Rehabilitación del nervio recurrente laríngeo postiroidectomía / Recurrent laryngeal nerve rehabilitation after thyroidectomy

El carcinoma papilar tiroideo es el tipo de cáncer más común de esta glándula, y su tratamiento de elección es la tiroidectomía. Entre las complicaciones asociadas resalta la parálisis de las cuerdas vocales, la cual ocurre por una lesión directa del nervio laríngeo recurrente durante la cirugía. Se presenta una paciente de 22 años de edad con este diagnóstico, a la cual se le realizó una tiroidectomía total; en el postoperatorio inmediato la paciente comenzó con estridor laríngeo intenso que requirió una traqueotomía de urgencia. En el examen físico se constató una parálisis bilateral de las cuerdas vocales y se decidió comenzar un tratamiento de rehabilitación del nervio recurrente laríngeo con laserterapia y HIVAMAT-200 como modalidades combinadas. Los resultados alcanzados con la fisioterapia fueron satisfactorios y la paciente se reintegró rápidamente a su ámbito familiar, escolar y social.

Papillary thyroid carcinoma is the most common type of cancer of this gland, and its treatment of choice is thyroidectomy. Vocal cord paralysis stands out among the associated complications, in which a direct injury to the recurrent laryngeal nerve occurs during surgery. We present a 22-year-old female patient with this diagnosis, who underwent a total thyroidectomy; in the immediate postoperative period the patient began with intense laryngeal stridor requiring an emergency tracheotomy. Physical examination revealed bilateral vocal cord paralysis and it was decided to begin rehabilitation treatment of the recurrent laryngeal nerve with laser therapy and HIVAMAT-200 as combined modalities. The results achieved with physiotherapy were satisfactory and the patient was quickly reintegrated into her family, school and social environment.

Neuropatía laríngea y movimiento paradojal de cuerdas vocales en la edad pediátrica: reporte de un caso / Laryngeal neuropathy and paradoxical vocal fold motion in the pediatric age: case report

Resumen La neuropatía laríngea es una condición de hipersensibilidad, hiperreactividad e hiper-función laríngea secundaria a un desequilibrio entre las aferencias y eferencias laríngeas. La respuesta individual y exagerada frente a diversos gatillantes específicos puede generar síntomas como tos crónica, parestesia laríngea, carraspera, disfonía, estridor, sensación de globus faríngeo, movimiento paradojal de las cuerdas vocales (también conocido como disfunción cordal) y/o laringoespasmo. Existe abundante literatura sobre neuropatía laríngea en adultos, sin embargo, en niños es limitada. El objetivo de este artículo es dar a conocer un caso de neuropatía laríngea en la edad pediátrica y la importancia de su consideración en el enfrentamiento de estos pacientes. Se presenta caso clínico de un paciente de 13 años, con antecedente de cirugía cardiaca reciente, evoluciona con disfonía severa evidenciándose aparente inmovilidad cordal bilateral con resultados discordantes entre nasofibrolaringoscopía y electromiografía laríngea. Posteriormente presenta mejorías en su voz, sin embargo, se agregan otros síntomas laringológicos como carraspera, globus faríngeo y estridor no explicados por causas anatómicas. Se expone la evaluación y abordaje otorrinolaringológico-fonoaudiológico para el caso. Se concluye que el diagnóstico de neuropatía laríngea requiere un alto índice de sospecha clínica ante signos laringológicos sugerentes, debiendo descartarse causas orgánicas y estructurales. El abordaje otorrinolaringológico-fonoaudiológico constituye el pilar terapéutico asociado al uso de neuromoduladores en casos seleccionados.

