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Functional Outcomes Following Delayed Laryngeal Reinnervation Of Patients with Vagal Paralysis After Paraganglioma and Schwannoma Surgery

Candelo E, Borsetto D, Obholzer R, Clarke P, MatBaki M, Birchall M

J Voice, 2023 Jul;37(4):610-615.
PMID: 33994255 DOI: 10.1016/j.jvoice.2021.03.021

PURPOSE: We present a prospective case series that aimed to report the functional (voice and swallowing) outcomes of delayed laryngeal reinnervation following vagal interruption by resection of vagal paraganglioma and schwannoma.
MATERIALS AND METHODS: A dedicated, anonymized database was established in 2012 with a minimum eighteen-month follow up set for this report. Internationally validated self- and observer-reported measures were recorded preoperatively and at six, 12 and, 18 months together with demographics, diagnoses, and operative details.
RESULTS: A total of eight patients with a median age of 46 (37-54) underwent excision of vagal paraganglioma (five) and schwannoma (three) with few mild complications. Three underwent selective and five non selective reinnervation. Seven out of eight patients underwent synchronous injection medialization. The voice handicap index (VHI-30) improved from a baseline median 83 (range 52-102) to 7.5 (5-58) at 18 months; maximum phonation time improved from median 8 (range 5-15) to 10.5 (8.5-11); voice grade ("G" in grade, roughness, breathiness, asthenia, and strain [GRBAS] scoring) improved from median three (severe impairment, range 0-3) to one (mild impairment, 0-2); Eating Assessment Tool (EAT-10) score improved from median 12 (range 3.5-27) preoperatively to one (0-16); and reflux symptom index (RSI) improved from median 25 (range 17-36) to 7 (0-36). One patient exhibited no discernible reinnervation, while the remainder exhibited good cord bulk and tone, though without purposive abduction.
CONCLUSION: Delayed laryngeal reinnervation for high vagal paralysis is a safe technique associated with good voice and swallowing outcomes by 12-18 months. Potential confounders in this small series and the absence of a control arm both limit conclusions, but this study suggests that further prospective, controlled studies, and/or case registration are merited.

Matched MeSH terms: Recurrent Laryngeal Nerve/surgery
Recurrent laryngeal nerve schwannoma: same setting of resection and injection laryngoplasty

Fader F, Mohamad Yunus MR, Mat Baki M

BMJ Case Rep, 2021 Oct 27;14(10).
PMID: 34706913 DOI: 10.1136/bcr-2021-245193

A 33-year-old woman was diagnosed with right recurrent laryngeal nerve (RLN) schwannoma. She presented with a long history of hoarseness, and only recently developed dysphagia. On physical examination, a mass was observed over the right cervical level IV. Endoscopic examination of the larynx showed that she had right unilateral vocal cord palsy. She successfully underwent transcervical resection of the tumour followed by injection laryngoplasty. This study discusses the presentation of the tumour, radiological findings, our working diagnosis and treatment options of RLN schwannoma.

Matched MeSH terms: Recurrent Laryngeal Nerve; Recurrent Laryngeal Nerve Injuries*
Fulltext Non-recurrent laryngeal nerve in thyroid surgery

Hisham AN, Sarojah A, Alvin A

Med J Malaysia, 2001 Dec;56(4):500-2.
PMID: 12014772

A case of non-recurrent laryngeal nerve is reported. The non-recurrent laryngeal nerve was found on the right side and was not associated with any vascular abnormalities. The anatomy and surgical implication of this rare condition is discussed

Matched MeSH terms: Recurrent Laryngeal Nerve/abnormalities*; Recurrent Laryngeal Nerve/pathology
Challenges in electromyographic endotracheal tube (EMG ETT) placement via awake fibreoptic intubation during emergency thyroidectomy

