Unilateral paralysis is usually idiopathic but can be secondary to problems with the vagus nerve or recurrent laryngeal nerve trauma. The rln is important for speaking, breathing and swallowing. Anatomy and etiology etiologies of adult vocal paralysis are varied by the site of the lesion as well as the. 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. Microsurgical repair has been reported to induce a better function. It may present with a variety of symptoms, such as voice change and respiratory symptoms. Superior laryngeal nerve anatomy sln branches from the vagus and innervates the cricothyroid muscle the external branch controls longitudinal tension of the vocal folds and voice pitch symmetric contraction of the cricothyroid muscle raises the anterior cricoid cartilage resulting in narrowing of the. Laryngeal hemiplegia, in horses, partial or complete paralysis of muscles controlling the vocal fold and other components of the larynx as a result of degeneration of the recurrent laryngeal nerve. Selective reinnervation for bilateral vocal cord paralysis. This file contains additional information such as exif metadata which may have been added by the digital camera, scanner, or software program used to create or digitize it.
Recurrent laryngeal nerve rln injury is considered to be the most severe complication in thyroid surgery. Risk factors for recurrent laryngeal nerve rln lesions after thyroid gland surgery were evaluated retrospectively in 1026 patients. The risk of recurrent laryngeal nerve rln injury with postoperative vocal cord palsy vcp persists as one of the most feared complications in thyroid surgery. Other lesions can be due to demyelinating diseases. The vocal cord assumes a median or paramedian position. Among various treatments, stellate block and application of steroid seem to be effective for certain groups of recurrent laryngeal nerve palsy.
Nevertheless early forms of nerve injury with benign thyroid pathology could. A method to repair the recurrent laryngeal nerve during. Typically, the intervention techniques for bilateral abductor vocal fold paralysis or palsy tends to be surgical in nature. As the rln innervates all intrinsic muscles of the larynx except the cricothyroid muscle, injury of this nerve induces a paresis or palsy of the vocal cord. Prevention and treatment of recurrent laryngeal nerve injury. All subjects experienced postoperative improvements in voice quality. Galen named the nerve the recurrent nerve, and described the same effect in two human infants who had undergone surgery for goiter. Bilateral vocal fold cord paralysis bvfp refers to the neurologic causes of bilateral vocal fold immobility bvfi and specifically refers to the reduced or absent function of the vagus nerve or it. Accurate diagnosis can be made only by visualizing the vocal cords while the patient is awake. Ortners syndrome described 100 years ago in 1897 is a clinical entity with hoarseness due to a left recurrent laryngeal nerve lrln palsy caused by cardiac disease. Neurologic dysfunction resulting in vocal cord paralysis most common localizes to the recurrent laryngeal nerve, but can also be due to upstream lesions affecting the vagus nerve from which the recurrent laryngeal nerve branches off or the brain. The nerves control the movement of the larynx and the vocal cords. The cause of hoarseness is due to left vocal cord palsy as a result of compression of the left recurrent laryngeal nerve by enlarged mediastinal lymph nodes.
The computed tomogram see p 512 demonstrated enlarged mediastinal and bilateral hilar lymph nodes. Jul 01, 2010 all patients were evaluated with laryngoscopy following surgery. Aspiration is also a risk, especially in older patients. Current concepts in the management of unilateral recurrent. Congenital laryngeal palsy genetic and rare diseases. There is progressive degeneration of large myelinated axons, particularly in the distal portions of the nerve, and secondary neurogenic atrophy of the intrinsic laryngeal muscles that the nerve innervates. Laryngeal paralysis unilateral or bilateral may involve recurrent laryngeal nerve superior laryngeal nerve both rec. With the increase of awareness and the improvement of surgical techniques, the incidence of rln injury has declined about 0. Transient palsy of recurrent laryngeal nerve postresection of. Although the left recurrent laryngeal nerve rln is only one element of this physiology, it is a structure that is at uniquely high risk of damage during neonatal aortic arch reconstruction. Bilateral recurrent laryngeal nerve rln injury is rare for benign thyroid lesions 0. Jun 23, 2017 although the left recurrent laryngeal nerve rln is only one element of this physiology, it is a structure that is at uniquely high risk of damage during neonatal aortic arch reconstruction. The authors have previously published recurrent laryngeal palsy rates with rightsided surgery.
