Top

Surgical and Radiologic Anatomy

Published in:

01-09-2018 | Original Article

Bilateral patterns and motor function of the extralaryngeal branching of the recurrent laryngeal nerve

Authors: Ismail Cem Sormaz, Fatih Tunca, Yasemin Giles Şenyürek

Published in: Surgical and Radiologic Anatomy | Issue 9/2018

Abstract

Purpose

To evaluate the bilateral patterns and motor function of the extralaryngeal branches (ELB) of the recurrent laryngeal nerve(RLN).

Methods

This study included 500 consecutive patients who underwent total thyroidectomy. Intraoperative nerve monitoring (IONM) was used in 230 patients. Demographic data, indications for surgery, the bilateral patterns of ELB of the RLN, electromyographic activity of the ELB, distance between the branching point to the entrance into the larynx, and the rate of postoperative morbidity were analyzed.

Results

The overall rate of ELB was 27.6% (276/1000). A single trunk of the RLN on both sides was found in 269 (54%) patients, whereas ELB on both sides was observed in 45 (9%) patients. The rates of ELB on the left and right sides were 26.6 and 28.6%, respectively. Of the 89 branched nerves which were dissected using IONM, an evoked motor response was present in 100% of the anterior branches and 5.6% of the posterior branches. The mean branching distance of the RLN was significantly greater in female patients than in male patients on the left side (p = 0.031). The patterns of ELB showed no significant difference in male and female patients. The rates of postoperative transient and permanent hypoparathyroidism and unilateral RLN palsy were 21.6 and 2.8%, and 3.2 and 0.8%, respectively. The rate of RLN palsy was higher in branched nerves compared to those with a single trunk (0.75 vs 0.3%; p = 0.2).

Conclusion

Unilateral ELB of the RLN might be observed in approximately 1/4 of the patients, while bilateral branching is rare. A few number of posterior branches of the RLN can have motor function. The RLN’s with ELB might have a higher risk of injury compared to those with a single trunk.

Ardito G, Revelli L, D’Alatri L, Lerro V, Guidi ML, Ardito F (2004) Revisited anatomy of the recurrent laryngeal nerves. Am J Surg 187(2):249–253. https://doi.org/10.1016/j.amjsurg.2003.11.001 CrossRefPubMed

Barczynski M, Nowak W, Sancho JJ, Sitges-Serra A (2010) The motor fibers of the recurrent laryngeal nerves are located in the anterior extralaryngeal branch. Ann Surg 251:773–774. https://doi.org/10.1097/SLA.0b013e3181d57a59 CrossRefPubMed

Beneragama T, Serpell JW (2006) Extralaryngeal bifurcation of the recurrent laryngeal nerve: a common variation. ANZ J Surg 76(10):928–931. https://doi.org/10.1111/j.1445-2197.2006.03899.x CrossRefPubMed

Casella C, Pata G, Nascimbeni R, Mittempergher F, Salerni B (2009) Does extralaryngeal branching have an impact on the rate of postoperative transient or permanent recurrent laryngeal nerve palsy? World J Surg 33(2):261. https://doi.org/10.1007/s00268-008-9832-1 CrossRefPubMed

Cernea CR, Hojaij FC, De Carlucci D, Gotoda R, Plopper C, Vanderlei F, Brandão LG (2009) Recurrent laryngeal nerve: a plexus rather than a nerve? Arch Ototlaryngol 135(11):1098–1102. https://doi.org/10.1001/archoto.2009.151 CrossRef

Chandrasekhar SS, Randolph GW, Seidman MD et al (2013) Clinical practice guideline: improving voice outcomes after thyroid surgery. Otolaryng Head Neck 148(6_suppl):S1–S37. https://doi.org/10.1177/0194599813487301 CrossRef

Chiang FY, Lu IC, Chen HC et al (2010) Anatomical variations of recurrent laryngeal nerve during thyroid surgery: how to identify and handle the variations with intraoperative neuromonitoring. Kaohsiung J Med Sci 26(11):575–583. https://doi.org/10.1016/S1607-551X(10)70089-9 CrossRefPubMed

Chiang FY, Wang LF, Huang YF, Lee KW, Kuo WR (2005) Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve. Surgery 137.3:342–347. https://doi.org/10.1016/j.surg.2004.09.008 CrossRef

Chiang FY, Lu IC, Tsai CJ, Hsiao PJ, Hsu CC, Wu CW (2011) Does extensive dissection of recurrent laryngeal nerve during thyroid operation increase the risk of nerve injury? Evidence from the application of intraoperative neuromonitoring. Am J Otolaryng 32(6):499–503. https://doi.org/10.1016/j.amjoto.2010.11.001 CrossRef

10.

Dralle H, Sekulla C, Haerting J et al (2004) Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 136(6):1310–1322. https://doi.org/10.1016/j.surg.2004.07.018 CrossRefPubMed

11.

