Laryngeal and vocal alterations after thyroidectomy scielo. Involvement of the recurrent laryngeal nerve rln by welldifferentiated thyroid carcinoma may not invariably lead to unilateral cord palsy, although the presence of rln palsy is associated with locally advanced disease. Routine exposure of recurrent laryngeal nerve in thyroid surgery can. Recurrent laryngeal nerve palsy was diagnosed clinically by the presence of respiratory obstruction andor hoarseness and confirmed by laryngoscopy.
This outpatient procedure generally takes between two and three hours. Partial paralysis of the larynx is a term often used to describe a hypomobile vocal fold as is the term paresis. The paths of the left and right recurrent laryngeal nerves vary slightly with the left recurrent laryngeal nerve dividing from the main vagus nerve at the level of the aortic arch. Recurrent laryngeal nerve rln injury is a common severe complication in thyroid surgery 1, and unilateral rln injury is more common. Because abductor palsy is typically a result of damage to the recurrent laryngeal nerves, the presentation of symptoms is fairly homogeneous, presenting in two primary categories, respiratory and phonatory distress. Partial recurrent laryngeal nerve paralysis or paresis. Recurrent laryngeal nerve palsy and substernal goiter. Vcp paralysis can be the result of compression of the anterior motor branch of the recurrent laryngeal nerve between the inflated cuff of the endotracheal tube, the lateral projection of the abducted arytenoid, and the thyroid cartilage. Doctors give trusted, helpful answers on causes, diagnosis, symptoms, treatment, and more.
The recurrent laryngeal nerve will usually not be surgically exposed during anterior cervical spine surgery. There are many causes of laryngeal nerve paresis palsy. What you need to know about the recurrent laryngeal nerve. Pdf iatrogenic bilateral recurrent laryngeal nerve injury. The recurrent laryngeal nerve provides motor innervation to the intrinsic muscles of the larynx, which provide the majority of movement of the vocal cords see fig. In addition, the incidence of recurrent laryngeal nerve injury was significantly lower in patients with the inferior parathyroid gland and middle thyroid veins used as. Recurrent laryngeal nerve palsy was noticed in 10 3. Superior laryngeal nerve paralysis external branches. The most common anterior cervical spine complications are postoperative hematoma, dysphagia, and symptomatic recurrent laryngeal nerve palsy. From there, like the recurrent laryngeal nerve on the right, it moves upward to the larynx. Intraoperative recurrent laryngeal nerve monitoring in. What you need to know about the recurrent laryngeal nerve is in this article. The right and left nerves are not symmetrical, with the left nerve looping under the aortic arch, and the right nerve looping under the right. Causes of recurrent laryngeal nerve paralysis jama.
Combined leftsided recurrent laryngeal and phrenic nerve. The recurrent laryngeal nerve supplies the larynx voice box. Etiology vocal cord paralysis may result from lesions at the nucleus ambiguus, its supranuclear tracts, the main trunk of the vagus, or the recurrent laryngeal nerves. The function, location and importance of the nerve is explained.
Recurrent laryngeal nerve injury causes and surgery. Left recurrent laryngeal nerve palsy secondary to left. Accurate diagnosis can be made only by visualizing the vocal cords while the patient is awake. Patients with thyroid cancer have higher risk of laryngeal nerve impairment by. Original research article study on recurrent laryngeal. The left vocal cord is paralyzed more often than the right because the left recurrent nerve takes a longer course from the brain stem to the larynx, providing more opportunity for. Malignant neoplasms of the lung and pulmonary tuberculosis were the most frequent causes of the paralysis. Most of the references to this condition are in journals of anesthesia, while it has found rather less mention in otolaryngology research. Partial recurrent laryngeal nerve paralysis is a diagnosis inconsistent with the spectrum of vocal fold immobility disorders that have been proposed to date. Paralysis of the larynx voice box caused by damage to the recurrent laryngeal nerve or its parent nerve, the vagus nerve, which originates in the brainstem and runs down to the colon. Background the nonrecurrent laryngeal nerve nrln is a rare embryologicallyderived variant of the recurrent laryngeal nerve rln. Our aim was to provide a comprehensive metaanalysis of the overall prevalence of the nrln, its origin, and its association with an aberrant subclavian artery. The larynx will be paralyzed on the side where this nerve has been damaged, unless the problem originated with damage.
