in humans), glottic, and postglottic (subglottic in humans) levels.

RESULTS

Brachial arches were observed at E13. At E17, immature structures of the larynx, including skeletal muscle, cartilage, and the lumen were identifiable. Chondrification and muscle formation were clearly seen by E19. The muscular and cartilagenous components of the larynx were well established by E21. During the span between birth and adult maturation, the size of the larynx increased from a height of 1.10 mm to 2.90 mm, and from a width of 1.80 mm to 5.40 mm, and from a length of 1.38 mm to 4.77 mm in the stained section. Although developed at E21, the laryngeal structures continued to grow by approximately 30%.

CONCLUSION

Rat laryngeal development parallels that in mice and humans. In the rat, at E17 immature structures of the larynx are identifiable, they are well developed at birth and grow by approximately 30% into adulthood. Understanding the chronology and morphology of the embryogenesis of the rat laryngeal musculature is essential and will allow for further evaluation of the embryologic innervation of these muscles.

Reorganization of laryngeal motoneurons after crush injury in the recurrent laryngeal nerve of the rat

Motoneurons innervating laryngeal muscles are located in the nucleus ambiguus (Amb), but there is no general agreement on the somatotopic representation and even less is known on how an injury in the recurrent laryngeal nerve (RLN) affects this pattern. This study analyzes the normal somatotopy of those motoneurons and describes its changes over time after a crush injury to the RLN. In the control group (control group 1, n = 9 rats), the posterior cricoarytenoid (PCA) and thyroarytenoid (TA) muscles were injected with cholera toxin-B. In the experimental groups the left RLN of each animal was crushed with a fine tip forceps and, after several survival periods (1, 2, 4, 8, 12 weeks; minimum six rats per time), the PCA and TA muscles were injected as described above. After each surgery, the motility of the vocal folds was evaluated. Additional control experiments were performed; the second control experiment (control group 2, n = 6 rats) was performed labeling the TA and PCA immediately prior to the section of the superior laryngeal nerve (SLN), in order to eliminate the possibility of accidental labeling of the cricothyroid (CT) muscle by spread from the injection site. The third control group (control group 3, n = 5 rats) was included to determine if there is some sprouting from the SLN into the territories of the RLN after a crush of this last nerve. One week after the crush injury of the RLN, the PCA and TA muscles were injected immediately before the section of the SLN. The results show that a single population of neurons represents each muscle with the PCA in the most rostral position followed caudalwards by the TA. One week post-RLN injury, both the somatotopy and the number of labeled motoneurons changed, where the labeled neurons were distributed randomly; in addition, an area of topographical overlap of the two populations was observed and vocal fold mobility was lost. In the rest of the survival periods, the overlapping area is larger, but the movement of the vocal folds tends to recover. After 12 weeks of survival, the disorganization within the Amb is the largest, but the number of motoneurons is similar to control, and all animals recovered the movement of the left vocal fold. Our additional controls indicate that no tracer spread to the CT muscle occurred, and that many of the labeled motoneurons from the PCA after 1 week post-RLN injury correspond to motoneurons whose axons travel in the SLN. Therefore, it seems that after RLN injury there is a collateral sprouting and collateral innervation. Although the somatotopic organization of the Amb is lost after a crush injury of the RLN and does not recover in the times studied here, the movement of the vocal folds as well as the number of neurons that supply the TA and the PCA muscles recovered within 8 weeks, indicating that the central nervous system of the rat has a great capacity of plasticity.

Modulation of nerve fibers in the rat thyroarytenoid muscle following recurrent laryngeal nerve injury

CONCLUSION

Regeneration of nerve fibers in the thyroarytenoid (TA) muscle occurred actively after damage on the recurrent laryngeal nerve (RLN) compared with the vagus nerve (VN). However, remyelination did not occur after damage on the RLN.

OBJECTIVES

To determine the regeneration process of nerve fibers in the TA muscle following transection and immediate anastomosis of the RLN or VN.

METHODS

Three types of animal model were prepared: an RLN anastomosis model (RLNa), a VN anastomosis model (VNa), and a peroneal nerve anastomosis model (PNa). Animals were sacrificed at five time points following the procedure. The modulation of axons, myelin sheaths, Schwann cells (SCs), nerve terminals (NTs), and acetylcholine receptors (AchRs) in the TA or tibialis anterior muscles was examined by immunohistochemical analysis. The ratios of the expression areas in axons, myelin sheaths, and SCs, and the number of NTs and AchRs in the treated (T) and untreated (U) sides (T/U) were evaluated.

