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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: Edmund.Pribitkin@jefferson.edu 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.