Humes, md we report a 10yearold girl who developed persistent hoarseness after stent placement for the treatment of left pulmonary artery stenosis. Partial paralysis for most authors is identical to paresis, meaning that all muscles innervated by the iln are equally or almost affected. The location and type of the injury along the nerve pathway will determine the type of paralysis and the resultant voice quality. Indeed, the main benefit of ionm is its ability to guide the surgeon in the event of variations in the expected anatomic course of the inferior laryngeal nerve 9, or in case of a nonrecurrent inferior laryngeal nerve revealed by short latency, as recently demonstrated 30. Rlnp recurrent laryngeal nerve palsy acronymfinder. The incidence of recurrent laryngeal nerve palsy is different 120%, depending on the type of disease, the type of surabstract aim. Left recurrent laryngeal nerve palsy secondary to left pulmonary artery stent in a child daisuke kobayashi, md, daniel r. Recurrent laryngeal nerve rln injury is a common severe complication in thyroid surgery, and unilateral rln injury is more common. Recurrent laryngeal nerve palsy following heartlung. We present the first case of unilateral hypoglossal nerve palsy after use of the lma supreme. Teflon augmentation was performed but not in the acute phase.
Unilateral laryngeal paralysis or vocal cord paralysis. Both recurrent laryngeal nerves enter the larynx through. Unilateral vocal fold paralysis uvfp occurs from a dysfunction of the recurrent laryngeal or vagus nerve innervating the larynx. Hypoglossal nerve palsy after use of the laryngeal mask airway lma is an exceptionally rare complication.
In addition, intubation can result in fibrosis of the vocal cord, which can also mimic vcp. Even for experienced surgeons, a number of patients will have temporary laryngeal paralysis or paresis, which for some will become permanent after 12 months. Recurrent laryngeal nerve injury in the chest is due to cardiac surgery, lung cancer, pulmonary tuberculosis, oesophageal cancer, mitral stenosis, and thoracic aortic aneurysm. With the increase of awareness and the improvement of surgical techniques, the incidence of rln injury has declined about 0. The rln is important for speaking, breathing and swallowing. The various causes of recurrent laryngeal nerve paralysis that i have observed during the past 24 years are reported. The condition paralyzes the larynx on one or both sides, depending on the severity of the damage. Recurrent nerve palsy in patient with mitral stenosis in german. The presence of an nrln significantly increases the risk of iatrogenic injury and operative complications. Unilateral hypoglossal nerve palsy after use of the. Metaanalysis of recurrent laryngeal nerve injury in. A superior laryngeal nerve palsy changes the pitch of the voice and causes an inability to make explosive sounds due to paralysis of the cricothyroid muscle.
Recurrent laryngeal nerve injury in thyroid surgery. A higher probability of this complication occurs after secondary procedure of the thyroid and in malignant cases. In most series the incidence is reportedto beless than 1%. The dysphagia and recurrent laryngeal nerve rln palsy are the most common complications of the patients who underwent anterior cervical surgery in the current literature. Recurrent laryngeal nerve request pdf researchgate. Recurrent laryngeal nerve palsy and endotracheal intubation. It causes a characteristic breathy voice often accompanied by swallowing disabilty, a weak cough, and the sensation of shortness of breath. Recurrent laryngeal nerve palsy after cervical spine. Recurrent laryngeal nerve reinnervation is a surgery that can help alleviate hoarseness after damage to one side of the rln results in vocal cord paralysis. In laryngeal palsy, the larynx is paralyzed on the side where the recurrent laryngeal nerve has been damaged, unless the problem originated with. Laryngeal nerve damage is injury to one or both of the nerves that are attached to the voice box. Recurrent laryngeal nerve palsy occurs when the recurrent laryngeal nerve or vagus nerve becomes damaged.
Recurrent laryngeal nerve palsy laryngeal paralysis vagus. Thyroid disease and surgeries may create temporary or permanent paralysis of the superior laryngeal nerve. Laryngeal nerve palsy symptoms answers on healthtap. Hoarseness of voice due to left recurrent laryngeal nerve paralysis was first. Unilateral vocal cord paralysis following insertion of a supreme.