Abstract Laryngeal neuropathy is a condition of hypersensitivity, hyperresponsiveness and laryngeal hyperfunction secondary to an imbalance between laryngeal afferent and efferent information. The individual and exaggerated response to diverse specific triggers can lead to symptoms such as chronic cough, laryngeal paresthesia, throat clearing, dysphonia, stridor, globus pharyngeus, vocal cord dysfunction, and/or laryngospasm. There is plentiful literature on laryngeal neuropathy in adults, however, in children, it is limited. Here, we present a case report of laryngeal neuropathy in the pediatric age and discuss the importance of its consideration in the approach of these patients. A case of a 13-year-old patient, recently intervened with cardiac surgery that evolves with severe dysphonia is presented. Nasofibrolaryngoscopy shows apparent bilateral vocal fold immobility with discordant results in laryngeal electromyography. Later, his voice improves but other laryngological symptoms appeared, such as throat clearing, globus pharyngeus and stridor, not explained by anatomical causes. The otolaryngological-speech therapy evaluation and approach for the case is exposed. We conclude that for the diagnosis of laryngeal neuropathy, a high index of clinical suspicion is required in the presence of suggestive laryngological symptoms, and organic and structural causes must be previously ruled out. The otorhinolaryngological-logopedic approach constitutes the mainstay of treatment associated with the use of neuromodulators in selected cases.

Ligadura segregada de la arteria tiroidea superior. Minimizar la lesión posterior a la tiroidectomía en el rama externa del nervio laríngeo superior. Un nuevo enfoque práctico / Segregated ligation of the superior thyroid artery minimize post-thyroidectomy injury to the external branch of superior laryngeal nerve, a novel practical approach

External division of the superior laryngeal nerve supplies the crico-thyroid muscle to excite length and thickness of the vocal fold. Thus, increasing voice tone. The vicinity with the superior thyroid vessels sets the external branch of the superior laryngeal nerve in danger every time the superior end of the thyroid is dissected. Thus, the aim of present study is to assess the rate and complication of external branch of the superior laryngeal nerve injury post- thyroidectomy when segregated ligation of superior thyroid vessels closes to thyroid capsule without prior nerve identification and without nerve stimulator or intraoperative neuro-monitoring. The presented study is a prospective, non- randomized clinical study included 1450 patients who underwent thyroidectomy which either (total thyroidectomies, near total thyroidectomies or lobectomy and isthmectomy) in the Department of Surgery/AL-Diawania Teaching Hospital in Diawania City, Iraq, between January 2000 and February 2018. All patients underwent thyroidectomy through segregated ligation of superior thyroid artery very closely to thyroid capsule without prior nerve identification and without nerve stimulator or intraoperative neuromonitoring. Postoperative indirect laryngoscopy vocal cord examination with long term follow up through physical examination and clinical history to evaluate nerve integrity. In present study, the total cases with EBSLN injury were 38 (2.6%), in which the transient EBSLN injury occurred in 28 (1.9%) of patients and permanent injury occurred in 10 (0.7%) of patients and majority of cases with EBSLN injury were occur in patients with large size goiter 29 (2%) more than small size goiter 9 (0.6%) And these differences were statistically significant differences, (P<0.005). In addition to, the majority of cases with EBSLN injury were occur in male {25(1.7%)} more than female patients {13(0.9%)} And these differences were statistically significant differences, (P<0.005). Segregated ligation of superior thyroid artery is a safe technical option, cost effective, time preserved and need surgical skills to minimized risk of injury to the external laryngeal nerve

Trauma laríngeo abierto. Reporte de un caso / Open laryngeal trauma. Report of a case / Trauma laríngeo aberto. Relato de um caso

RESUMEN Introducción: la situación superficial de la laringe la hace vulnerable a diversos traumatismos externos, que pueden resultar atenuados gracias a una gran movilidad. El trauma laríngeo abierto constituye una de las urgencias en otorrinolaringología. Presentación del caso: presentamos un caso con el objetivo de describir la conducta a seguir ante un traumatismo laríngeo abierto. Paciente masculino de 37 años de edad raza negra, procedencia urbana, sin antecedentes de enfermedad recibió un balazo en la región posterior del cuello. Discusión: es llevado con prontitud al salón de operaciones dónde se le realiza laringoscopia directa flexible en la que se observa fractura del cartílago tiroideo, y edema de epiglotis como hallazgos más relevantes. Luego se le realiza traqueotomía y cervicotomía exploradora. Después de varios días de evolución satisfactoria es dado de alta quedando solamente como secuela una disfonía funcional. Conclusiones: ante cualquier traumatismo de cuello y en lo particular de este caso, de laringe, se impone la necesidad de una anamnesis adecuada, un exhaustivo examen físico general y de la especialidad, y de los complementarios de laboratorio e imagenológicos indicados.