This requires indirect laryngoscopy preoperatively, and, as soon as. Sarcoidosis presenting as recurrent left laryngeal nerve. Management of bilateral recurrent laryngeal nerve paresis. However, it may remain undetected and the true incidence may be under. It may affect one unilateral or both bilateral vocal cords. Aug 04, 2015 congenital laryngeal palsy is also known as congenital vocal cord paralysis. Therapy techniques for bilateral abductor palsy bridget.
Partial paralysis for most authors is identical to paresis, meaning that all muscles innervated by the iln are equally or almost affected. Delayed diagnosis led to a recurrent laryngeal nerve palsy, which persisted despite successful surgical removal of the foreign. In 4 patients with recurrent laryngeal nerve paralysis, the left recurrent nerve was most commonly involved. 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. Sitgesserra1 1endocrine surgery unit, department of surgery and 2life sciences department, universitat pompeu fabra, and 3endocrine and metabolism. Treatment of recurrent laryngeal nerve injury jama. Left vocal cord paralysis detected by petct in a case of. Recurrent laryngeal nerve an overview sciencedirect topics.
Recurrent laryngeal nerve rln injuries represent one of the most feared complications after thyroid and parathyroid surgery. The various causes of recurrent laryngeal nerve paralysis that i have observed during the past 24 years are reported. Left recurrent laryngeal nerve palsy as the presenting feature of sarcoidosis. Recurrent laryngeal neuropathy rln is a common disease of horses that has been recognised for centuries. Paralysis of the recurrent laryngeal nerve, a branch of the vagus nerve a long and important nerve that originates in the brainstem and runs down to the colon. The condition paralyzes the larynx on one or both sides, depending on the severity of the damage. Get a printable copy pdf file of the complete article 702k, or click on a page image below to browse page by page. This study investigates the incidence of temporary and permanent recurrent laryngeal nerve palsy rlnp and possible risk factors for patients with different types of thyroid gland diseases. If the file has been modified from its original state, some details such as the timestamp may not fully reflect those of the original file.
The authors found a significant difference in terms of symptomatic and asymptomatic recurrent laryngeal nerve palsy between these groups. The recurrent laryngeal nerve in its course from the brain stem to the larynx follows a path that brings it in proximity to numerous structures. Vocal cord paralysis vcp due to recurrent laryngeal nerve rln dysfunction may herald the presence of mediastinal disease, including a variety of neoplastic, inflammatory, and vascular conditions 1, 2. A 35yearold woman presented with a lrln palsy due to a huge thoracic aneurysm. A recurrent laryngeal nerve palsy occurs in thyroid tumors, most often in malignant conditions, rarely in benign ones.
Aug 17, 2016 recurrent laryngeal nerve paralysis 1. Birth trauma that causes excessive tension in the neck can cause transient bilateral vocal cord paralysis that can last 69 months. Stretching or squashing of the recurrent laryngeal nerve that supplies nerves to the larynx as it has a very long, tortuous pathway to the larynx 2. However, there are also cases of vocal cord paralysis due to right recurrent laryngeal nerve paralysis in the literature. Recurrent laryngeal nerve rln injury and voice alteration after thyroid surgery. The recurrent laryngeal nerve carries both abductor and adductor fibers to the vocal cords. The abductor fibers are more vulnerable, and moderate trauma causes a pure abductor paralysis selmons law. Recovery of laryngeal function after intraoperative injury to the recurrent laryngeal nerve loss of function in the recurrent laryngeal nerve rln during thyroidparathyroid surgery, despite a macroscopically intact nerve, is a challenge which highlights the sensitivity and complexity of laryngeal innervation. It represents 15%20% of all cases of congenital anomalies of the larynx. Original article prevention and treatment of recurrent laryngeal. We present a case of a dental plate in the thoracic oesophagus that caused high dysphagia. Recurrent laryngeal nerve injury after thyroid and. Humes, md we report a 10yearold girl who developed persistent hoarseness after stent placement for. Risk factors for transient vocal cord palsy after thyroidectomy j.
