Recurrent Laryngeal Nerve Anatomy and Thyroid Surgery Risks
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This presentation discusses the recurrent laryngeal nerve (RLN) and its relevance to thyroid surgery. It covers the surgical anatomy of the RLN, including its origin, relationship to surrounding structures like the inferior thyroid artery, and anatomical variations. Risks of injury to the RLN during thyroid surgery are reviewed. The presentation emphasizes identifying the RLN to reduce risks of temporary or permanent paralysis, with identification allowing average permanent paralysis rates of 0.9% with localization only versus 0.1% with complete dissection. Factors like anatomical variations, branching patterns, scarring, and extent of disease must be considered during dissection to prevent mechanical, thermal, or severing injuries to the nerve.
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Recurrent Laryngeal Nerve Anatomy and Thyroid Surgery Risks
- 1. KDU Presentation Recurrent Laryngeal Nerve And Thyroid Surgery Dr. MTD Lakshan MBBS(Col) MS(ORL-HNS) DOHNS(Eng) FEB ORL-HNS FRCSEd ORL-HNS
- 2. KDU Presentation Outline » Surgical Anatomy – Origin and function – Relationship with ITA – Suspensory Ligament » Anatomical variations – Extra-laryngeal division – Non-recurrent » Surgical considerations
- 3. KDU Presentation RLN • Motor : ALL intrinsic laryngeal musculature except cricothyroid • Sensory: Glottic larynx • Arises from the vagus – Right : level of the subclavian artery – Left : level of the aortic arch
- 4. KDU Presentation Surgical Anatomy • Turn superior–medial to run toward the tracheoesophagel (TE) groove • Oesophageal and tracheal branches • Close association with the trachea and esophagus • Not necessarily in the true TE groove • May run laterally in this visceral compartment R>L
- 6. KDU Presentation Inferior Thyroid Artery & RLN • Intimate relationship • Nerves may pass – Superficial – Deep – Or between branches of the ITA
- 7. KDU Presentation Anatomical variations of the RLN and the ITA
- 8. KDU Presentation ITA and RLN • Variable branching pattern – nerve and artery • Limits the ability to rely solely on the ITA
- 9. KDU Presentation Identifying RLN above the thoracic inlet • Cricothyroid joint • TE groove - posterior thyroid gland • Suspensory ligament of the thyroid gland (Berry’s Ligament)
- 10. KDU Presentation Berry’s Ligament • Pretracheal fascia condenses and attatches the thyroid to the upper two to three tracheal rings • Anchors the gland • RLN often passes through
- 11. KDU Presentation Extralaryngeal division-RLN • 35% to 80% of anatomic dissections • Typically – anterior (motor division) – posterior (sensory) – but patterns with two to eight branches described
- 12. KDU Presentation Anomalous or nonrecurrent nerve • 0.3% to 0.8% • Directly from the cervical portion of the vagus at about the level of the larynx or thyroid gland • Enters the larynx posterior to the cricothyroid joint without looping low in the neck.
- 13. KDU Presentation Anomalous or non recurrent nerve • The vast majority → Right side – in conjunction with an anomalous retro- esophageal subclavian artery • Rarely Left
- 14. KDU Presentation Surgical Considerations • Hermann, in their review of 16,443 patients who underwent thryroidectomy, showed that the incidence of temporary and permanent RLN paralysis was significantly reduced if the nerve was identified. Hermann M, Alk G, Roka R, et al. Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon in more than 27,000 nerves at risk. Ann Surg 2002;235:261–8.
- 15. KDU Presentation Surgical considerations Average permanent RLN injury rate – 0.9% for localization only – 0.3% for partial dissection – 0.1% for complete dissection
- 16. KDU Presentation Factors that must be considered during dissecting • anatomic variations • branching patterns • scarring as a result of previous surgery • radiation therapy • underlying pathology • extent and bulkiness of disease • surgical experience • mechanisms of injury.
- 17. KDU Presentation Mechanisms of injury-RLN • Stretch or traction, • Compression or crush (eg, ligature entrapment, hematoma formation • Thermal • Electrical • Severing injuries (complete or incomplete transection)
- 18. KDU Presentation RLN Injury • Paresis or a Temporary paralysis- 7.1% • Permanent paralysis-3.6%
- 19. KDU Presentation Summary » Complicated course » Relationship to ITA and Berry's Ligament » Anatomical variations » Prevention of damage
- 20. KDU Presentation Any Questions? » Thank You!