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Right recurrent laryngeal nerve mobilization for primary anastomosis following segmental resection
DiLorenzo M1, Cognetti DM1, Spiegel J1, Jabbour S2, Pribitkin EA1
1Thomas Jefferson University Department of Otolaryngology-Head & Neck Surgery, 2Thomas Jefferson University Division of Endocrinology
INTRODUCTION DISCUSSION
RESULTS
Fig 2. RLN mobilized from where it was originally transected…(Debakey forceps)
Figure 1. Papillary Thyroid Cancer (PTC) invading Recurrent Laryngeal Nerve (RLN) with bulky lymphadenopathy precluding use of ipsilateral ansa cervicalis.
Figure 7. Abduction.
ABSTRACT
METHODS AND MATERIALS
CONCLUSIONS
REFERENCES
CONTACT
Educational Objective
At the conclusion of this
presentation, the participants should
be able to mobilize the right recurrent
laryngeal nerve to effect primary
anastomosis following segmental
resection
Objective
Describe technique of right
recurrent laryngeal nerve mobilization
and primary re- anastomosis
Study Design
Case Report and review of
literature
Methods
Following segmental resection of
the right recurrent laryngeal nerve
due to invasion by papillary thyroid
cancer, the nerve is mobilized from
underneath the right subclavian artery
and tunneled under the artery to
increase the length available for
tension free anastomosis, which is
then accomplished through standard
microsurgical technique.
Results
Successful restoration of tone and
progressive partial restoration of vocal
fold mobility on videostroboscopy is
demonstrated at 3, 6, 12 and 18
months following surgery.
Conclusions
Successful transposition of the
right recurrent laryngeal nerve from its
course around the subclavian artery
to achieve primary anastomosis
following segmental resection of the
RLN can be accomplished with good
voice outcomes. This technique
avoids the need for a nerve
interposition graft and provides an
alternate method for re-innervation
when the ipsilateral ansa cervicalis
nerve is unavailable due to
involvement by cancer or sacrifice
during neck dissection.
Vocal fold tone was recovered by 3 months (Fig 6) and improved over course of 18 months. Airway was preserved by vocal fold abduction seen at 18 mo. (Fig 7) and voice was judged to be good by the patient with some recovery of adduction seen on videostroboscopy.
Normal vocal fold function requires about 50% of recurrent laryngeal nerve fibers be present and correctly routed3. Although adductor (ADD) and abductor (ABD) fibers are not spatially segregated, ADD fibers outnumber ABD fibers in a 4:1 ratio. Such a preponderance may contribute to poor vocal results following direct reanastomosis. Other factors possibly contributing to poor glottic function after neurorrhaphy include misdirection of the ABD and ADD nerve fibers, impaired axonal regeneration, the substantially greater laryngeal ADD vs. ABD muscle mass and impaired muscle or cricoarytenoid joint function. At a minimum, self-perceived functional vocal outcomes following neurorrhaphy require an immobile vocal fold in the median, physiologic phonating position with preserved bulk, recovered tension, and glottic closure during phonation. Superior voice outcomes have been demonstrated in both immediate and delayed ansa cervicalis to RLN anastomosis in large series by Wang4 and Miyauchi5. Nonetheless, situations arise during which the ansa cervicalis is unavailable for neurorrhaphy due to involvement with the primary cancer or with cervical metastases. If this occurs on the right side, the RLN may be mobilized from underneath the right subclavian artery and tunneled under the artery to achieve tension free anastomosis. Our work replicates the results achieved by Suehiro et al. in an unpublished series of 32 patients in Japan6.
A 63 old female underwent a total thyroidectomy, bilateral level 6 and right level 3, 4 and 5 functional neck dissection for PTC. At the time of surgery, the Right RLN was grossly invaded by cancer (Fig 1) and required resection. The defect in the RLN measured 3.0 cm (Fig 2). The nerve was rerouted from the original area of transection (Fig 3) underneath the right subclavian artery (Fig 4) and reanastomosed directly to the remnant RLN with 7-0 prolene epineurial suture (fig 5).
In situations where the ansa cervicalis is unavailable for neurorrhaphy due to involvement with the primary cancer or with cervical metastases, the RLN may be mobilized from underneath the right subclavian artery and tunneled under the artery to achieve tension free anastomosis and consequent good self-perceived vocal outcomes.
About 1 in 25 patients experience prolonged voice difficulties following thyroid surgery1 . Although many times injury is not appreciated at time of surgery, sometimes the RLN is accidentally transected or purposely resected. In such situations several interventions are possible, including direct reanastomosis, interposition nerve grafting, and ansa cervicalis to RLN anastomosis. Recent studies comparing these modalities have produced equivalent results2. Nonetheless, situations arise when a substantial portion of the RLN is resected, preventing direct anastomosis. In such situations, the ipsilateral ansa cervicalis may also be unavailable due to involvement with the tumor or cervical metastases. We present an alternate technique for right RLN repair whereby the nerve is mobilized from underneath the right subclavian artery and tunneled under the artery to increase the length available for tension free anastomosis, which is then accomplished via a standard microsurgical technique.
1. Clinical Practice Guideline: Improving Voice Outcomes after Thyroid Surgery Otolaryngology -- Head and Neck Surgery June 2013 148: S1-S37
2. Rohde S L et al. Otolaryngology -- Head and Neck Surgery 2012;147:733-736
3. Mu L., Yang S .Laryngoscope 1991; 101(7 Pt 1) 699-708.
4. Wang W etal PLoS One. 2011; 6(4): e19128
5. Miyauchi A et al. Surgery 2012; 152: 57 - 60
6. Suehiro A, Nagahara K, Okuyama H, Yamashita M, Moritani S, Yajin S. Recurrent Laryngeal Nerve Repair-A New Method 8° International Congress of Head and Neck Cancer http://ahns.jnabstracts.com/2012/Detail.aspx?ID=1288 accessed on 12-27-13.
Edmund A. Pribitkin, MD Thomas Jefferson University Email: [email protected] Phone: 215-955-6784 Website: jeffersonthyroidcenter.com
Fig 3. underneath the subclavian artery …(Debakey forceps)
Fig 4. and carotid artery …(Debakey forceps)
Fig 5. providing a tension free reanastomosis
Figure 6. Adduction.