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Objective: Recurrent laryngeal nerve (RLN) injury is a serious complication during thyroid reoperation. Intraoperative neuromonitoring (IONM) is one of the means to reduce RLN paralysis. However, the role of IONM during thyroidectomy is still controversial. The aim of this study was to assess whether the IONM could reduce the incidence of RLN injury during thyroid reoperation. Methods: We performed a systematic review to identify studies in English language which were published between January 1, 2004, and March 25, 2023 from PubMed, EMBASE, and Cochrane Library, comparing the use of IONM and Visualization Alone (VA) during thyroid reoperation. The RLN injury rate was calculated in relation to the number of nerves at risk. All data were analyzed using Review Manger (version 5.3) software. The Cochran Q test (I2 test) was used to test for heterogeneity. Odds ratios were estimated by fixed effects model or random effects model, according to the heterogeneity level. Results: Eleven studies (3655 at-risk nerves) met criteria for inclusion. Data presented as odds ratio(OR) and their 95% confidence intervals(CI). Incidence of overall, temporary, and permanent RLN injury in IONM group were, respectively, 4.67%, 4.17%, and 2.39%, whereas for the VA group, they were 8.30%, 6.27%, and 2.88%. The summary OR of overall, temporary, and permanent RLN injury compared using IONM and VA were, respectively, 0.68 (95%CI 0.4-1.14, p=0.14), 0.82 (95%CI 0.39-1.72, p=0.60), and 0.62 (95%CI 0.4-0.96, p=0.03). Conclusions: The presented data showed benefits of reducing permanent RLN injury by using IONM, but without statistical significance for temporary RLN injury.
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During thyroidectomy, both needle electrodes (NE) and endotracheal tube electrodes (ETE) can be used. Incomplete contact of the endotracheal tube electrode with the vocal cords, endotracheal tube electrode may hinder an optimal outcome and even result in an inability to obtain an electromyography wave while neuromonitoring the external branch of the superior laryngeal nerve (EBSLN). There is no study that compares NE and ETE for EBSLN monitoring. Therefore, this study compares NE and ETE recordings during EBSLN monitoring. Twenty-six consecutive patients undergoing total thyroidectomy were included in this study. Intraoperative neuromonitoring was performed simultaneously with both NEs and ETEs. Pre-resection (V1, R1, and S1) and post-resection (V2, R2, and S2) amplitudes and latencies were recorded for both types of electrodes. The Mann-Whitney U test was used for statistical analysis. Twenty-one women and five men were included, and 52 nerves at risk were evaluated. The mean amplitudes for right S1 (314 vs. 168 µV, p = 0.009) and right S2 (428 vs. 161 µV, p: 0.001) and for left S1 (346 vs. 229 µV, p: 0.017) and left S2 (413 vs. 229 µV, p: 0.009) were statistically higher for the NE group. All amplitudes obtained using NEs, except on the left for V1, R1, V2, and R2, were statistically higher than those obtained using ETEs. There was no loss of signal or vocal cord palsy in the patients. There were no needle-related complications. EBSLN monitoring using NE is a safe alternative to ETE. With NE, higher amplitudes were obtained. Level of evidence: Level 3.
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OBJECTIVES: Surgery is the mainstream treatment for early-stage esophageal squamous cell carcinoma (ESCC) and occult recurrent laryngeal nerve lymph node metastasis (RLNM) is not uncommon among those with R0 resection. The clinical value of postoperative radiotherapy (PORT) in patients with RLNM only is still controversial. METHODS: Consecutive patients with early-stage ESCC treated with R0 resection and pathologically confirmed RLNM only from June 2012 to July 2022 were retrospectively reviewed. PORT, covering the supraclavicular and superior mediastinum area (small T-field) at a dose of 50.4 Gy for 28 fractions, was performed in some patients. Propensity score matching (PSM) was performed to balance the baseline characteristics between patients with or without PORT. Pattern of failure, disease-free survival (DFS), and overall survival (OS) were compared. RESULTS: Among the 189 patients identified, 69 (35.5%) received PORT and the other 120 (63.5%) did not. After PSM, 154 patients were included in the matched cohort, including 62 in the PORT group and 92 in the non-PORT group. With a median follow-up of 48 (95% CI: 40.3-55.7) months, 69 patients developed their initial disease recurrence in the whole population and PORT significantly decreased the frequency of local recurrence (61.2% vs 21.4%) among those with recurrent disease. Additionally, in the PSM matched cohort, PORT significantly prolonged patients' DFS (HR 0.393, P = 0.002) and OS (HR 0.462, P = 0.020). Moreover, PORT remained as the independent factor associated with improved DFS (HR 0.360, P = 0.001) and OS (HR 0.451, P = 0.021) after multivariate Cox analyses. In addition, tumor location and pathological TNM stage were found to be independent prognostic factors associated with survival outcomes. CONCLUSION: PORT is associated with improved DFS and OS in ESCC patients with R0 resection and RLNM only, which warrants future validation.
