Anomalous Relationship of Coexisting Ipsilateral Recurrent and Nonrecurrent Inferior Laryngeal Nerves During Thyroid Surgery

Babademez, Mehmet Ali; Günbey, Emre; Özmen, Erkan; Çelik, Emrah

doi:10.1097/scs.0b013e3182801edd

Cited by 8 publications

(8 citation statements)

References 7 publications

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“…Type I arises very high from the vagus opposite the upper thyroid pole; whereas type II arises from a lower level of the vagus as compared to type I, and runs in an upward sloping direction and then tracks transversely along the inferior thyroid artery . Large anastomotic branches between the sympathetic chain and distal RLN may mimic a NRLN, but with IONM such fibers should be diagnosed without confusion …”

Section: Discussionmentioning

confidence: 99%

“…11 Large anastomotic branches between the sympathetic chain and distal RLN may mimic a NRLN, but with IONM such fibers should be diagnosed without confusion. [27][28][29][30][31][32] Our anatomical electrophysiologic algorithm (utilizing the upper margin of the thyroid cartilage as the proximal point and the lower border of fourth tracheal ring as the distal point for stimulation) takes into account all of the variations of the NRLN in terms of exact vagal takeoff, as well as the course of the NRLN to the larynx, and represents a robust algorithm for intraoperative identification of the NRLN (Fig. 1).…”

Section: Anatomical Types Of Nrlnmentioning

confidence: 99%

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The nonrecurrent laryngeal nerve: Anatomic and electrophysiologic algorithm for reliable identification

et al. 2014

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Non recurrent laryngeal nerve is a rare anatomical variation with an incidence in literature of 0.3 % to 1.6 % on the right side. This variation places the nerve at risk of inadvertent injury during head and neck surgeries. Awareness about this abnormality and meticulous dissection of the nerve in every case is the only way to stay safeguarded. Here we present a case of right non recurrent laryngeal nerve in a 32 years old female patient who underwent near total thyroidectomy for nontoxic multi nodular goitre. During surgery, the right recurrent laryngeal nerve could not be identified in its normal location. Further dissection revealed a non recurrent laryngeal nerve arising from the vagal trunk. A CT angiogram was done post operatively and showed an anomalous origin of the right subclavian artery as the last branch of the aortic arch and a bi-carotid trunk. Every surgeon operating on the neck should be aware of and anticipate this variation of the recurrent laryngeal nerve especially when the nerve cannot be identified in the normal location. Case report: A 32 yr old female presented with a swelling in front of the neck .clinical examination showed a thyroid swelling with multiple palpable nodules in both lobes which were firm in consistency and had no retro sternal extension. There were no palpable cervical lymph nodes. An USG of neck confirmed this findings. The patient was clinically and biochemically euthyroid. FNAC was consistent with nodular goiter. On direct laryngoscopy vocal cord function was normal bilaterally. With the diagnosis of euthyroid multinodular goitre the patient was posted for near total thyroidectomy. During thyroidectomy the recurrent laryngeal nerve could not be identified in its usual location. Instead there was a white cord like structure transversing parallel to and between the branches of the inferior thyroid artery. This structure was traced laterally in to the carotid sheath and was found to arise from the right vagal trunk. Medially this structure was found to enter the crico thyroid membrane and hence identified to be non recurrent laryngeal nerve. Thyroidectomy was completed and the recurrent laryngeal nerve on the left side had a normal course. The postoperative period of the patient was uneventful and a vocal cord examination showed equal movement on both sides. A CT angiogram done retrospectively revealed an anomalous origin of a right subclavian artery as the last branch of the aortic arch. This artery crossed from left to right posterior to the esophagus. Moreover the right and left common carotid artery originated from the aortic arch as a common trunk (bicarotid trunk) which was the first branch of the aortic arch. A normal left subclavian artery arose between the bicarotid trunk and the anomalous right subclavian artery. The patient did not have any difficulty in swallowing (dysphagia lusoria) on retrospective questioning.