The effects of immediate recurrent laryngeal nerve rln reconstruction during thyroid cancer surgery with or without uvfp before the surgery were evaluated with videostroboscopic, aerodynamic, and perceptual analyses. Laryngeal nerve palsy or paralysis anatomy, physiology, classification, causes, pathophysiology video laryngeal nerve palsy usually refers to the palsy of the recurrent largyngeal nerve. The disorder usually affects the left side of the larynx. 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. The risk of lesion to the recurrent laryngeal nerve exists in all cases of thyroid surgery. Vocal fold paralysis in painless aortic dissection ortners syndrome. Even for experienced surgeons, a number of patients will have temporary laryngeal paralysis or paresis, which for some will become permanent after 12 months. Exposure of the intralaryngeal portion of the recurrent laryngeal nerve the thyroid cartilage was exposed. How to reduce recurrent laryngeal nerve palsy in anterior. Partial recurrent laryngeal nerve paralysis is a diagnosis inconsistent with the spectrum of vocal fold immobility disorders that have been proposed to date. The anatomy of the lrln and the cardiothoracic complaints which may cause the palsy are discussed. Left recurrent laryngeal nerve palsy secondary to left pulmonary artery stent in a child daisuke kobayashi, md, daniel r. Five patients with preoperative recurrent laryngeal nerve paralysis as a result of involvement of metastasis were enrolled in the present study.
Departmentof medicine faelkassimi departmentof surgery,collegeof. Diagnosis of recurrent laryngeal nerve palsy after. Transient palsy of recurrent laryngeal nerve postresection of giant substernal goiter rwakaryebe muhoozi1 fenglei yu1 jingqun tang1 xiang wang1,2 1department of cardiothoracic surgery, second xiangya hospital of central south university, changsha, hunan, china 2key laboratory of carcinogenesis and cancer invasion, cancer. Recurrent laryngeal nerve radiology reference article.
Overall incidence of transient rlnp is reported to be 0. Nerve regeneration was not accounted for heuer et al 1997, dalatri et al 2008, schindler et al 2008 mattioli et al 2011. Optimal management of acute recurrent laryngeal nerve injury. 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 returnin. This prospective study assessed the impact of surgical injury and. From there, like the recurrent laryngeal nerve on the right, it moves upward to the larynx. These injuries induce a significant postoperative morbidity. Videoassisted esophagectomy using a portfree organ. Recurrent laryngeal nerve palsy due to impacted dental plate.
The condition is rare but serious and medical attention will be required. The left rln courses around the distal aortic arch and the patent ductus arteriosus close to the area of dissection needed to reconstruct the distal arch. Parathyroidectomy operations that recurrent laryngeal nerves were not fully dissected. There are two recurrent laryngeal nerves, right and left, in the human body. Theresponse to corticosteroids was dramatic and complete. The larynx is involved in producing speech, breathing and it also protects the trachea. Thyroid and parathyroid surgery is associated with a risk of traumatic injury to the. Laryngeal nerve palsy or paralysis anatomy, physiology. A 63yearold man presented with acute dysphonia immediately after insertion of a hickman line via the subclavian route. 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 subclavian artery then traveling upwards. Additionally, the nerves are one of few nerves that. Keywords acute ischaemic stroke, vocal cord palsy, vagus nerve, stroke.