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Carcinoma de Células Escamosas de Esófago , Metástasis Linfática , Nervio Laríngeo Recurrente , Humanos , Masculino , Femenino , Persona de Mediana Edad , Carcinoma de Células Escamosas de Esófago/cirugía , Carcinoma de Células Escamosas de Esófago/radioterapia , Carcinoma de Células Escamosas de Esófago/patología , Nervio Laríngeo Recurrente/patología , Estudios Retrospectivos , Anciano , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/radioterapia , Neoplasias Esofágicas/mortalidad , Neoplasias Esofágicas/cirugía , Ganglios Linfáticos/patología , Radioterapia Adyuvante/métodos , Recurrencia Local de Neoplasia/patología , Supervivencia sin EnfermedadRESUMEN
Vocal cord paralysis results from involvement of the recurrent laryngeal nerve (RLN), either before the surgery or following excision. Coaptation of the resected edges utilising microsurgical techniques is the most promising therapeutic strategy available for RLN excision. The RLN can be repaired by direct epineural coaptation or using nerve grafts adhering to recommended microsurgical techniques. This article aims to convey our experience with RLN resections/injuries and their subsequent effects. We assessed the RLN repairs that our institute had completed from April 2018 to September 2023(5 years and 5 months) including follow-up of minimum 1 year. The Functional Oral Intake Scale (FOSI) was applied to assess dysphagia, aspiration risk, and glottic gap by laryngoscopy, and GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) comprised the basis for the assessment of voice quality by speech specialists. Surgical technique included using 9-0 Ethilon either for primary repair or for repair with a nerve graft. Ten patients were included in the study; six (60%) of them were male with the median age of 32 years. At 12-month follow-up, only 10% (n = 1) was found to have dysphagia. Only 10% (n = 1) had a mild harsh voice. This same patient was the only patient to show a minimal remnant glottic gap. Ten percent (n = 1) patient showed B/l cord mobility at 12 months, while 30% (n = 3) showed flickering movements of the affected vocal cord. In all the patients, the opposite vocal cord was found to be compensating. Thus, immediate repair of RLN is helpful along with the general physiological adaptation of vocal cords to improve phonation and reduce aspiration and dysphagia risks, thus helping to improve the quality of life. The right procedure should choose from the armoury after careful intraoperative assessment.
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BACKGROUND AND PURPOSE: This study aimed to investigate the risk factors for recurrent laryngeal nerve (RLN) injury after microwave ablation (MWA) of thyroid nodules and to identify factors influencing the recovery time of post-procedure hoarseness. MATERIALS AND METHODS: We retrospectively analyzed data from patients who underwent MWA for thyroid nodules at five hospitals between November 2018 and July 2022. Patients were divided into malignant and benign nodule groups. Variables analyzed included nodule size and location, the shortest distance from nodules to the thyroid capsule and tracheoesophageal groove (TEG-D), and ablation parameters. Univariate and multivariate analyses were performed to identify risk factors. Kaplan-Meier and Cox analyses were used to evaluate the recovery time of hoarseness after MWA. RESULTS: The study included 1,216 patients (mean age 44 ± 12 [SD] years; 901 women) with 602 malignant nodules and 614 benign nodules. The posterior capsule distance (PCD) and TEG-D were identified as independent influencing factors for hoarseness in all patients (P = 0.014, OR = 0.068; P < 0.001, OR = 0.005; AUC = 0.869). TEG-D was a significant risk factor for hoarseness, with safe thresholds identified at 4.9 mm for malignant nodules and 2.2 mm for benign nodules. Among patients who developed hoarseness, those in the close-distance group (TEG-D≤2 mm) had a longer recovery time compared to the distant-distance group. TEG-D was an independent factor influencing recovery time (P = 0.008, HR = 11.204). CONCLUSION: Clinicians should consider several factors, particularly TEG-D and PCD, when assessing the risk of RLN injury before MWA. TEG-D was a vital independent factor influencing recovery time. SUMMARY: Clinicians should pay attention to several influencing factors for RLN injury before MWA and TEG-D was an independent influencing factor for recovery time of hoarseness after MWA.