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Section: Discussionmentioning

confidence: 99%

Section: Anatomical Types Of Nrlnmentioning

confidence: 99%

The nonrecurrent laryngeal nerve: Anatomic and electrophysiologic algorithm for reliable identification

et al. 2014

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“…However, recurrent laryngeal nerves with abnormal anatomy are still susceptible to injury. Based on the literature, several variations of recurrent laryngeal nerves have been reported [1][2][3][4][5]. Similar to the non-recurrent laryngeal nerve, the variants identified in this study were all located on the right side, but not directly divided from the vagus, and divided into intracranial branches except for the tracheal, esophageal, and laryngeal branches.…”

Section: Discussionmentioning

confidence: 79%

“…Therefore, the clarification and recognition of the variation and passage of recurrent laryngeal nerves are very important for preventing postoperative complications. To date, multiple variations of the recurrent laryngeal nerve have been reported [1][2][3][4][5]. Here, we reported a new variation of the right recurrent laryngeal nerve that should be carefully considered during neck surgery.…”

mentioning

confidence: 93%

New Variation of Right Recurrent Laryngeal Nerve: Cases Report

et al. 2014

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“…Therefore, a left NRLN is rare and is associated with situs inversus. 9 On the right side, both the innominate artery and the right subclavian artery in the normal anatomical position are absent. Arising from the cervical vagus nerve, the RLN directly innervates the throat without the recurrent course because of the absence of the vessel.…”

Section: Discussionmentioning

confidence: 99%

Anatomic Characteristics, Identification, and Protection of the Nonrecurrent Laryngeal Nerve during Thyroidectomy

Qiao

Gao

et al. 2017

Otolaryngol.--head neck surg.

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Objective We aimed to investigate the anatomical features and variation pattern of the nonrecurrent laryngeal nerve (NRLN), summarize the methods for identifying the NRLN before and during thyroidectomy, and share experiences regarding preventing and treating its injury. Study Design Retrospective case data analysis. Setting First Affiliated Hospital of Harbin Medical University. Subjects and Methods Between January 2002 and May 2016, 7392 patients underwent thyroidectomy in our hospital. Of them, 28 patients with NRLN were identified, and their clinical data were retrospectively analyzed. Results This study included 7392 patients in which the recurrent laryngeal nerves (RLNs) were routinely identified during surgery. The presence of NRLN was intraoperatively confirmed in 28 patients. All the NRLNs were located on the right side and its overall incidence was 0.37%. Five of the NRLNs were classified as type I, 19 as type IIa, and 4 as type IIb. Of the 28 cases, 4 NRLNs were injured during surgery, in which primary end-to-end anastomosis or local seal with corticosteroid injection was performed as a remedy. In the 4 patients with NRLN injury, 2 presented with postoperative hoarseness that indicated vocal cord paralysis confirmed by laryngoscope; the other 2 patients' voices had no significant changes. Conclusion The NRLN, which is rare in clinical practice and predominantly right-sided, is anatomically more complex and variant at a higher risk of surgical injury. The key factors to accurately identify NRLN and to effectively prevent its injury include careful interpretation of auxiliary examination results before surgery, raising awareness of its presence, meticulous dissection, and routine exposure of the RLN during surgery.

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Anomalous Relationship of Coexisting Ipsilateral Recurrent and Nonrecurrent Inferior Laryngeal Nerves During Thyroid Surgery

Cited by 8 publications

References 7 publications

The nonrecurrent laryngeal nerve: Anatomic and electrophysiologic algorithm for reliable identification

The nonrecurrent laryngeal nerve: Anatomic and electrophysiologic algorithm for reliable identification

New Variation of Right Recurrent Laryngeal Nerve: Cases Report

Anatomic Characteristics, Identification, and Protection of the Nonrecurrent Laryngeal Nerve during Thyroidectomy

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