Mohammad Iskandar FF, Nik Lah NAS, Ismail AJ, Yeap TB

BMJ Case Rep, 2021 May 13;14(5).
PMID: 33986014 DOI: 10.1136/bcr-2021-242286

Recurrent laryngeal nerve (RLN) injury is one of the main complications of total thyroidectomy. If the injury is bilateral, total airway obstruction, aphonia and hoarseness of voice could be precipitated. Hence, it is wise for the operating surgeon to be guided by neural monitoring during thyroidectomy. We present a valuable experience handling a middle-aged man with a huge papillary thyroid carcinoma . He needed an urgent thyroidectomy due to obstructive symptoms. We highlight our intraoperative dexterity in handling his surgery in the context of continuous monitoring of RLN using electromyography.

Matched MeSH terms: Recurrent Laryngeal Nerve; Recurrent Laryngeal Nerve Injuries*
Fulltext Outcome of total thyroidectomy and subtotal thyroidectomy in non toxic multinodular goiter: Hospital Universiti Sains Malaysia experience

Ikhwan, S.M., Irfan, M., Nazli, M.Z.M., Hassan, S., Rahman, M.N.G.

Malaysian Journal of Medicine and Health Sciences, 2013;9(1):3-8.
MyJurnal

Thyroid enlargement is one of the common surgical presentations in the Department of Surgery, Hospital Universiti Sains Malaysia (HUSM). Among them, benign non-toxic multinodular goiter constitutes one third (30%) of patients who underwent thyroidectomy. Common complications of thyroidectomy include recurrent laryngeal nerve (RLN) injury, hypocalcaemia, and recurrence of the thyroid lesion. Objective & Methods: This is a retrospective study of patients diagnosed with multinodular goiter treated in HUSM between January 1996 and December 2005. A total of 111 patients were studied and 52 of them underwent subtotal thyroidectomy while 59 underwent total thyroidectomy. The outcome in terms of RLN injury, hypocalcaemia and mass recurrence were analyzed. Results: Post operative complications were studied in both groups. Permanent recurrent laryngeal nerve injury occurs in 2.4% (1 case) in subtotal thyroidectomy group compared to total thyroidectomy group (3.6%, 2 cases). Five cases from total thyroidectomy group suffered from permanent hypocalcaemia but none in the other group. 70.7% (29 cases) from subtotal thyroidectomy group have functional remnant of thyroid tissue. Recurrence rate post subtotal thyroidectomy after 5 years is only 4.9% (2 cases). Conclusion: The post operative outcome in patients who underwent subtotal thyroidectomy in HUSM from January 1996 to
December 2005 was better than total thyroidectomy with significant functional thyroid remnant.

Matched MeSH terms: Recurrent Laryngeal Nerve; Recurrent Laryngeal Nerve Injuries
Nonselective Laryngeal Reinnervation Versus Type 1 Thyroplasty in Patients With Unilateral Vocal Fold Paralysis: A Single Tertiary Centre Experience

Mat Baki M, Abdul Rani A

J Voice, 2022 Jul;36(4):581.
PMID: 32951955 DOI: 10.1016/j.jvoice.2020.08.007
Matched MeSH terms: Recurrent Laryngeal Nerve/surgery
Fulltext Primary Nonselective Laryngeal Reinnervation in Iatrogenic Acute Recurrent Laryngeal Nerve Injury: Case Series and Literature Review

Mansor WNW, Azman M, Remli R, Yunus MRM, Baki MM

Ear Nose Throat J, 2023 Mar;102(3):164-169.
PMID: 33559496 DOI: 10.1177/0145561321993605