ABSTRACT Introduction: the superficial situation of the larynx makes it vulnerable to various external injuries, which can be attenuated thanks to great mobility. Open laryngeal trauma is one of the emergencies in otorhinolaryngology. Presentation of the case: we present a case with the objective of describing the behavior to be followed when faced with open laryngeal trauma. A 37-year-old black male, urban origin, with no history of disease, was shot in the back of the neck. Discussion: he was promptly taken to the operating room where he underwent flexible direct laryngoscopy in which a fracture of the thyroid cartilage and edema of the epiglottis were observed as the most relevant findings. Then she undergoes tracheotomy and exploratory cervicotomy. After several days of satisfactory evolution, he was discharged, leaving only functional dysphonia as a sequel. Conclusions: in the event of any neck trauma and, in particular, of this case, of the larynx, the need for an adequate anamnesis, an exhaustive general and specialty physical examination, and the indicated laboratory and imaging supplements.

RESUMO Introdução: a situação superficial da laringe torna-a vulnerável a várias lesões externas, que podem ser atenuadas graças à grande mobilidade. O trauma aberto da laringe é uma das emergências da otorrinolaringologia. Apresentação do caso: apresentamos um caso com o objetivo de descrever o comportamento a ser seguido diante de um trauma laríngeo aberto. Um homem negro de 37 anos de idade, de origem urbana, sem histórico de doença, foi baleado na parte de trás do pescoço. Discussão: Ele foi prontamente levado à sala de cirurgia, onde foi submetido à laringoscopia direta flexível, na qual foram observadas as fraturas da cartilagem tireoidiana e edema da epiglote como os achados mais relevantes. Em seguida, ela é submetida a traqueotomia e cervicotomia exploradora. Após vários dias de evolução satisfatória, recebeu alta, deixando apenas a disfonia funcional como sequela. Conclusões: no caso de qualquer trauma no pescoço e, em particular, neste caso, da laringe, a necessidade de anamnese adequada, um exame físico geral e especial exaustivo e os suplementos laboratoriais e de imagem indicados.

Recurrent laryngeal nerve paralysis and hypocalcemia in superior to inferior compared to inferior to superior dissection approaches in thyroidectomy

@#<p><strong>OBJECTIVE</strong>: To compare the incidence of recurrent laryngeal nerve injury and hypocalcemia in patients who underwent thyroidectomy using superior-inferior versus an inferior to superior approach in identifying the recurrent laryngeal nerve in a tertiary government hospital between January 2012 to December 2016.</p><p><strong>DESIGN</strong>: Retrospective Cohort Study</p><p><strong>SETTING</strong>: Tertiary Government Hospital</p><p><strong>PATIENTS</strong>: Records of 241 adult patients who underwent surgery for thyroid diseases in the Department of Otorhinolaryngology - Head and Neck Surgery between January 2012 to December 2016 were evaluated. Records of patients with postoperative hoarseness after total thyroidectomy or lobectomy with isthmusectomy and hypocalcemia after total thyroidectomy were reviewed, and operative techniques analyzed for the approaches to recurrent laryngeal nerve identification.</p><p><strong>RESULTS</strong>: Records of 119 patients (aged 20-73; median 41 years old) meeting inclusion and exclusion criteria were analyzed. 57 of thyroidectomies using a superior-inferior approach, 40 were bilateral, totaling 102. There was a higher incidence of post-operative complications among those who underwent superior-inferior dissection. Chi square test showed the former approach (versus the latter) HAD 4.86 times the relative risk (RR) of permanent injury (1.9%, 0.3971 TO 6.5889, P = .5021), 1.92 times the RR of permanent hypocalcemia (1.9%), 0.1806 to 21.2838, p = 0.5910), and 2.06 times the RR of transient hypocalcemia (17%, 0.9055 to 4.4333, p = 0.0738). However, there was no significant difference between the two approaches with regard to hoarseness (independent t test, t value 0.90; p=.367) or hypocalcemia (t=0.428; p=.796).</p><p><strong>CONCLUSION</strong>: There is no significant difference in the incidence of recurrent laryngeal nerve injury and hypocalcemia in patients who underwent thyroidectomy using a superior-inferior versus and inferior to superior approach in identifying the recurrent laryngeal nerve. Intraoperatively, surgeons may shift from one approach to the other as needed, and we recommend thatthey be well versed in both approaches and fully knowledgeable of the various anatomical courses of the recurrent laryngeal nerve and locations of parathyroid gland.</p><p> </p>