Recurrent laryngeal nerve palsy due to endotracheal tube pressure is usually temporary and once the condition is recognized and understood, need not be cause for undue alarm. Paralysis of the larynx voice box that is caused by damage to the recurrent laryngeal nerve, which supplies the larynx voice box, or its parent nerve, the vagus nerve, which originates in the brain stem and runs down to the colon. For patients with bilateral vocal fold paralysis bvfp due to iatrogenic injury in which the recurrent laryngeal nerve rln or vagus nerve is injured neurapraxia but not severed, permanent surgical treatment should be postponed for at least 9 months after injury to allow spontaneous recovery. Among various treatments, stellate block and application of steroid seem to be effective for certain groups of recurrent laryngeal nerve palsy. The present study evaluates the clinicopathologic features and outcomes of patients surgically treated for welldifferentiated thyroid carcinoma with documented. A spontaneous partially thrombosed ductal aneurysm presenting. Cases of transient phrenic nerv ane palsd a bilateray l vagal trunk palsy are also reported jamieso etn al. The recurrent laryngeal nerve is a branch of the vagus nerve and supplies all intrinsic muscles of the larynx, with the exception of the cricothyroid. There are two recurrent laryngeal nerves, right and left. In 4 patients with recurrent laryngeal nerve paralysis, the left recurrent nerve was most commonly involved. Persistent hoarseness due to recurrent laryngeal nerve paralysis rlnp reduces the quality of life unless it is adequately treated.
It is mostly caused by thyroid and cervical surgery, trauma, endotracheal intubation, central. Injury to the recurrent laryngeal nerve rln andor external branch of the. If no recovery is evident three months after the palsy initially presents, the damage is most likely to be permanent. Prevention and treatment of recurrent laryngeal nerve injury in. Recurrent laryngeal nerve paralysis linkedin slideshare. Causes of recurrent laryngeal nerve paralysis sciencedirect. History viral infection at the onset of voicing difficulties. A total of 6110 patients were operated in our hospital between 1 january 2005 and 31 december 20 for various goiters. Vocal fold paresis, also known as recurrent laryngeal nerve paralysis or vocal fold paralysis, is an injury to one or both recurrent laryngeal nerves rlns, which control all muscles of the larynx except for the cricothyroid muscle. Recurrent laryngeal nerve palsy and endotracheal intubation anatomical grounds with a palsy of the anterior branch of the nerve when only the posterior cricoarytenoid, interarytenoid and cricothyroid muscles are left functioning. Recurrent laryngeal nerve palsy in welldifferentiated. It could be caused by a tumor or mass affecting the nerve.
Vocal cord paralysis merck manuals professional edition. Current concepts in the management of unilateral recurrent. Recurrent laryngeal nerve paralysis is one of the most frequent complications after thyroid surgery due to goiter and cancers. How to reduce recurrent laryngeal nerve palsy in anterior. Possible risk factors for respiratory complications after. The primary larynxrelated functions of the mainly efferent nerve fiber rln, include the transmission. The vocal cord assumes a median or paramedian position. The aim of this study was to evaluate the ability of intraoperative recurrent laryngeal nerve monitoring to predict the postoperative functional outcome and the potential role of this technique in reducing. A healthy 67yearold female was scheduled for a hallux valgus correction under general anesthesia combined with femoral and sciatic nerve blocks. Although recurrent laryngeal nerve injury has been described following central venous access via the jugular route, it has not previously been reported following access via the subclavian route. Recurrent laryngeal nerve injury produces an abductor laryngeal paralysis.
