RECURRENT LARYNGEAL

NERVE INJURY DURING

THYROIDECTOMY- WHAT
NEXT?
Dr. Anirban Das
MTTR & PGT
MS(General Surgery)
IPGMER & S.S.K.M. Hospital, kolkata
 Introduction
The incidence of laryngeal nerve
paralysis during thyroidectomy
dropped to 1- 3%.
Still, it represents one of the most
common aetiologies of laryngeal
nerve paralysis.
Risk factors are-
Completion thyroidectomy
Volume of thyroid resection &
Surgeons inexperience.
Variable anatomic location of RLN
are also responsible for its injury.
 RLN
RLN is a mixed motor, sensory and
autonomous nerve.
It innervates all intrinsic muscle of
larynx except Cricothyroid.
Mechanism of iatrogenic RLN injury
may include
Mechanical,
Thermal &
Vascular factors.
 RLN Injury
Neropraxia- Focal demyelination after
minimal injury(compression) leads to
temporary blockage of nerve conduction-
recovers completely and spontaneously after
6-8 weeks.

Axonotemesis- More severe trauma(crush,

stretch or ischemic injury) damage the myelin
sheath- recovers spontaneously, but can lead
to misdirected fibre regrowth and vocal cord
muscular contractions that are poorly co-
ordinated with altered glottic
function(synkinesis)
 Nerotmesis- More complete trauma
(laceration, severe crush or stretch
injury) leads to interruption of
endoneurial, epineurial and/or
perineurial sheaths- incomplete or
absent nerve re growth and
permanent vocal cord paralysis.
 For understanding RLN injury, it is
essential to know its course and supplies.
 RLN supplies-

Adductor of larynx-
i. Thyro-arytenoid muscle
ii. Lateral Crico-arytenoid muscle &
iii. Interarytenoid muscle.

. Abductor of larynx-
a. Posterior Crico-arytenoid muscle.
 RLN trauma during
thyroidectomy
Presents with various symptoms-
Dysphonia or hoarseness- voice is breathy,
weak, diplophonic or completely aphonic.
Dyspnea
Aspiration during swallowing & coughing-
due to
I. alteration of sensory feedbacks and
inputs from laryngeal mucosa and
II. inefficient motor laryngeal closure of
vocal folds during swallowing.
 Severity of symptoms and
prognosis depends on-

1. Type of nerve lesion

2. Transient or permanent
3. Partial or complete
4. Unilateral or bilateral.
 Unilateral RLN injury
Presents with
Mostly asymptomatic.
Hoarseness of voice due to glottal air
leak during phonation.
Vocal fold may be
1. Median (midline)
2. Paramedian (1.5 mm from midline) or
3. intermediate (3.5 mm)
 Bilateral RLN Injury
Presents acutely after extubation.
Biphasic stridor and respiratory
distress.
Difficulty in Phonation due to
bilateral fixed focal cord.
Vocal fold may be- median,
paramedian or intermediate
bilaterally.
 Associated SLN Injury
Voice is weak and pitch can not be
raised.
Aspiration due to anaesthesia at
supra-glottic mucosa.
Shortening of cord with loss of
tension
Flapping of paralysed cord- sags
down during inspiration and bulges
out during expiration.
Askew position of glottis-anterior
 Diagnosis by ENT surgeons
Voice- Breathy and very unstable quality,
loss of power and loss of voice range-
worsening on shouting.
Diplophonic- two sounds of different
pitch are heard at the same time.
Patients are out of breath when speaking
and experience vocal strain.
Sore throat is noted due to increased
vocal effort.
Associated with aspiration of liquids
during swallowing.
 Observation of Larynx
Indirect laryngoscopy.
Rigid and flexible endoscopy through
fibroscope - video tapped or
numerical recording.
Stroboscopy.
 Indirect laryngoscopy
Oldest and simplest way by use of
mirror.
But, No documentation by
videotapped or stroboscopy.
 Fibroscopy
Observation of larynx in natural condition
and in different tasks-calm breathing, single
vowel phonation, connected speech
phonation, singing, coughing, sniffing,
swallowing.
Allows to documents supraglottic
squeezing, ventricular phonation of
pharyngeal constriction.
Visualise quality of glottis closure during
phonation and signs of vocal fold
denervation.
 Signs of denervation
More lateral position-poor glottic closure.
Reduced length of paralysed folds.
Lowered paralysed folds.
Exaggerated vertical movement during
stroboscopy.
Atrophic vocal folds- loss of muscle bulk and
concavity of free edges.
Arytenoid rolls forward leaning over glottis on
denervated side.
On phonation, contralateral normal vocal fold
shortens and adduct to match reduced length
of denervated vocal fold.
Signs of partial denervation
Persistence of some muscle tone on
paralysed side.
Closer position of paralysed vocal
folds.
No VF atrophy.
Better glottic closure
Some residual abduction during
sniffing.
 Stroboscopy
Method which artificially slows down the
VF vibration and hence permit
observation of mucosal wave and lateral
movement of vibration.
Vocal fold vibration on denervated side
shows reduction in amplitude both of
lateral movement and of mucosal wave.
Paralysed vocal fold behaves like flag in
breeze with loose and lax appearance.
 Electromyography(EMG)
Innervation status of Intrinsic muscle of larynx
is done by EMG for diagnosis and prognosis.
Thyro-arytenoid muscle is used for EMG
through percutaneous route.
Electrical pattern are examined for
spontaneous and evoked activity.
Signs of denervation are-
1. Electrical silence.
2. Fibrillation potential
3. Positive sharp waves appear after 10 days of
paralysis.
 Reinnervation in EMG
Nascent motor unit appera- low
amplitude and short duration
polyphasic waves.