The role of intraoperative nerve monitoring in thyroidectomy and parathyroidectomy: identification,prevention and repair of recurrent laryngeal nerve injury / 中华普通外科杂志

Objective To investigate the efficacy and value of intra-operative neuromonitoring (IONM) in preventing,identifying and repairing recurrent laryngeal nerve injury (RLNI) during thyroidectomy and parathyroidectomy.Methods Data were collected from a series (n =351) of patients operated in our department between Jan 2015 and Dec 2017.Results With IONM navigation a total of 460 recurrent laryngeal nerves were identified during surgery.Anatomic variations were found in 6 cases,3 were non-recurrent laryngeal nerve.Others were morphological branching variation.There were 4 cases of temporary RLNI,all were unilateral.Total temporary RLNI rate was 1.1％.All 4 cases recovered completely in 3 months after surgery.Complete transection injury of RLN were found in 2 cases,one underwent immediate nerve anastomosis,with the voice significantly improved in 6 months.The total permanent RLNI rate was 0.5％.There was no hoarseness after operation in patients with normal IONM signal.The incidence of vocal cord paralysis was 57.14％ in patients with loss of IONM signal but normal appearance of RLN.Use of IONM did not increase operation time.Conclusions IONM had significant advantages in recognition of RLN,repair of intraoperative RLNI and prediction of postoperative voice condition,which could improve the safety of surgery.

Técnica de Horsley para la reconstrucción del nervio laríngeo / Reconstruction of the laryngeal nerve by yhe Horsley technique

Introducción. La temida complicación de la tiroidectomía es la parálisis de las cuerdas vocales secundaria a lesiones del nervio laríngeo recurrente. En este estudio se analiza una técnica de reconstrucción para estas lesiones neurales. Objetivo. Describir los resultados funcionales de la reconstrucción inmediata de las lesiones del nervio laríngeo recurrente con la técnica de Horsley. Material y métodos. Se llevó a cabo un estudio prospectivo entre enero del 2000 y diciembre del 2015, en pacientes con sección del nervio laríngeo recurrente y reconstrucción de Horsley, en el cual se evalúan: a) los índices del análisis acústico de voz [tiempo máximo de fonación, perturbación involuntaria de la frecuencia (jitter), perturbación de la amplitud (shimmer) y frecuencia fundamental], b) los hallazgos estroboscópicos, y c) el índice de discapacidad vocal. El análisis estadístico se hizo con la prueba exacta de Fisher y con el programa SPSS™. Resultados. Se practicaron 1.547 tiroidectomías y se produjeron 10 secciones del nervio laríngeo recurrente (0,64 %): dos (0,12 %) inadvertidas (p=0,0001) y 8 (0,51 %) advertidas por infiltración tumoral. En los exámenes de la calidad de voz, se encontraron: frecuencias fundamentales bajas con medias de 104,79 ± 0,29 Hz en hombres (valor de referencia, VR=141,74) y de 208,12 ± 22,72 Hz en mujeres (VR=241,08), que se correlaciona con un jitter de 1,39 ± 0,99 % (VR=1,04); y también, disminución del tiempo máximo de fonación (media=10,9 ± 3,07 s). El índice de percepción de calidad de la voz fue de discapacidad leve de la voz (22,7 ± 11,8). La estroboscopia mostró cierre completo de la glotis en nueve pacientes (90 %) (p=0,005), con una posición adecuada de los cartílagos aritenoides, en siete. Conclusiones. La tasa de lesión inadvertida del nervio laríngeo recurrente en el Hospital Militar Central es de 0,12 %. La técnica de Horsley tiene unos resultados funcionales satisfactorios en el 90 % de los casos

