A functional assessment of anatomical variants of the recurrent laryngeal nerve during thyroidectomies using neuromonito
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ENDOCRINE SURGERY
A functional assessment of anatomical variants of the recurrent laryngeal nerve during thyroidectomies using neuromonitoring Beata Wojtczak 1 Krzysztof Kaliszewski1 Krzysztof Sutkowski1 Marek Bolanowski2 Marcin Barczyński3 ●
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Received: 28 July 2017 / Accepted: 26 October 2017 © The Author(s) 2017. This article is an open access publication
Abstract Purpose The aim of the study was to assess the usefulness of intraoperative neuromonitoring (IONM) in identifying anatomical variants of the recurrent laryngeal nerve (RLN) during thyroidectomies, with emphasis on the nerve’s relationship to the inferior thyroid artery (ITA), Zuckerkandl’s tubercle, nonrecurrent laryngeal nerves (NRLNs), and extralaryngeal bifurcation. Methods A total of 128 subjects undergoing surgery for thyroid disorders were enrolled in the study, and the course and anatomical variants of RLN were assessed with IONM application. Results The standard relationship between RLN and ITA was that the artery and nerve intersect (100%). The right RLN was below the ITA in 76.67% of the patients, and the left RNL was below it in 75.81%. There were no statistically significant differences in the relationship between RLN and ITA on the two sides; and gender did not significantly influence the relationship between the RLN and ITA on either side. In one patient a nonrecurrent inferior laryngeal nerve was present on the right side (0.83%). RLN bifurcation was observed in 33.33% of the patients on the right and in 19.35% on the left side; the difference between
* Beata Wojtczak [email protected] 1
Department and Clinic of General, Gastroenterological and Endocrine Surgery Wroclaw Medical University, Wroclaw, Poland
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Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
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Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Kraków, Poland
sides was statistically significant (p < 0.05). Posterior tubercle (Zuckerkandl’s tubercle) was observed on the right in 83% of the subjects and on the left in 69%. The age, thyroid volume and body mass index (BMI) did not influence the size of the tumor. Conclusions The utilization of IONM of the RLN in thyroid surgery adds a new dimension to the standard of visual nerve identification allowing for functional nerve testing at the most vulnerable area of the dissection: at the level of Berry’s ligament, posterior tubercle (Zuckerkandl’s tubercle) and crossing of the RLN with the inferior thyroid artery. Keywords Thyroid surgery Recurrent laryngeal nerve Neuromonitoring ●
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Introduction Recurrent laryngeal nerve (RLN) palsy is one of the most serious complications after thyroid surgery. The average incidence of temporary postoperative vocal fold palsy is approaching 10% and incidence of permanent RLN injury is 2.3% [1]. The wide range of RLN injury rates found in the literature—from 2.3 to 26%—is related to whether and when a laryngeal examination was performed after surgery, the type of disease (es
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