RESULTS

At 18 weeks, the T/U ratios of expression in RLNa, VNa, and PNa were 68.5, 0, and 100.4%, respectively, in axons; 0, 0, and 97.6% in myelin sheaths; 53.7, 0, and 93.6% in SCs; 61.0, 0, and 96.4% in NTs; and 99.4, 67.0, and 101.2% in AchRs.

Diagnosis and Prognosis of Iatrogenic Injury of the Recurrent Laryngeal Nerve

Objectives:

Following perioperative injury to a macroscopically intact recurrent laryngeal nerve (RLN), there are two possible intraneural injury types: 1) axonal injury, including disruption of axons, and 2) conduction block, only affecting the Schwann cells and the nodes of Ranvier. In this study, it was hypothesized that the functional outcome after RLN injury may depend on the type of nerve injury.

Methods:

Fifteen patients with acute postoperative unilateral RLN paralysis were prospectively studied. Electrophysiological examination (laryngeal electromyography) was used to differentiate between the two types of nerve injury. Vocal fold motions were monitored by repeated laryngoscopy during the study period (up to 6 months). Three of the patients with axonal injury were treated with the regeneration-promoting agent nimodipine.

Results:

The patients with conduction block all recovered normal vocal fold motion, whereas patients with axonal injury within the nerve had a significantly worse outcome. The 3 patients who were treated with nimodipine all recovered normal or near-normal vocal fold mobility despite the more severe axonal injury.

Conclusions:

In contrast to previous reports, our results show that laryngeal electromyography is a reliable tool for diagnosing the type of injury within the injured RLN, making it possible to predict the functional outcome in these patients. On the basis of the results, a future randomized study on nimodipine treatment for RLN axonal injury is suggested.

Preserved Regeneration and Functional Recovery of the Injured Recurrent Laryngeal Nerve after Secondary Surgical Repair in Adult Rats

Objectives:

Transection of the recurrent laryngeal nerve (RLN) is accompanied by poor functional recovery, despite primary repair, because of regeneration difficulties. Nimodipine can promote regeneration, but it is not yet clear whether preoperative treatment is necessary. It is also not clear whether surgical repair following RLN injury may be performed in a second procedure, with preserved regeneration. This study investigated the time window for secondary surgical repair of the transected RLN and the need for preoperative administration of nimodipine.

Methods:

In adult rats, the left RLN was transected and repaired at time intervals up to 3 weeks after transection, in combination with nimodipine treatment starting either before or after the operation. Regeneration and neuromuscular recovery were assessed by electrophysiology, retrograde tracing, and immunohistochemistry.

Results:

Similar (whether 0, 2, or 7 days) regenerative results were obtained when the RLN was repaired up to 1 week after injury, given nimodipine administration, whereas fewer motor neurons managed to regenerate after nerve repair at 3 weeks after the initial transection. No beneficial effect was detected from preoperative nimodipine administration.

Conclusions:

Provided that nimodipine is administered, surgical reconstruction of the RLN can be performed within 1 week after the initial nerve trauma, with preserved neuromuscular function. Nimodipine may be administered at the time of RLN transection injury.

Collateral reinnervation by the superior laryngeal nerve after recurrent laryngeal nerve injury

This study investigates the role of the intact superior laryngeal nerve (SLN) in the reinnervation process of one of the laryngeal muscles, the posterior cricoarytenoid muscle (PCA), following recurrent laryngeal nerve (RLN) injury. Using a chronic RLN injury model in the adult rat, PCA reinnervation was assessed by retrograde double-tracing techniques in combination with electrophysiology and immunohistochemistry of muscle sections. The results demonstrate that the PCA receives dual innervation from both laryngeal nerves even in the uninjured system. Functionally significant collateral reinnervation originates from intact SLN fibers following RLN injury, mainly due to intramuscular sprouting rather than by recruitment of more motor neurons. This may be important when choosing surgical and/or medical treatment for patients with RLN injury.

Nimodipine and Microsurgery Induced Recovery of the Vocal Cord after Recurrent Laryngeal Nerve Resection

Transection of the recurrent laryngeal nerve leads to permanent palsy of the vocal cord. Experimental studies have confirmed that nimodipine increases the pace of axonal regeneration. We present a case of a 19-year-old male, suffering a thyroid cancer disease, who was subjected to unilateral resection of the recurrent laryngeal nerve during surgery. The nerve was repaired with a nerve graft and the patient further treated with nimodipine for 3 months. Evaluation of the patient showed normalization of voice, movement of the vocal cord on the injured side, and electromyography evidence of reinnervation of the larynx muscles at 15 months after surgery.