Recurrent Laryngeal Nerve Liberations and Reconstructions: A Single Institution Experience

Abstract

Background: Recurrent laryngeal nerve (RLN) palsy rates vary from 0.5 to 10%, even 20% in thyroid cancer surgery. The aim of this paper was to present our experience with RLN liberations and reconstructions after various mechanisms of injury.

Methods: Patients were treated in our institution from year 2000 to 2015. First group (27 patients) had large benign goiters, locally advanced thyroid/parathyroid carcinomas, or incomplete previous surgery of malignant thyroid disease. Second group (5 patients) had reoperations due to RLN paralysis on laryngoscopy. Liberations and reconstructions of injured RLNs were performed.

Results: Surgical exploration of central compartment enabled identification of the RLN injury mechanism. Liberations were performed in 11 patients, 2 months to 16 years after RLN injury, by removing misplaced ligations. Immediate or delayed (18 months to 23 years) RLN reconstructions were performed in 21 patients, by direct suture or ansa cervicalis-to-RLN anastomosis (ARA). RLN liberation provided complete voice recovery within 3 weeks in all patients. Patients with direct sutures had better phonation 1 month after reconstruction. Improved phonation was observed 2-6 months after ARA in 43% of patients.

Conclusions: Vocal cords do not regain normal movement once being paralyzed after RLN transection, but they restore tension during phonation by reconstruction. Nerve liberation is a useful method which enables patients with RLN paresis/paralysis a significant improvement in phonation, even complete voice recovery. Reinnervation of vocal cords, using one of the mentioned techniques, should be a standard in thyroid and parathyroid surgery, with aim to improve quality of patient's life.

Fig. 1

Intraoperative photo of accidentally transected left recurrent laryngeal nerve, immediately reconstructed by direct anastomosis of transected neural ends using 7-0 nylon thread perineural sutures (white arrow). Photo was originally taken during one of the primary surgeries due to a large follicular lesion of the left thyroid lobe, performed by first author (RD) and his team in our institution

Fig. 2

Intraoperative photos showing recurrent laryngeal nerve liberation technique. On the upper photo, tip of the tweezer is showing a misplaced ligation on the right recurrent laryngeal nerve (pointed by white arrow), at its laryngeal entry point. On the lower photo, misplaced ligation is retracted by the Mosquito forceps, while the ligation is being meticulously removed by scissors. Photos were originally taken during one of the reoperations of thyroid carcinoma, performed by the first author (RD) and his team in our institution

Fig. 3

Intraoperative photo showing ansa cervicalis to recurrent laryngeal nerve (RLN) anastomosis (ARA) on the right side. The right ansa cervicalis neural fiber used for reconstruction is crossing over the right internal jugular vein and is pointed by the tip of the tweezer. It is anastomosed with distal stump of the right RLN at the laryngeal entry point, using 7-0 nylon thread perineural sutures. RLN was infiltrated by papillary thyroid carcinoma (pT4aN1b), without possibility for partial layer resection of the nerve. In order to achieve “clear” resection margins, RLN was transected, and immediately reconstructed by ARA technique. Total thyroidectomy, complete central dissection, and right modified radical neck dissection on two incisions were performed by the first author (RD) and his team during primary surgery in our institution