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OBJECTIVE: Postoperative recurrent laryngeal nerve paralysis is one of the complications of thyroid surgery, and the prevention and management of paralysis is an important issue for surgeons. In this study, in order to gain further understanding of recurrent laryngeal nerve paralysis after thyroid surgery, we analyzed and examined the usefulness of nerve stimulators for recurrent laryngeal nerve paralysis and the factors that may cause recurrent laryngeal nerve paralysis. Furthermore, in cases where transient recurrent laryngeal nerve paralysis occurred, we analyzed and examined the timing of improvement in vocal cord movement for each intraoperative finding and intraoperative operation that caused the paralysis. METHODS: At the Department of Otorhinolaryngology Head and Neck Surgery, Sapporo Medical University Hospital, between January 2012 and December 2021, the subjects were 543 thyroid surgery cases (692 nerves) without preoperative paralysis or cancer nerve invasion performed. The relationship between postoperative transient and permanent paralysis of the recurrent laryngeal nerve was evaluated using univariate and multivariate analysis. The factors evaluated were gender, age, BMI, total thyroidectomy, benignity, malignancy, Graves' disease, using IIONM (intermittent intraoperative nerve monitoring), using CIONM (continuous intraoperative nerve monitoring), malignant tumor T3b or higher, with lateral neck dissection, and years of experience of the surgeon. Furthermore, by targeting 87 nerves with transient paralysis, surgical operations were divided into three groups: minor injury, major injury, and adhesion, and their relationship with the timing of postoperative vocal fold movement improvement was evaluated. RESULTS: Permanent paralysis of the recurrent laryngeal nerve occurred in 12 nerves (1.7 %), and transient paralysis occurred in 100 nerves (14.5 %). Univariate analysis showed no association with each factor, but multivariate analysis showed that transient paralysis was significantly lower in men and in patients using IIONM. The improvement time for vocal cord paralysis was 2.8 months in the minor injury group, 4.5 months in the major injury group, and 3.2 months in the adhesion group, indicating a statistically significant difference between the minor injury group and the major injury group. CONCLUSION: This study suggests that the use of IIONM and gentle manipulation of women may prevent recurrent laryngeal nerve paralysis during thyroid surgery. In addition, understanding the period of nerve recovery for each operation for postoperative transient recurrent laryngeal nerve paralysis may contribute to patient explanations and determining the timing of therapeutic intervention for speech improvement surgery.
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Complicaciones Posoperatorias , Tiroidectomía , Parálisis de los Pliegues Vocales , Humanos , Parálisis de los Pliegues Vocales/etiología , Parálisis de los Pliegues Vocales/prevención & control , Masculino , Tiroidectomía/efectos adversos , Femenino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Adulto , Anciano , Traumatismos del Nervio Laríngeo Recurrente/prevención & control , Neoplasias de la Tiroides/cirugía , Disección del Cuello/efectos adversos , Adulto Joven , Enfermedad de Graves/cirugía , Recuperación de la Función , Factores Sexuales , Factores de Riesgo , Pliegues Vocales/inervación , Pliegues Vocales/cirugía , Anciano de 80 o más Años , Nervio Laríngeo Recurrente , Adolescente , Análisis MultivarianteRESUMEN
We present an unusual case of a 62-year-old male presenting with contralateral hypoglossal and recurrent laryngeal nerve palsies following endotracheal intubation for emergency cardiac surgery. Postoperative, the patient was referred to Speech and Language Therapy due to concerns regarding the safety of his swallow. Oromotor assessment revealed left-sided tongue weakness and aphonia. Flexible endoscopic evaluation of swallowing (FEES) revealed a right vocal cord palsy and severe oropharyngeal dysphagia. There were no other focal neurological signs. An MRI head did not demonstrate a medial medullary stroke or other intracranial lesion. CT neck showed no abnormality identified in relation to the course of the right vagus nerve or recurrent laryngeal nerve at the skull base or through the neck respectively. The patient required a gastrostomy for nutrition and hydration. He continued to be assessed at several month intervals over the course of a year using FEES to obtain a range of voice, secretion and swallowing outcome measures. The patient commenced intensive dysphagia therapy targeting pharyngeal drive, hyolaryngeal excursion and laryngeal sensation. Swallow manoeuvres were trialled during FEES and a head-turn to the side of the vocal cord palsy during deglutition reduced aspiration risk which expedited return to oral intake. The patient had partial recovery over twelve months. Hypoglossal nerve palsy completely resolved. The right vocal cord remained paralysed however the left vocal cord compensated enabling the patient to produce a normal voice. The patient was able to take thin fluids and regular diet and the gastrostomy was removed.