Background. The most feared complication of thyroidectomy is the vocal cord palsy secondary to injury of the recurrent laryngeal nerve. In this study we analize the Horsley technique for reconstruction for this surgical injury. Objective. The aim of this study was to describe the functional outcomes of the reconstruction of the recurrent laryngeal nerve by the Horsley technique. Materials and methods. A prospective study including patients with section of the recurrent laryngeal nerve and the use of the of the Horsley technique for reconstruction was carried out in the period January 2000 to December 2015. The outcomes evaluated were: a) acoustic voice analysis indexes (maximum phonation time, involuntary disturbance of frequency (jitter), disturbance of amplitude (shimmer), and fundamental frequency); b) stroboscopic findings; and c) vocal disability index. The Fisher's exact test and the SPSS™ program were used for the statistical analysis. Results.The study included 1,547 thyroidectomies with 10 complete sections of the recurrent laringeal nerve (0.64%), 2 unnoticed injuries (0.12%) (p=0,0001), and 8 injuries identified intraoperatively in patients with tumor infiltration. In the voice quality test we found: low fundamental frequencies with median values of 104.79 ± 0, Hz in the male population (reference value, RV=141,74) and 208,12 ± 22,72 Hz in the female population (RV=241,08), wich correlates with a jitter of 1,39 ± 0,99% (RV=1,04) and with a decrease in maximum phonation time (median=10,9 ±3,07s). Index of perception of voice quality was mild voice disability (22,7 ± 11,8). Stroboscopy showed complete clossure of glottis in 9 patients (90%) (p=0,005), with an adequate position of the arytenoid cartilages in 7 patients. Conclusions. The rate of unnoticed injuries of recurrent laringeal nerve at Central Military Hospital in Bogotá, Colombia, is 0.12%. The Horsley reconstruction technique demonstrated satisfactory functional results in 90% of cases

Intraoperative Recurrent Laryngeal Nerve Monitoring in a Patient with Contralateral Vocal Fold Palsy

Recurrent laryngeal nerve injury can develop following cervical or thoracic surgery; however, few reports have described intraoperative recurrent laryngeal nerve monitoring. Consensus regarding the use of this technique during thoracic surgery is lacking. We used intraoperative recurrent laryngeal nerve monitoring in a patient with contralateral vocal cord paralysis who was scheduled for completion pneumonectomy. This case serves as an example of intraoperative recurrent laryngeal nerve monitoring during thoracic surgery and supports this indication for its use.

Intraoperative Recurrent Laryngeal Nerve Monitoring in a Patient with Contralateral Vocal Fold Palsy

Recurrent laryngeal nerve injury can develop following cervical or thoracic surgery; however, few reports have described intraoperative recurrent laryngeal nerve monitoring. Consensus regarding the use of this technique during thoracic surgery is lacking. We used intraoperative recurrent laryngeal nerve monitoring in a patient with contralateral vocal cord paralysis who was scheduled for completion pneumonectomy. This case serves as an example of intraoperative recurrent laryngeal nerve monitoring during thoracic surgery and supports this indication for its use.

