How are injuries to the recurrent laryngeal nerve (RLN) during thyroid surgery prevented?

Updated: Feb 27, 2020
  • Author: Pramod K Sharma, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Deliberate identification of the RLN minimizes the risk of injury. When the nerve is identified and dissected, the reported RLN injury rate during thyroidectomy is 0-2.1%. This rate is reportedly higher if surgery is repeated (2-12%) or if the nerve is not clearly identified (4-6.6%). [1] Intraoperative hemostasis and a thorough understanding of the anatomy are essential for identifying and preserving the nerve.

The course of the RLN differs on the right and left sides of the neck (see the image below). The left RLN branches from the vagus at the level of the aortic arch. It then passes below the arch and reverses its course to continue superiorly, posterior to the aortic arch and into the visceral compartment of the neck. It travels near or in the tracheoesophageal groove until it enters the larynx just behind the cricothyroid articulation. The right RLN branches from the vagus more superiorly than does the left, at the level of the subclavian artery. It loops behind the right subclavian artery and ascends superomedially toward the tracheoesophageal groove. It then continues superiorly until entering the larynx behind the cricothyroid articulation.

Anatomy of the recurrent laryngeal nerve (RLN). Anatomy of the recurrent laryngeal nerve (RLN).

Classic descriptions of the RLNs hold that they ascend in the tracheoesophageal groove; however, they may in fact be lateral to it. Low in the neck, the course of the right RLN is relatively oblique and lateral and, probably, more prone to injury than the left RLN. The nerve may branch several times before entering the larynx. Take care to identify and preserve each branch.

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