Treating an acutely injured recurrent laryngeal nerve by primary nonselective laryngeal reinnervation (LR) during thyroidectomy is encouraged to minimize postoperative morbidity. Performing a concurrent transoral temporary injection laryngoplasty (IL) may improve the patient's voice while waiting for the effect of successful reinnervation. Chronological multidimensional voice outcomes (qualitative and quantitative) and combination of the primary nonselective LR with concurrent transoral IL were not explicitly demonstrated in previous cases that published the literature. In this study, the authors presented the multidimensional voice parameters of 3 patients undergoing primary nonselective LR with concurrent IL during thyroidectomy. The parameters were measured at different time points (2 weeks and 1, 3, 6, and 12 months) following the surgery. Laryngeal electromyography was done at 1 to 2 months and 12 months postsurgery. The results showed that the voices, qualitatively and quantitatively, were within normal range at within 3 months postintervention. The parameters were slightly beyond the normal limit at 3 months and returned to normal at 6 months postintervention and beyond. The LEMG depicted evidence of successful reinnervation in which the motor unit was normal comparable to the opposite normal vocal fold.

Matched MeSH terms: Recurrent Laryngeal Nerve/surgery
Fulltext Thoracic aortic aneurysm as a cause of Ortner's syndrome - a case series

Zaharudin I, Azizi ZA

Med J Malaysia, 2016 Jun;71(3):139-41.
PMID: 27495889

Hoarseness due to left recurrent laryngeal nerve paralysis was first described in 1897 by Norbert Ortner. Various cardiopulmonary and thoracic arch aorta pathologies associated with left recurrent laryngeal nerve palsy have been described over the last 100 years and is also known as cardio-vocal syndrome. We report our experience with seven cases of Ortners syndrome due to thoracic aortic aneurysm with compression of the left recurrent laryngeal nerve and resultant hoarseness.

Matched MeSH terms: Recurrent Laryngeal Nerve Injuries*
Fulltext Lessons of the month: A forgotten classic: Delayed diagnosis of mitral stenosis presenting initially as Ortner's syndrome

Shariff RER, Abidin HAZ, Kasim SS

Clin Med (Lond), 2020 Nov;20(6):e267-e268.
PMID: 33199335 DOI: 10.7861/clinmed.2020-0750

We present a rare case of delayed diagnosis of mitral stenosis, initially presenting with hoarseness in her voice due to left recurrent laryngeal nerve (LRLN) compression. A 60-year-old woman presented to the otorhinolaryngology department following complaints of progressive hoarseness in voice over a 6-month period. There was dysphonia but no additional evidence of a cranial nerve IX or X palsy on examination, with subsequent flexible nasopharyngolaryngoscopy demonstrating left vocal cord palsy. She was referred for a cardiology consult following findings of atrial fibrillation on electrocardiography. Transthoracic echocardiography revealed an enlarged left atrium with evidence of severe mitral stenosis. A diagnosis of Ortner's syndrome was made and the patient underwent mitral valve replacement. Common causes of Ortner's syndrome include mitral stenosis with left atrium compression of the LRLN, but it can occur due to other causes including pulmonary hypertension or aortic aneurysm compression, among others. There are few data at present to conclude that regression of left atrial enlargement and pulmonary arterial hypertension with symptoms are associated with Ortner's syndrome. Therefore, it remains pertinent for clinicians to be aware of clinical features linked to mitral stenosis including its more uncommon presentations, such as in our case, as earlier intervention may improve prognosis.

Matched MeSH terms: Recurrent Laryngeal Nerve
Fulltext Bilateral vocal cord palsy as the sole presentation of acquired syphilis

Asha'ari ZA, Razali MS, Ahmad RA

Malays J Med Sci, 2010 Apr;17(2):56-60.
PMID: 22135539

Bilateral vocal cord palsy is almost always caused by neck surgery, particularly surgery of the thyroid. We report a case of bilateral vocal cord palsy requiring emergency surgery to relieve the airway obstruction as the sole presentation of acquired syphilis. As the incidence of syphilis worldwide is rising, this unusual presentation may give clinicians a different perspective on the disease.

Matched MeSH terms: Recurrent Laryngeal Nerve Injuries
Fulltext Hoarseness as the sole symptom of an impending thoracic aneurysm rupture?