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PURPOSE: This research aimed to clarify the metastatic patterns of subcarinal, right and left recurrent laryngeal nerve lymph nodes in thoracic esophageal squamous cell carcinoma and to investigate appropriate strategies for lymph node dissection. METHODS: Patients with thoracic esophageal squamous cell carcinoma receiving esophagectomy from December 2020 to April 2024 were retrospectively analyzed. Risk factors for subcarinal, right and left recurrent laryngeal nerve lymph nodes metastasis were determined by chi-square test and multivariate logistic regression analysis. We visualized the metastasis rates of these specific lymph nodes based on the different clinicopathological characteristics. Correlation between subcarinal, right and left recurrent laryngeal lymph nodes metastasis and postoperative complications were also analyzed. RESULTS: A total of 503 thoracic esophageal squamous carcinoma patients who underwent esophagectomy were enrolled. The metastasis rates of subcarinal, right and left recurrent laryngeal nerve lymph nodes were 10.3%, 10.3%, and 10.9%, respectively. The lymphovascular invasion status and tumor location were the significant predictors for subcarinal and right recurrent laryngeal nerve lymph nodes metastasis, respectively (P < 0.001 and P = 0.013). For left recurrent laryngeal nerve lymph node metastasis, younger age (P = 0.020) and presence of lymphovascular invasion (P = 0.009) were significant risk factors. Additionally, pulmonary infection is the most frequent postoperative complication in patients with dissection of subcarinal, right and left recurrent laryngeal lymph nodes. There was no significant difference in the incidence of anastomotic leakage (P = 0.872), pulmonary infection (P = 0.139), chylothorax (P = 0.702), and hoarseness (P = 0.179) between the subcarinal lymph node dissection cohort and the reservation cohort. The incidence of hoarseness significantly increased in both right (P = 0.042) and left (P = 0.010) recurrent laryngeal nerve lymph nodes dissection cohorts compared by the reservation cohorts, with incidence rates of 5.9% and 6.7%, respectively. CONCLUSIONS: The metastasis rates of subcarinal, right and left recurrent laryngeal nerve lymph nodes in thoracic esophageal squamous cell carcinoma were all over 10%. The dissection of subcarinal lymph nodes does not increase postoperative complications risk, while recurrent laryngeal nerve lymph nodes dissection significantly increases the incidence of hoarseness. Thus, lymph node dissection of subcarinal lymph nodes should be conducted routinely, while recurrent laryngeal nerve lymph nodes dissection may be selectively performed in specific patients.