A novel variation of the recurrent laryngeal nerve bmc surgery. Ortners syndrome, which describes the occurrence of vocal hoarseness due to a cardiopulmonary disease that results in the compression of the left recurrent laryngeal nerve, is usually associated with severe mitral stenosis. Reversible left recurrent laryngeal nerve palsy in. All other intrinsic laryngeal muscles are innervated by the recurrent laryngeal nerve. Recurrent laryngeal nerve rln palsy is the most common and serious complication after thyroid surgery. Visual identification of the rln during thyroid surgery has been shown to be associated with lower rates of palsy, and although it has been recommended as the gold standard for rln treatment. The recurrent laryngeal nerve is responsible for both abduction opening and adduction closing of the vocal fold. The cause of bilateral paralysis of the vocal cords is often unknown idiopathic. Recurrent laryngeal nerve palsy occurs when the recurrent laryngeal nerve or vagus nerve becomes damaged. Effect of recurrent laryngeal nerve identification technique in thyroidectomy on recurrent laryngeal nerve paralysis and hypoparathyroidism. The superior laryngeal nerve consists of two branches. Recurrent laryngeal nerve injury produces an abductor laryngeal paralysis. Causes of recurrent laryngeal nerve paralysis jama. 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.
Recurrent laryngeal nerve rln injury is commonly encountered by. The surgeon must be aware of the possibility of a non recurrent laryngeal nerve, which arises directly from the cervical vagus and therefore represents a severe potential pitfall during thyroidectomy. Recovery of post thyroidectomy aphonia with peri recurrent. Injury to the recurrent laryngeal nerve affects motor function of most of the intrinsic laryngeal. The other branch of the superior laryngeal nerve, the external laryngeal nerve, passes under sternothyroid deep to the superior thyroid artery. The larynx will be paralyzed on the side where this nerve has been damaged, unless the problem originated with damage. Recurrent laryngeal nerve rln injury is a com mon severe complication in thyroid surgery 1, and unilateral rln injury is more common. Gelfoam injection as a treatment for temporary vocal fold paralysis. Recurrent laryngeal nerve palsy after thyroid gland. It pierces the thyrohyoid membrane above the superior laryngeal artery.
The calcium channel antagonist nimodipine improves functional recovery after experimental nerve injury and also after cranial nerve. The recurrent laryngeal nerve supplies sensation from the rest of the larynx below the level of the vocal folds. Ansa cervicalis recurrent laryngeal nerve anastomosis in the neck was performed in 4 patients and direct anastomosis of recurrent laryngeal nerve in the mediastinum in 1 patient. Get a printable copy pdf file of the complete article 907k.
The recurrent laryngeal nerve rln supplies all the muscles in the larynx voice box apart from the cricothyroid muscles. Risk factors for transient vocal cord palsy after thyroidectomy. External laryngeal nerve an overview sciencedirect topics. Pdf risk factors for recurrent laryngeal nerve palsy. Recurrent laryngeal nerve injury and swallowing dysfunction. The recurrent laryngeal nerve is a branch of the vagus nerve that supplies all the intrinsic muscles of the larynx, with the exception of the cricothyroid muscles. Recurrent laryngeal nerve injury causes and surgery. Laryngeal hemiplegia occurs in all breeds of horses, but mainly in large breeds, and it is probably heritable. Treatment of recurrent laryngeal nerve injury jama surgery. Original article neurotrophin expression and laryngeal muscle. Partial recurrent laryngeal nerve paralysis or paresis. Injury to the recurrent laryngeal nerve is one of the most severe.
Sciences, research unit of anaesthesia and intensive care, rizzoli orthopaedic institute, university of bologna. 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 laryngeal nerve is a nerve branching down from the vagus nerve towards the larynx. Postoperative left rln paralysis claviendindo grade i was observed in one patient in whom the left rln could not be preserved because the metastatic lymph nodes had invaded the nerve. Vocal cord function during recurrent laryngeal nerve injury. Aug 29, 2019 bilateral vocal fold vocal cord immobility bvfi is a broad term that refers to all forms of reduced or absent movement of the vocal folds. Recurrent laryngeal nerve palsy has a detrimental impact on patients outcomes, 1 and it often leads to accusations of malpractice. 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. Background the non recurrent laryngeal nerve nrln is a rare embryologicallyderived variant of the recurrent laryngeal nerve rln.