Jaafar R, Mohamad I

Malays Fam Physician, 2014;9(1):25-7.
PMID: 25606294 MyJurnal

Unilateral vocal cord palsy secondary to thoracic aortic aneurysm is a rare occurrence. Direct compression of the enlarging thoracic aneurysm on the left recurrent laryngeal nerve causes neuronal injury of the nerve, which is manifested as hoarseness. We present a rare case of unilateral vocal cord palsy in a 60-year-old healthy gentleman caused by a large thoracic aortic aneurysm. This rare presentation, with a serious underlying pathology might be misdiagnosed or delayed. Therefore, it is important for us to have high index of suspicion in cases with a rare presentation such as this.

Matched MeSH terms: Recurrent Laryngeal Nerve
Fulltext Thoracic aortic aneurysm presenting as vocal cord paralysis

Norly, S., Noorizan, Y., Ros’aini, P.

International Medical Journal Malaysia, 2013;12(1):67-68.
MyJurnal

We present a case of 80-year-old man with two-year history of hoarseness of voice secondary to left vocal cord paralysis. CT scanning revealed a saccular thoracic aneurysm compressing the left recurrent laryngeal nerve. A review of literature on Ortner's or cardiovocal syndrome is presented.

Matched MeSH terms: Recurrent Laryngeal Nerve
Fulltext A case of Hodgkin's disease presenting with recurrent laryngeal nerve palsy and tracheoesophageal fistula

Munshi A, Pandey MB, Kumar L, Karak AK, Mohanti BK

Med J Malaysia, 2006 Mar;61(1):97-9.
PMID: 16708743

Malignancy is the most common cause of tracheoesophageal fistulas. The malignancies commonly implicated in the development of tracheoesophageal fistulas are primary bronchial or esophageal carcinomas. Hodgkins disease rarely leads to such a fistula. We report a case of Hodgkin's disease with a tracheoesophageal fistula as well as a left recurrent nerve palsy at presentation. This presentation has no precedent in literature. The patient was treated with systemic chemotherapy and involved field radiotherapy. On follow up 1 year after the completion of treatment, he was clinically and radiologically disease free.

Matched MeSH terms: Recurrent Laryngeal Nerve/pathology*
Recurrent laryngeal nerve in thyroid surgery: a critical appraisal

Hisham AN, Lukman MR

ANZ J Surg, 2002 Dec;72(12):887-9.
PMID: 12485227 DOI: 10.1046/j.1445-2197.2002.02578.x

BACKGROUND: Identification and preservation of the recurrent laryngeal nerve (RLN) is of major concern in surgery of the thyroid gland. The purpose of this study was to review the surgical anatomy of the nerve and to describe its relationship to other important structures.
METHODS: A total of 325 patients were accrued in this prospective non-randomized study from January 1999 to December 2000. All patients who had total, subtotal and hemithyroidectomies were included in this study. Each side of the thyroid gland was considered as a separate unit in the analysis of the results.
RESULTS: Two hundred and seventy-six patients had thyroidectomies as their primary operation, while 49 patients had them as a reoperative procedure. There were 276 women and 46 men (6:1 female to male ratio) with a mean age of 43.1 years (range: 10-84 years). The total number of dissections was 502. The RLN was clearly identified in 491 (97.8%) dissections: single trunk in 323 dissections (65.8%), two extralaryngeal branches in 164 dissections (33.4%), and three extralaryngeal branches in three dissections (0.6%). One non-recurrent laryngeal nerve was encountered (0.2%) in the series. The proximity of the RLN to the inferior thyroid artery (ITA) was noted in 444 (90.4%) dissections: 372 (83.8%) nerves were described to be posterior and intertwined between the branches of the ITA, and in 72 (16.2%) RLNs, they were observed to be anterior to the ITA. The close association of RLN to an enlarged tubercle of Zuckerkandl was documented in 381 dissections (73.7%). A total of 231 RLNs (60.8%) was seen in the tracheoesophageal groove, 18 (4.9%) nerves were observed to be lateral to the trachea, and in 109 (28.3%), they were posterior in location. Of concern in 23 (6.0%) dissections the RLN was on the anterior surface of the thyroid gland, which is at highest risk of injury before curving down to pass behind the tubercle of Zuckerkandl. It appears that the anterior course of the RLN was seen more often in the reoperative procedures to the thyroid gland (20%).
CONCLUSIONS: Although various methods of localizing the RLN have been described, surgeons should be aware of the variations and have a thorough knowledge of normal anatomy in order to achieve a high standard of care. This will ensure the integrity and safety of the RLN in thyroid surgery. The anatomical variation may be minor in degree, but is of great importance as it may affect the outcome of the surgery and the patient's quality of life.

