What is the risk of injury to the recurrent laryngeal nerve during thyroidectomy and what are the treatment options?

Updated: May 08, 2018
  • Author: Neerav Goyal, MD, MPH; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Injury to the recurrent laryngeal nerve (RLN) can yield vocal fold paresis or paralysis. The implementation of nerve monitoring has not been proven to lower this risk, but may provide prognostic value [19] . Studies show that identifying the RLN is associated with lower rates of injury.

Permanent RLN paralysis occurs in 1-2% of thyroidectomies in experienced hands. [44, 45] These cases may be underestimated, as not all patients undergo postoperative laryngeal evaluation. Should an injury occur, the patient usually presents with postoperative persistent hoarseness. Patients may also describe dysphagia or aspiration with thin liquids. Patients who undergo total thyroidectomy are at risk for bilateral vocal fold paralysis, a devastating complication. This usually manifests in the immediate postoperative period with airway obstruction, biphasic stridor, or respiratory distress.

Patients with suspected recurrent laryngeal nerve injury should be evaluated with flexible laryngoscopy or videostroboscopy to confirm the position and movement of the vocal folds. Should they have aspiration or dysphagia symptoms, they should be evaluated by a speech language pathologist. Patients with suspected bilateral vocal fold paralysis may require urgent and definitive airway management with a tracheotomy.

Permanent corrective procedures for vocal fold paralysis are not entertained until 9-12 months have passed. At this point, any persistent injury may be considered permanent.

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