How are injuries to the recurrent laryngeal nerve in thyroid surgery managed?

Updated: Feb 27, 2020
  • Author: Pramod K Sharma, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

Answer

Do not perform corrective procedures for unilateral vocal-fold paralysis until at least 6 months after thyroidectomy because a reversible injury improves by that time. If the nerve was definitely transected during surgery, treatment for the paralyzed fold may be performed sooner than this.

Two surgical treatment options are available for patients with unilateral vocal-fold paralysis: medialization and reinnervation. Medialization is most commonly performed. However, the authors' knowledge, no investigator has compared the efficacy of these 2 procedures.

Medialization of the impaired vocal fold improves contact with the contralateral mobile fold. It may be accomplished with injection laryngoplasty or laryngeal framework surgery. Type I thyroplasty is probably the most common procedure. A window in the thyroid cartilage is created at the level of the true vocal fold. An implant is then placed to push the vocal fold medially. Medialization with an injection of absorbable gelatin sponge (Gelfoam; Pharmacia & Upjohn Company, Kalamazoo, MI) may be performed before 6 months if the patient desires it or if he or she has is aspirating. The gelatin sponge resorbs over time and is, therefore, a temporary treatment.

An implant made of silicone or polytetrafluoroethylene (PTFE, Gore-Tex; W. L. Gore & Associates, Inc; Newark, DE) is considered permanent. However, most authorities agree that no negative consequences occur if nerve recovers function after a type I thyroplasty. In addition, the implant may be removed, though this requires another surgical procedure.

A number of reinnervation procedures have been described for addressing the permanently injured RLN. These procedures maintain or restore tone to the intrinsic laryngeal musculature. When the true vocal fold atrophies after denervation, it loses contact with the contralateral fold and the voice weakens. By preventing atrophy, reinnervation procedures may help maintain or improve the patient's voice.


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