Recurrent laryngeal nerve (RLN) injury is a feared complication after thyroid and parathyroid surgery. It induces important postoperative morbidity. The present study aimed to assess the incidence of transient/permanent postoperative RLN injuries after thyroid and parathyroid surgery in the present cohort, to observe the timing of recovery, and to identify risk factors for permanent RLN injury after thyroidectomy.All consecutive patients operated on at our institution for thyroid and parathyroid pathologies from 2005 to 2013 were reviewed for vocal cord paresis. Vocal cord paresis was defined based on postoperative fiberoptic laryngoscopy. Demographics, intraoperative details, and postoperative outcomes were collected. Treatment types were assessed, and recovery times collected. Patients with vocal cord paresis on preoperative fiberoptic laryngoscopy were excluded from the analysis.The cohort included 451 thyroidectomies (756 nerves at risk) and 197 parathyroidectomies (276 nerves at risk). There were 63 postoperative vocal cord pareses after thyroidectomy and 13 after parathyroidectomy. Sixty-nine were transient (10.6%) and 7 permanent (1.1%). The main performed treatment was speech therapy in 51% (39/76) of the patients. Median recovery time after transient injuries was 8 weeks. In the group with vocal cord paresis, risk factors for permanent injuries after thyroidectomy were previous thyroidectomy and intraoperative RLN injury on univariate analysis. On multivariate analysis, only intraoperative RLN injury remained significant.Most of the patients with transient postoperative RLN injury recovered normal vocal cord mobility within 6 months. The most common performed treatment was in this cohort speech therapy. Permanent RLN injuries remained rare (1.1%).

Contradictory opinions are found in the literature concerning the precise anatomy and role of the inferior laryngeal nerve, the terminal portion of the recurrent laryngeal nerve. Moreover, operative damage to this nerve beyond the thyroid area is seldom described. Twenty-one human larynges were dissected to give a precise description of the inferior laryngeal nerve and to draw attention to the risks of injury to the nerve during specific laryngological operations. In contrast with the varied descriptions found in the literature, only small variations in the terminal branching of the nerve were found. The nerve divides generally extralaryngeally into two branches: a motor, anterior one, innervating the intrinsic laryngeal musculature (except the cricothyroid muscle), and a sensory, posterior one, forming Galen's anastomosis. The anterior branch of the nerve is particularly susceptible to damage just behind the cricothyroid joint; two of its terminal rami, supplying respectively the interarytenoid and thyro-arytenoid muscles, incur potential risks of injury during endoscopic CO2 laser surgery.

Velopharyngeal insufficiency (VPI) is a structural or functional trouble, which causes hypernasal speech. Velopharyngeal flaps, speech therapy and augmentation pharyngoplasty, using different implants, have all been used to address this trouble. We hereby present our results following rhinopharyngeal autologous fat injection in 18 patients with mild velopharyngeal insufficiency (12 soft palate clefts, 4 functional VPI, 2 myopathy). 28 injections were carried out between 2004 and 2007. The degree of hypernasal speech was evaluated pre- and postoperatively by a speech therapist and an ENT specialist and quantified by an acoustic nasometry (Kay Elemetrics). All patients were exhaustively treated with preoperative speech therapy (average, 8 years). The mean value of the nasalance score was 37% preoperatively and 23% postoperatively (p = 0.015). The hypernasality was reduced postoperatively in all patients (1-3 degrees of the Borel-Maisonny score). There were no major complications, two minor complications (one hematoma, one cervical pain). The autologous fat injection is a simple, safe, minimally invasive procedure. It proves to be efficient in cases of mild velopharyngeal insufficiency or after a suboptimal velopharyngoplasty.

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