What you need to know about the recurrent laryngeal nerve. Transient recurrent laryngeal nerve palsy affects to 510 per cent of patients after extracapsular thyroidectomy. After extubationstridor, respiratory distress, aphonia occurs due to the closure of the glottic aperture necessitating immediate intervention and emergency intubation or tracheostomy. Causes of recurrent laryngeal nerve paralysis jama network. 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. This complication can be recognized intraoperatively or diagnosed postoperatively by laryngoscopy. Recovery of laryngeal function after intraoperative injury to the. Recurrent laryngeal nerve palsy complicating subclavian line. Recurrent laryngeal nerve has a much longer course which makes it more prone to paralysis as compared to the right one. In laryngeal paralysis, the stiffness of the denervated vocal fold is decreased. Recurrent laryngeal nerve rln injury is a common severe complication in thyroid surgery, and unilateral rln injury is more common. There are two recurrent laryngeal nerves, right and left. It then branches into the superior and recurrent laryngeal nerves rln, of which the latter is remarkably interesting from the point of view of evolutionary biology. Recurrent laryngeal nerve paralysis definition of recurrent.
Injury may be caused by an endotracheal tube cuff that is situated too high or by a centrally positioned esophageal stethoscope or nasogastric tube that can compress the posterior branch of the recurrent laryngeal nerve. Flexible laryngoscopy revealed a left vocal fold palsy. Paralysis of the recurrent laryngeal nerve can be due to central causes affecting the vagus nerve. Unilateral recurrent laryngeal nerve paralysis urlnp is a known complication of thyroid surgery. Sarcoidosispresenting recurrent left laryngeal nerve palsy. The recurrent laryngeal nerve supplies the larynx voice box.
Recurrent laryngeal nerve palsy may be devastating in the early postoperative period owing to an inability to cough and clear secretions. Preoperative recurrent laryngeal nerve palsy, intentional nerve transection because of cancer invasion, assessment failure of recurrent laryngeal nerve function due to the deficiency of the intraoperative neuromonitoring equipment. Transection injury to the recurrent laryngeal nerve rln has been associated with permanent vocal fold palsy, and treatment has been limited to voice therapy or local treatment of vocal folds. Although vocal cord function contributes to the ability to breathe, swallow, and phonate effectively, up to 40% of individuals with vcp may be asymptomatic 3. Stretching or squashing of the recurrent laryngeal nerve that supplies nerves to the larynx as it has a very long. Left recurrent laryngeal nerve palsy secondary to left. Recovery of voice after reconstruction of the recurrent. Nov 12, 2007 recurrent laryngeal nerve palsy is rare and has not been reported in association with a foreign body in the thoracic oesophagus. The clinical and radiographic features are consistent with the diagnosis of sarcoidosis. The novel variation of left recurrent laryngeal nerve. This requires indirect laryngoscopy preoperatively, and, as soon as possible, postoperatively. This outpatient procedure generally takes between two and three hours. Recurrent laryngeal nerve injury may result in vocal cord paralysis and hoarseness.
After the recurrent laryngeal nerve leaves the vagus nerve, it goes down into the chest and then loops back up to supply the larynx the voice box. Original article neurotrophin expression and laryngeal muscle pathophysiology in response to recurrent laryngeal nerve crush injury baoxin wang1, junjie yuan2, xinwei chen 1, jiafeng xu3, pin dong 1department of otolaryngology, head and neck surgery, shanghai general hospital, school of medicine. Schneider, ms, cccslp codirector, ucsf voice and swallowing center speech language pathology director. Pdf effect of recurrent laryngeal nerve identification. Recurrent laryngeal nerve paralysis was assessed by an otolaryngologist on postoperative day 4 or 5. Hoarseness was found to be caused by right recurrent laryngeal nerve palsy. 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. Stretching or squashing of the recurrent laryngeal nerve that supplies nerves to. Such a risk of injury to the recurrent laryngeal nerve is a wellrecognized risk of thyroid surgery 27, 31, 32 but has been even described with radioiodine therapy.