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Neoplasias Esofágicas , Carcinoma de Células Escamosas de Esófago , Esofagectomía , Escisión del Ganglio Linfático , Ganglios Linfáticos , Metástasis Linfática , Nervio Laríngeo Recurrente , Humanos , Masculino , Femenino , Persona de Mediana Edad , Nervio Laríngeo Recurrente/patología , Estudios Retrospectivos , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Carcinoma de Células Escamosas de Esófago/cirugía , Carcinoma de Células Escamosas de Esófago/patología , Carcinoma de Células Escamosas de Esófago/secundario , Ganglios Linfáticos/patología , Ganglios Linfáticos/cirugía , Esofagectomía/efectos adversos , Esofagectomía/métodos , Anciano , Escisión del Ganglio Linfático/efectos adversos , Escisión del Ganglio Linfático/métodos , Terapia Neoadyuvante , Adulto , Factores de Riesgo , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
BACKGROUND: The aim of this study is to describe the management and associated follow-up strategies adopted by thyroid surgeons with different surgical volumes when loss of signal (LOS) occurred on the first side of planned bilateral thyroid surgery, and to further define the consensus on intraoperative neuromonitoring (IONM) applications. METHODS: The International Neural Monitoring Study Group (INMSG) web-based survey was sent to 950 thyroid surgeons worldwide. The survey included information on the participants, IONM team/equipment/procedure, intraoperative/postoperative management of LOS, and management of LOS on the first side of thyroidectomy for benign and malignant disease. RESULTS: Out of 950, 318 (33.5%) respondents completed the survey. Subgroup analyses were performed based on thyroid surgery volume: <50 cases/year (n = 108, 34%); 50 to 100 cases/year (n = 69, 22%); and >100 cases/year (n = 141, 44.3%). High-volume surgeons were significantly (P < .05) more likely to perform the standard procedures (L1-V1-R1-S1-S2-R2-V2-L2), to differentiate true/false LOS, and to verify the LOS lesion/injury type. When LOS occurs, most surgeons arrange otolaryngologists or speech consultation. When first-side LOS occurs, not all respondents decided to perform stage contralateral surgery, especially for malignant patients with severe disease (eg, extrathyroid invasion and poorly differentiated thyroid cancer). CONCLUSIONS: Respondents felt that IONM was optimized when conducted under a collaborative team-based approach, and completed IONM standard procedures and management algorithm for LOS, especially those with high volume. In cases of first-site LOS, surgeons can determine the optimal management of disease-related, patient-related, and surgical factors. Surgeons need additional education on LOS management standards and guidelines to master their decision-making process involving the application of IONM.
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Tiroidectomía , Humanos , Tiroidectomía/métodos , Encuestas y Cuestionarios , Monitorización Neurofisiológica Intraoperatoria , Enfermedades de la Tiroides/cirugía , Pautas de la Práctica en Medicina/estadística & datos numéricos , Traumatismos del Nervio Laríngeo Recurrente/prevención & control , Traumatismos del Nervio Laríngeo Recurrente/etiología , Parálisis de los Pliegues Vocales/etiología , Femenino , MasculinoRESUMEN
BACKGROUND: Bronchial artery pseudoaneurysms (BAP) or aneurysms (BAA) are rare, potentially life-threatening and remain poorly understood. They are most commonly idiopathic but may be associated with a number of other disease processes. Bronchial artery embolisation (BAE) is considered the first line treatment while surgical techniques are reserved for patients with a clear contraindication to embolisation or where anatomical factors preclude an endovascular approach. CASE PRESENTATION: We present an interesting case of a 56 year-old male presenting with an idiopathic unruptured right BAP causing clinical and radiological signs of left recurrent laryngeal nerve (RLN) palsy. He was otherwise clinically well with no other reported symptoms and no significant past medical history. There were no significant findings on work-up and investigation. He was ultimately treated successfully with selective transarterial coil embolization of the right bronchial artery. This is an atypical presentation of a rare clinical entity and has not previously been published in the literature to our knowledge. CONCLUSIONS: BAPs and BAAs are highly variable in their presentation, ranging from incidental asymptomatic findings to catastrophic haemorrhage, depending on their location and if they are contained or ruptured. Timely diagnosis and referral to facilitate urgent embolisation is essential to prevent potentially serious clinical sequelae. Endovascular treatment in the form of BAE is considered first line.
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Non-recurrent laryngeal nerve (NRLN) is an anatomic variation seen in about 0.52-0.7% patients, generally on right side. It exits the vagus nerve having a direct route to the larynx, unlike usual recurrent laryngeal nerve, supplying intrinsic laryngeal muscles except cricothyroid. It is sited over left side on extremely rare occasions, that is, 0.04% of the cases. Some cases of NRLN co-exists with aberrant right subclavian artery which courses behind the esophagus, also known as 'arteria lusoria'. Here we present a case of 60-years old patient, diagnosed as goiter presented to us in june 2023 at the department of head and neck surgery at a tertiary care setup of Karachi Pakistan. Intra-operatively, non-recurrent nerve was encountered, whose association was found with arteria lusoria, observed in pre-operative CT-scan. The nerve was saved and no post-operative complications were seen in patient. The association of arteria lusoria in this case emphasize its importance in predicting NRLN via pre-operative imaging techniques which can prevent its injury intra-operatively.