Matched MeSH terms: Recurrent Laryngeal Nerve/anatomy & histology*
Zuckerkandl's tubercle of the thyroid gland in association with pressure symptoms: a coincidence or consequence?

Hisham AN, Aina EN

Aust N Z J Surg, 2000 Apr;70(4):251-3.
PMID: 10779054

BACKGROUND: The Zuckerkandl's tubercle (ZT) of the thyroid gland is a well-described anatomical landmark, but few studies have clearly defined its association with pressure symptoms.
METHODS: Sixty-six consecutive patients who had primary thyroid surgery were prospectively included in the present study between late January and early August 1998.
RESULTS: A total of 96 capsular dissections were performed at thyroid surgery. Grades two and three ZT were recognized in 77 (80.2%) dissections. In general 49 (63.6%) of them were associated with significant pressure symptoms. In 43 (87.8%) of the dissections with pressure symptoms, grade 3 ZT was observed (mean weight of goitre: 154.8 g). Interestingly in this group, 16 (37.2%) patients with pressure symptoms had a goitre that was < 100 g and in one patient it was only 21 g.
CONCLUSIONS: The pressure symptom of the thyroid gland does not always appear to be due to the large size of the goitre. In a relatively small-size goitre the ZT may cause significant pressure symptoms. Observations in the present study supported a strong association of enlarged ZT with pressure symptoms. We believe this is unlikely to be simply a coincidence but rather a consequence of the enlarged tubercle. Nonetheless a prospective randomized study is called for to allow meaningful and objective evidence to be drawn.

Matched MeSH terms: Recurrent Laryngeal Nerve/anatomy & histology
Fulltext A Ten-Year Kuala Lumpur Review on Laser Posterior Cordectomy for Bilateral Vocal Fold Immobility

Mawaddah A, Marina MB, Halimuddin S, Mohd Razif MY, Abdullah S

Malays J Med Sci, 2016 Jul;23(4):65-70.
PMID: 27660547 MyJurnal DOI: 10.21315/mjms2016.23.4.9

Bilateral vocal fold immobility (BVFI) is commonly caused by injury to the recurrent laryngeal nerve (RLN) and leads to stridor and dyspnea of varying onsets. A retrospective study was done at the Department of Otorhinolaryngology of Universiti Kebangsaan Malaysia Medical Centre on laser microsurgical posterior cordectomy for BVFI. The objectives were to identify the average duration of onset of stridor from the time of insult and to evaluate the outcome of laser posterior cordectomy as a surgical option. From 1997 to 2007, a total of 31 patients with BVFI were referred for surgery. Twelve patients had tracheostomy done prior to the procedure, whereas 19 patients were without tracheostomy. Ten patients were successfully decannulated, and only 4 patients had complications related to the procedure. The minimum onset of stridor was 7 months, maximum onset of stridor was 28 years, and the mean onset of stridor was 8.7 years. The commonest complication observed was posterior glottic adhesion following bilateral posterior cordectomy. Laser endolaryngeal posterior cordectomy is an excellent surgical option as it enables successful decannulation or avoidance of tracheostomy in patients with BVFI. The onset of stridor took years after the insult to the recurrent laryngeal nerves.

Matched MeSH terms: Recurrent Laryngeal Nerve

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