Fellmer PT, Bohner H, Wolf A, Roher HD, Goretzki PE (2008) A left nonrecurrent inferior laryngeal nerve in a patient with right-sided aorta, truncus arteriosus communis, and an aberrant left innominate artery. Thyroid 18:647–649. https://doi.org/10.1089/thy.2007.0284 CrossRefPubMed

12.

Fontenot TE, Randolph GW, Friedlander PL, Masoodi H, Yola IM, Kandil E (2014) Gender, race, and electrophysiologic characteristics of the branched recurrent laryngeal nerve. Laryngoscope 124(10):2433–2437. https://doi.org/10.1002/lary.24631 CrossRefPubMed

13.

Gurleyik E (2013) Extralaryngeal terminal division of the inferior laryngeal nerve: anatomical classification by a surgical point of view. J Thyroid Res. https://doi.org/10.1155/2013/731250 PubMedPubMedCentralCrossRef

14.

Gurleyik E (2015) Location of motor fibers within branches of the recurrent laryngeal nerve with extralaryngeal terminal bifurcation; functional identification by intraoperative neuromonitoring. Surgery 158(5):1339–1344. https://doi.org/10.1016/j.surg.2015.04.019 CrossRefPubMed

15.

Henry JF, Audiffret J, Denizot A, Plan M (1988) The nonrecurrent inferior laryngeal nerve: review of 33 cases, including two on the left side. Surgery 104(6):977–984PubMed

16.

Hermann M, Alk G, Roka R, Glaser K, Freissmuth M (2002) Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon in more than 27,000 nerves at risk. Ann Surg 235(2):261–268CrossRefPubMedPubMedCentral

17.

Jatzko GR, Lisborg PH, Müller MG, Wette VM (1994) Recurrent nerve palsy after thyroid operations–principal nerve identification and a literature review. Surgery 115(2):139–144PubMed

18.

Kamani D, Potenza AS, Cernea CR, Kamani YV, Randolph GW (2015) The nonrecurrent laryngeal nerve: anatomic and electrophysiologic algorithm for reliable identification. Laryngoscope 125(2):503–508. https://doi.org/10.1002/lary.24823 CrossRefPubMed

19.

Kandil E, Khalek MA, Aslam R, Friedlander P, Slakey D, Bellows CF (2011) Recurrent laryngeal nerve: significance of the anterior extralaryngeal branch. Surgery 149(6):820–824. https://doi.org/10.1016/j.surg.2011.02.012 CrossRefPubMed

20.

Kandil E, Abdelghani S, Friedlander P, Alrasheedi S, Tufano RP, Bellows CF, Slakey D (2011) Motor and sensory branching of the recurrent laryngeal nerve in thyroid surgery. Surgery 150(6):1222–1227. https://doi.org/10.1016/j.surg.2011.09.002 CrossRefPubMed

21.

Kaplan EL, Salti GI, Roncella M, Fulton N, Kadowaki M (2009) History of the recurrent laryngeal nerve: from Galen to Lahey. World J Surg 33(3):386–393. https://doi.org/10.1007/s00268-008-9798-z CrossRefPubMed

22.

Knight MJ, McDonald SE, Birchall MA (2005) Intrinsic muscles and distribution of the recurrent laryngeal nerve in the pig larynx. Eur Arch Otorhinolaryngol 262:281–285. https://doi.org/10.1007/s00405-004-0803-3 CrossRefPubMed

23.

Lahey FH (1938) Routine dissection and demonstration of the recurrent laryngeal nerve in subtotal thyroidectomy. Surg Gynecol Obstet 66:775–777

24.

Makay O, Icoz G, Yilmaz M, Akyildiz M, Yetkin E (2008) The recurrent laryngeal nerve and the inferior thyroid artery—anatomical variations during surgery. Langenbeck Arc Surg 393(5):681–685. https://doi.org/10.1007/s00423-008-0320-8 CrossRef

25.

Maranillo E, Leon X, Ibanez M, Orus C, Quer M, Sanudo JR (2003) Variability of the nerve supply patterns of the human posterior cricoarytenoid muscle. Laryngoscope 113:602–606. https://doi.org/10.1097/00005537-200304000-00004 CrossRefPubMed

26.

Pradeep PV, Jayashree B, Harshita SS (2012) A closer look at laryngeal nerves during thyroid surgery: a descriptive study of 584 nerves. Anat Res Int. https://doi.org/10.1155/2012/490390 PubMedPubMedCentralCrossRef

27.

Randolph GW (2003) Surgical anatomy of the recurrent laryngeal nerve. In: Randolph GW (ed) Surgery of the thyroid and parathyroid glands. Sounders, Philadelphia, pp 300–302

28.

Randolph GW, Dralle H, Abdullah H et al. (2011) Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope. https://doi.org/10.1002/lary.21119 CrossRefPubMed

29.

Riddel VH (1956) Injury to recurrent laryngeal nerves during thyroidectomy: a comparison between the results of identification and non-identification in 1022 nerves exposed to risk. Lancet 29:638–641. https://doi.org/10.1016/S0140-673656)92333-9 CrossRef

30.