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Anterior cervical discectomy and fusion (ACDF) is a surgical procedure used to manage spine pathology including disc herniation, spondylosis, and myelopathy. During the operation, the vertebral segment of interest is accessed via the anterior neck and the disc space is fully resected along with osteophytes to relieve the compression along the affected nerve. While the procedure is regarded as being highly effective in improving symptoms, there are several complications associated with the surgery that patients should be cautioned about. We present a case of a patient with oropharyngeal and cervical esophageal dysphagia and left vocal cord paralysis following a C5/C6, C6/C7, and C7/T1 ACDF for multilevel cervical stenosis and disc herniation. Otolaryngology evaluation confirmed vocal cord paralysis from recurrent laryngeal nerve palsy (RLNP) and the patient's symptoms were managed with a vocal cord injection and speech therapy. This report explores the surgical approach for ACDF along with its complications and postoperative care.
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BACKGROUND: Different approach ultrasound-guided superior laryngeal nerve block was used to aid awake intubation, but little is known which approach was superior. We aimed to compare the parasagittal and transverse approaches for ultrasound-guided superior laryngeal nerve block in adult patients undergoing awake intubation. METHODS: Fifty patients with awake orotracheal intubation were randomized to receive either a parasagittal or transverse ultrasound-guided superior laryngeal nerve block. The primary outcome was patient's quality of airway anesthesia grade during insertion of the tube into the trachea. The patients' tube tolerance score after intubation, total procedure time, mean arterial pressure, heart rate, Ramsay sedation score at each time point, incidence of sore throat both 1 h and 24 h after extubation, and hoarseness before intubation, 1 h and 24 h after extubation were documented. RESULTS: Patients' quality of airway anesthesia was significantly better in the parasagittal group than in the transverse group (median grade[IQR], 0 [0-1] vs. 1 [0-1], P = 0.036). Patients in the parasagittal approach group had better tube tolerance scores (median score [IQR],1[1-1] vs. 1 [1-1.5], P = 0.042) and shorter total procedure time (median time [IQR], 113 s [98.5-125.5] vs. 188 s [149.5-260], P < 0.001) than those in the transverse approach group. The incidence of sore throat 24 h after extubation was lower in the parasagittal group (8% vs. 36%, P = 0.041). Hoarseness occurred in more than half of the patients in parasagittal group before intubation (72% vs. 40%, P = 0.023). CONCLUSIONS: Compared to the transverse approach, the ultrasound-guided parasagittal approach showed improved efficacy in terms of the quality of airway topical anesthesia and shorter total procedure time for superior laryngeal nerve block. TRIAL REGISTRATION: This prospective, randomized controlled trial was approved by the Ethics Committee of Nanjing First Hospital (KY20220425-014) and registered in the Chinese Clinical Trial Registry (19/6/2022, ChiCTR2200061287) prior to patient enrollment. Written informed consent was obtained from all participants in this trial.
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Intubación Intratraqueal , Nervios Laríngeos , Bloqueo Nervioso , Ultrasonografía Intervencional , Humanos , Femenino , Masculino , Ultrasonografía Intervencional/métodos , Persona de Mediana Edad , Intubación Intratraqueal/métodos , Bloqueo Nervioso/métodos , Adulto , Estudios Prospectivos , Ronquera/prevención & control , Ronquera/etiología , AncianoRESUMEN
INTRODUCTION: Vagal nerve stimulator (VNS) implantation is a vital therapy for epilepsy refractory to other treatments; however, it is associated with a very high rate of voice changes. Relatively few of these patients are evaluated for vocal fold motion impairments. In this series, we evaluate 5 such patients with a novel phenotype of forced abduction with VNS stimulation. METHODS: Retrospective case series. RESULTS: Five patients with a VNS implant who underwent operative direct or in-office rigid laryngoscopy and had vocal fold motion impairment associated with VNS activation are included. All 5 patients had vocal fold mobility with VNS off and a fixed with activation. All patients exhibited vocal fold abduction with VNS activation. Patient 2 has since undergone laryngeal reinnervation, which helped her intermittent dysphonia but left a small glottic gap. A type 1 thyroplasty corrected this gap and improved her voice further. Patient 3 has undergone laryngeal reinnervation for which early results show improvement in perceptual and patient reported outcomes. Patients 4 and 5 have both undergone laryngeal reinnervation with improvement in voice. CONCLUSION: Previous reported cases of stimulated immobility associated with VNS use describe only adduction of the vocal fold. This series expands the previous work showing the VNS activation can also cause stimulated immobility in an abducted position, for which reinnervation and other medialization procedures offer promising treatment.