Partial denervation shows normal

potentials in reduced in number.
Accoustic and aerodynamic measures
To follow laryngeal efficiency in terms of voice
production and aerodynamic retentability.
Characteristics of paralysis are-
Reduction in maximum phonation time.
Reduction of dynamic range both in loudness
and frequency.
Loss of high frequency harmonics and high
frequency formants on spectrogram.
Increased aperiodicity of vibratory period.
Increased noise to harmonic ratio.
Increased mean air flow.
Sub glottic air pressure is diminished.
 Management
Three corner stones are-
1. Observation
2. Speech therapy and
3. Surgery.
. Choice of treatment guided by
aetiology, importance of type of
functional deficit and prognosis for
recovery.
 Recognition by surgeon of laryngeal
mobility problem after thyroidectomy
and urgent referral to ENT specialist for
neuro-laryngeal evaluation.
Corticosteroid- reduce perineural
inflammation.
Speech therapy
Surgery is postponed between 6 months
and 1 year of onset of paralysis.
 Indication of early surgery
1. Aspiration
2. Breathy hypophonia
3. Ineffective cough.
4. Compromised cardiac and pulmonary
reserve.
5. Aetiology of nerve cut injury.
6. Professional voice users.

. Tracheostomy for bilateral RLN injury with

severe respiratory distress.
 Surgical techniques
Purpose to improve glottis closure and glottis
resistance during phonation.
Medialisation techniques-
1. Intracordal injection (injection laryngoplasty)
of Teflon, bovine collagen, micronised human
dermis, autologus collagen, autologus fat,
modified hyaluronic acid in paralysed VF to
increase muscle bulk and resitance so that
free edges adopts more medial position,
improving glottis closure during phonation.
2. Type 1 thyroplasty
3. Arytenoidopexy
4. Crico thyroid sublaxation to improve
longitudinal tension.

. Reinnervation procedure-
1. Ansa omohyoid neuromuscular pedicle
onto vocal muscle.
2. Ans cervicalis-RLN anstomosis.
 Bilateral RLN Injury with
Dyspnea
Emergency tracheostomy.
Endoscopic vocal fold lateralisation.
Endoscopic laser cordotomy.
CO2 lased arytenoidectomy.
 References
Head Neck surgery and Oncology-
Jiten shah
Laryngeal dysfunction after thyroid
surgery: Diagnosis, Evaluation and
Treatment.- C. Fink.
Thyroid surgery, Voice and the
Laryngeal Examination- Time for
increased awareness and accurate
Evaluation-Radu Mihai, gregory W
randolph.
 Thank
You