Rustad VH (1954) Revised anatomy of the recurrent laryngeal nerve: surgical importance based on dissection of 100 cadavers. J Clin Endocr Metab 14:87–96. https://doi.org/10.1210/jcem-14-1-87 CrossRefPubMed

31.

Sanders I, Wu BL, Mu L, Li Y, Biller HF (1993) The innervation of the human larynx. Arch Otolaryngol Head Neck Surg 119:934–939. https://doi.org/10.1001/archotol.1993.01880210022003 CrossRefPubMed

32.

Sasaki CT, Mitra S (2001) Recurrent laryngeal nerve monitoring by cricopharyngeus contraction. Laryngoscope 111:4:738–739. https://doi.org/10.1097/00005537-200104000-00032 CrossRefPubMed

33.

Scheid SC, Nadeau DP, Friedman O, Sataloff RT (2004) Anatomy of the thyroarytenoid branch of the recurrent laryngeal nerve. J Voice 18:279–284. https://doi.org/10.1016/j.jvoice.2003.08.003 CrossRefPubMed

34.

Schweizer V, Dorfl J (1997) The anatomy of the inferior laryngeal nerve. Clin Otolaryngol 22:362–369. https://doi.org/10.1046/j.1365-2273.1997.00028.x CrossRefPubMed

35.

Serpell JW, Yeung MJ, Grodski S (2009) The motor fibers of the recurrent laryngeal nerve are located in the anterior extralaryngeal branch. Ann Surg 249:648–652. https://doi.org/10.1097/SLA.0b013e31819ed9a4 CrossRefPubMed

36.

Snyder SK, Lairmore TC, Hendricks JC, Roberts JW (2008) Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy. J Am Coll Surgeons 206(1):123–130. https://doi.org/10.1016/j.jamcollsurg.2007.07.017 CrossRef

37.

Snyder SK, Hendricks JC (2005) Intraoperative neurophysiology testing of the recurrent laryngeal nerve: plaudits and pitfalls. Surgery 138.6:1183–1192. https://doi.org/10.1016/j.surg.2005.08.027 CrossRef

38.

Spinelli C, Berti P, Miccoli P (1995) Identification of the recurrent nerve in thyroid surgery. Techn Note Minerva Chir 50(1–2):93–96

39.

Steurer M, Passler C, Denk DM, Schneider B, Niederle B, Bigenzahn W (2002). Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope 112(1):124–133. https://doi.org/10.1097/00005537-200201000-00022 CrossRefPubMed

40.

Sunderland S, Swaney WE (1952) The intraneural topography of the recurrent laryngeal nerve in man. Anat Rec 114(3):411–426. https://doi.org/10.1002/ar.1091140303 CrossRefPubMed

41.

Toniato A, Mazzarotto R, Piotto A, Bernante P, Pagetta C, Pelizzo MR (2004) Identification of the nonrecurrent laryngeal nerve during thyroid surgery: 20-year experience. World J Surg 28(7):659–661. https://doi.org/10.1007/s00268-004-7197-7 CrossRefPubMed

42.

Uludag M, Aygun N, Isgor A (2016) Motor function of the recurrent laryngeal nerve: sometimes motor fibers are also located in the posterior branch. Surgery 160(1):153–160. https://doi.org/10.1016/j.surg.2016.02.003 CrossRefPubMed

43.

van Heerden JA, Groh MA, Grant CS (1987) Early postoperative morbidity after surgical treatment of thyroid carcinoma. Surgery 101.2:224–227

44.

Yalçın B, Tuğcu H, Cantürk N, Ozan H (2006) Laryngeal branching pattern of the inferior laryngeal nerve, before entering the larynx. Surg Radiol Anat 28:339. https://doi.org/10.1007/s00276-006-0118-8 CrossRefPubMed

Title: Bilateral patterns and motor function of the extralaryngeal branching of the recurrent laryngeal nerve
Authors: Ismail Cem Sormaz
Fatih Tunca
Yasemin Giles Şenyürek
Publication date: 01-09-2018
Publisher: Springer Paris
Published in: Surgical and Radiologic Anatomy / Issue 9/2018
Print ISSN: 0930-1038
Electronic ISSN: 1279-8517
DOI: https://doi.org/10.1007/s00276-018-1989-1

At a glance: The STEP trials

Springer Medicine

Bilateral patterns and motor function of the extralaryngeal branching of the recurrent laryngeal nerve

Abstract

Purpose

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 9/2018

Accessory abductor pollicis longus in separate volar subsheath: a rare anatomic variation

Accessory liver within the thoracic cavity

Topographic anatomical landmarks for pulley system of the thumb

The prevalence and ossification pattern of the biphalangeal and triphalangeal lateral toes

Anatomical feasibility study of flexor hallucis longus transfer in treatment of Achilles tendon and posteromedial portal of ankle arthroscopy

Accessory head of the extensor carpi radialis longus muscle merging with extensor carpi radialis brevis muscle