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OBJECTIVE: Superior laryngeal nerve (SLN) function is critical to laryngeal sensation. Sensory dysfunction in the larynx, mediated through the internal branch of the superior laryngeal nerve (iSLN), is thought to occur with aging and neurodegenerative disease. However, objective analysis of iSLN neurophysiology is difficult due to its anatomic location and small diameter. This study measures sensory nerve action potentials (SNAP) from the iSLN in a rat model. METHODS: SNAP data were obtained from two adult rat strains (Sprague-Dawley, SD and Fischer 344 × Brown Norway F1 Hybrid rats, FBN). Evoked responses were obtained by stimulating the main trunk of the SLN and recording the response using a 160-µm cuff electrode placed around the iSLN. SNAP were averaged from 10 stimulations. Laryngeal adductor reflex (LAR) threshold measurements were obtained with stimulation of the iSLN and direct laryngoscopy. The sections of the iSLN were obtained for histologic analysis. RESULTS: SLN-evoked responses were successfully obtained in 18 hemi-laryngeal preparations (SD n = 13 and FBN n = 5) with corresponding LAR threshold measurements. Mean(±SD) SNAP latency, total duration, amplitude, negative durations, and intensity were 2.28 ms (±0.56), 2.13 ms (±0.70), 879 µV (±535), and 0.69 mA (±0.25), respectively. SLN stimulation threshold to elicit an LAR was of 0.84 mA (±0.31). CONCLUSION: It is feasible to record evoked SLN responses in two adult rat strains. This work may lead to a tractable animal model for objective measurements of SLN neurophysiology with various disease states. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.
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Laser thermal ablation (LTA) is an increasingly common procedure to treat benign and malignant thyroid nodules, allowing patients to avoid thyroidectomy. There are few reported postprocedural complications of LTA among patients with benign thyroid nodules. While vocal fold paralysis is a well-known potential complication after thyroidectomy, we present the first case report of vocal fold paralysis following LTA. A female in her 80s presented to an outside endocrinologist with symptoms of hyperthyroidism and benign thyroid nodules. The patient underwent a fine needle aspiration biopsy, radioiodine uptake scan, radioactive thyroid ablation, and LTA at an outside institution. The patient first noticed hoarseness 2days after LTA, and she presented to our office with a weak, breathy voice more than 4months postprocedure. Videostroboscopic examination revealed immobility of the left vocal fold with incomplete glottic closure. After awake injection laryngoplasty in the office, the patient experienced voice improvement. In conclusion, LTA is a relatively new treatment modality with limited literature on adverse outcomes. As minimally invasive techniques such as LTA are becoming more common, it is essential to remain fully aware of risks to recognize and mitigate complications like vocal fold paralysis.
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Complete and precise knowledge of the neck anatomy and its eventual anomalies is crucial while performing a safe thyroid and parathyroid surgery. Embryo-genetic malformations of the IV branchial arch can lead to an uncommon anatomical alteration known as non-recurrent inferior laryngeal nerve. Its prevalence varies between 0.7% for the dextral branch and 0.04% for the sinistral. In these cases, the inferior laryngeal nerve branches originate directly from the cervical vagus nerve, entering the larynx without hooking, on the right side around the subclavian artery or on the left around the aortic arch. The presence of a non-recurrent laryngeal nerve is challenging, due to the increased risks of iatrogenic damage to the nerve, which results in hoarseness, dysphagia, glottal obstruction, vocal cords palsy, and serious airway impairment. We present the case of a 58-year-old woman. The patient was admitted to our department for a nodule classified as Bethesda IV in the right thyroid lobe. Through the use of intraoperative neuromonitoring (IONM), surgeons detected intraoperatively a non-recurrent laryngeal nerve. A subsequent computed tomography scan confirmed an anomalous right subclavian artery branching from the left aortic arch, the Lusoria Artery. Anatomical variants represent pitfalls in this case and an accurate knowledge of the neck region is imperative while performing thyroid surgery. Devices such as IONM are useful for detecting abnormalities that may lead to iatrogenic damages.