The recurrent laryngeal nerve rln, also known as the inferior laryngeal nerve, is a branch of the vagus nerve cn x which has a characteristic loop around the right subclavian artery on the right and the aortic arch on the left before returning up to achieve the tracheoesophageal groove and then the larynx summary. This requires indirect laryngoscopy preoperatively, and, as soon as possible, postoperatively. Abstract recurrent laryngeal nerve palsy rlnp is an important and potentially. Combined leftsided recurrent laryngeal and phrenic nerve palsy after coronary artery operation prabhat tewari, md, and surendra kumar aggarwal, mch department of anaesthesiology and department of cardiothoracic and vascular surgery, sanjay gandhi post graduate institute of medical sciences, lucknow, india background. Recurrent laryngeal nerve palsy complicating subclavian. Vocal cord paresis or paralysis due to iatrogenic injury of the recurrent laryngeal nerve rlni is one of the main problems in thyroid surgery. We present a case of a dysphonic patient with a mobility disorder of the vocal fold, for whom idiopathic partial paralysis was the diagnosis made after laryngeal electromyography, and discuss a proposition for a different implementation of the term. The most common cause is after surgery thyroid surgery, neck surgery or cardiac surgery. Flexible laryngoscopy revealed a left vocal fold palsy.
Recurrent laryngeal nerve rln injury is commonly encountered by thyroid. Clinically relevant anatomy of recurrent laryngeal nerve. Bilateral recurrent laryngeal nerve injury is mostly iatrogenic following. Unilateral rln injury can cause varying degrees of hoarseness, microaspiration. Vocal fold paralysis may be bilateral or unilateral and is typically caused by nerve involvement of the recurrent laryngeal nerve and, less commonly, the superior laryngeal nerve.
The recurrent laryngeal nerve rln is a branch of the vagus nerve cranial nerve x that supplies all the intrinsic muscles of the larynx, with the exception of the cricothyroid muscles. To investigate the risk of symptomatic recurrent laryngeal nerve palsy rlnp following cervical spine surgery, to examine risk factors for its development, and to report its treatment and outcomes. Unilateral recurrent laryngeal nerve paralysis urlnp is a known complication of thyroid surgery. Therapy techniques for bilateral abductor palsy bridget. The risk of nerve injury increases in patients with an anomalous rln. Transient dysphagia occurs secondary to the retraction on the esophagus and trachea and the endotracheal intubation and typically resolves weeks after surgery. Optimal management of acute recurrent laryngeal nerve injury. After resolution of acute laryngeal findings, etiology is distinguished from two major causes of this condition. Injury to the left and right laryngeal nerves at the same time can cause a breathing problem.
Recurrent laryngeal nerve radiology reference article. Recurrent laryngeal nerve an overview sciencedirect topics. Bilateral recurrent laryngeal nerve paralysis can be a fatal emergency. Injury to the recurrent laryngeal nerve rln andor external branch of the superior. Vocal cord paralysis may result from lesions at the nucleus ambiguus, its supranuclear tracts, the main trunk of the vagus, or the recurrent laryngeal nerves. Surgical management of the recurrent laryngeal nerve in. Typically, the intervention techniques for bilateral abductor vocal fold paralysis or palsy tends to be surgical in nature. Recurrent laryngeal nerve palsy rates rlnpr varied widely after thyroid surgery, ranging from 0%7. Recurrent laryngeal nerve injury in thyroid surgery wiley online. A 63yearold man presented with acute dysphonia immediately after insertion of a hickman line via the subclavian route. There was no significant difference in sex ratio and a survey of age distribution showed a peak at the third decade of life. The rate of recovery of voice or mobility was markedly high in recurrent laryngeal nerve was found in palsy resulted from common cold or in palsy of unknown etiology.
Mediastinal spread hoarseness with leftsided lesions due to recurrent laryngeal nerve palsy. Damage to a recurrent laryngeal nerve rln with resultant paralysis of the. Damage to a recurrent laryngeal nerve rln with resultant paralysis of the sole. Nonrecurrent laryngeal nerve in thyroid surgery a n hisham ms, a sarojah ms, a alvin ms, nteast and endoetine surgical unit, departmentofsurgety,kualalumpurhospital, kualalumpur, malaysia introduction the nonrecuncntlaryngeal nerve nrin is a rare clinical entity. Ta the terminal branch of the recurrent laryngeal nerve as the latter passes deep to the inferior pharyngeal constrictor. Following heartlung transplantation th couge h refle, is x. Treatment of recurrent laryngeal nerve injury jama. This study examined the indications for phonosurgical intervention in patients with rlnp. Prevention and treatment of recurrent laryngeal nerve.
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