Current Treatment Options for Bilateral Vocal Fold Paralysis: A State-of-the-Art Review

Vocal fold paralysis (VFP) refers to neurological causes of reduced or absent movement of one or both vocal folds. Bilateral VFP (BVFP) is characterized by inspiratory dyspnea due to narrowing of the airway at the glottic level with both vocal folds assuming a paramedian position. The primary objective of intervention for BVFP is to relieve patients’ dyspnea. Common clinical options for management include tracheostomy, arytenoidectomy and cordotomy. Other options that have been used with varying success include reinnervation techniques and botulinum toxin (Botox) injections into the vocal fold adductors. More recently, research has focused on neuromodulation, laryngeal pacing, gene therapy, and stem cell therapy. These newer approaches have the potential advantage of avoiding damage to the voicing mechanism of the larynx with an added goal of restoring some physiologic movement of the affected vocal folds. However, clinical data are scarce for these new treatment options (i.e., reinnervation and pacing), so more investigative work is needed. These areas of research are expected to provide dramatic improvements in the treatment of BVFP.

Clinical studies of surgical methods for small papillary thyroid cancers and prevention of recurrent laryngeal nerve injury / 解放军医学杂志

Objective To investigate the surgical methods for thyroid microcarcinoma (TMC) and prevention of recurrent laryngeal nerve injury. Methods We retrospectively analyzed 238 TMC patients during the January 2006 to December 2013 in 309 Hospital of PLA. All the 238 patients had no clinical symptoms and the diagnosis was made by thyroid ultrasound. Thyroid ultrasound exhibited very small nodules (<1cm). At preoperation, 84 patients received fine needle aspiration (FNA). Among the 84 patients, 72 were diagnosed with TMC and 12 were false-negative for TMC by FNA. The remaining was proved by postoperative pathological examination. All of these 238 cases, 144 were of unilateral and solitary, 46 unilateral and multiple, and the remaining 48 multiple unilateral. Results Ninety-seven patients were operated for affected side and isthmus resection plus contralateral subtotal resection, 56 for affected side plus isthmus resection, 23 for bilateral thyroid resection, 62 for bilateral thyroid subtotal resection. 132 patients underwent cervical lymph node dissection and the remaining 106 did not. During operation, the recurrent laryngeal nerve was exposed in 122 patients, involving a total of 182 recurrent laryngeal nerves. In the postoperative period (1–7 years), 6 cases of recurrent and 6 cases of laryngeal nerve injury were found. Conclusions High-intensity focused ultrasound (HIFU) is an important method for diagnosis of TMC. FNA is the most reliable procedure for preoperative determination of the nature of thyroid nodule. Finally, the reasonable and effective surgery is the key to optimize the long-term therapeutic effect and reduce side-effects. During thyroid surgery, to expose and protect recurrent laryngeal nerve is the best means for preventing injury to the recurrent laryngeal nerve.

Clinical evaluation of end-to-end neurorrhaphy for unilateral recurrent laryngeal nerve transaction injury / 中华普通外科杂志

Objective To investigate the necessity of primary neurorrhaphy (direct end-to-end anastomosis) when the recurrent laryngeal nerve(RLN) is severed during thyroid surgery.Methods 15 patients who suffered from iaotmgenic unilateral complete RLN injury or whose unilateral RLN had to be sacrificed because of disease invasion had a primary repair of RLN by direct end-to-end anastomosis.In control group,26 patients who did not have a nerve repair were enrolled into this study.Subjective evaluation of aspiration and voice quality were based on patient reports and hearer reports for all patients.9 patients with neurorrhaphy and 12 patients without nerve repair were followed with videolaryngoscopic examination.Results 14 patients undergoing neurorrhaphy restored normal voice at 2-5 months postoperatively.Although there were no significant functional motion of the vocal fold,slight adductory movement of the affected arytenoid was found with good tension vocal cords and symmetric arytenoids of the glottis during phonation.Only 2 patients without nerve repair had nearly restored normal voice.The patients with hoarseness had stiff arytenoids and atrophic folds resulting in glottal gap.Conclusions Neurorrhaphy is a simple and effective method to restore the normal aspiration and voice quality of patients with unilateral complete recurrent laryngeal nerve injuries.