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Nervios Laríngeos , Arteria Subclavia , Tiroidectomía , Humanos , Tiroidectomía/efectos adversos , Femenino , Persona de Mediana Edad , Arteria Subclavia/anomalías , Nervios Laríngeos/anomalías , Tomografía Computarizada por Rayos X , Monitorización Neurofisiológica Intraoperatoria , Monitoreo Intraoperatorio/métodos , Traumatismos del Nervio Laríngeo/prevención & control , Traumatismos del Nervio Laríngeo/etiologíaRESUMEN
INTRODUCTION: Neurogenic cough (NC) is thought to be related to sensory neuropathy in the hypopharynx and larynx. Defined as a cough persisting longer than 8 weeks refractory to standard therapy, it is a diagnosis of exclusion when other common etiologies (asthma, gastroesophageal reflux disease (GERD), medication side effects) are ruled out. It affects roughly 11 % of Americans and can negatively impact quality of life. METHODS: Following institutional review board approval, we evaluated the medical records of adult patients seen at the University of Arizona's tertiary laryngology center from 2018 to 2023. Patients were included if their cough persisted for >8 weeks, and they either did not respond to prior proton pump inhibitor and asthma therapy or had GERD and asthma ruled out. These patients underwent a progressive escalation of therapy, which included neuromodulators with or without cough suppression therapy, superior laryngeal nerve (SLN) block, and laryngeal botulinum toxin injections. The primary outcome was patient-reported improvement in cough symptoms rated on a 1-5 scale: 1 = no response, 2 = mild improvement, 3 = moderate improvement, 4 = significant improvement, 5 = complete resolution. RESULTS: A total of 56 patients were included. Mean (SD) age was 64.6 (14.8) years, and 66 % were female. Overall, 42 patients (75.0 %) responded to treatment. Among responders, 7 (16.7 %) experienced mild improvement, 14 (33.3 %) experienced moderate improvement, 17 (40.5 %) experienced significant improvement, and 4 (9.5 %) experienced complete resolution of their cough. 33 patients (58.9 %) were managed exclusively with neuromodulators ± cough suppression therapy; 27 responded, with an average response rating of 3.0 (SD = 1.2). 11 patients (19.6 %) failed medical therapy and underwent SLN block without subsequent botox treatment; 7 responded, with an average response rating of 2.5 (SD = 1.4). 9 patients (16.1 %) failed all previous therapies and underwent laryngeal botulinum toxin injections; 6 responded with an average response rating of 2.4 (SD = 1.3). The remaining 3 patients underwent cough suppression therapy alone, with 2 responding and an average response rating of 3.3 (SD = 1.7). CONCLUSIONS: Neurogenic cough can be effectively treated with a stepwise multimodal approach, including neuromodulators, cough suppression therapy, SLN block, and laryngeal botulinum toxin injections.
Asunto(s)
Tos , Humanos , Tos/etiología , Tos/tratamiento farmacológico , Femenino , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Anciano , Nervios Laríngeos , Bloqueo Nervioso/métodos , Toxinas Botulínicas Tipo A/administración & dosificación , Calidad de VidaRESUMEN
BACKGROUND: Head and neck surgical simulation training (SST) is an important part in otolaryngology head and neck surgical education. In this study, we provide a live porcine model for SST in recurrent laryngeal nerve (RLN) and facial nerve (FN) dissection for otolaryngology head and neck residents. METHODS: A lecture with surgical manual is provided to illustrate the surgical landmarks of pig, and step-by-step procedures for thyroid and parotid surgery, as well as neck dissection. We used 4-month-old pig weighting 32 kg for the SST. The mentor demonstrated result of RLN injury with continuous nerve monitoring. Participants used monopolar stimulation probe (4 pulse/s, 100 µs, 3-8 mA; Medtronic) to identify and intermittent monitor the RLN and FN during the SST. After the dissection course, we conducted a questionnaire survey to check the effectiveness of this training model. RESULTS: Total 30 participants were recruited, including 16 female and 14 male resident doctors. There were 1, 4 and 25 learners for 3rd year, 4th and 5th years residents, respectively. Before this training course, 53 % (16/30) and 63 % (19/30) had successful experience in finding the RLN and FN, respectively. After the SST, all of our participants had successful identify the RLN and FN (p-value <0.01); all had positive response to stimulation and familiar with the procedure. CONCLUSIONS: The live porcine model is effectiveness in SST for RLN and FN dissection. Live porcine model with real-time RLN and FN monitoring should be provided for otolaryngology head and neck resident training.