What is the role of primary neurorrhaphy in the management of recurrent laryngeal nerve injury due to thyroid surgery?

Updated: Jan 25, 2018
  • Author: Pramod K Sharma, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

Answer

Primary neurorrhaphy may be used to immediately repair the transected RLN. This procedure typically results in synkinesis because of nonselective reinnervation of abductor and adductor muscles. Reinnervation procedures have been described by using the phrenic nerve, ansa cervicalis, and preganglionic sympathetic neurons. Although animal models demonstrated EMG and histologic evidence of reinnervation, as well as restored movement of the vocal fold, experience in humans has not been as impressive as this. Improvement in phonation quality has been documented in humans after reinnervation with the ansa cervicalis, but no movement is observed. Transfer of neuromuscular pedicles have been described and reportedly restore movement of the vocal fold. However, these reports are limited, and success is not universal.

In bilateral vocal-cord paralysis, initial treatment involves obtaining an adequate airway. Emergency tracheotomy may be required. If possible, first perform endotracheal intubation. Consider exploring the neck to ensure that no reversible causes of nerve injury (eg, misplaced ligature) are present. When good preservation of the RLNs is ascertained, a trial of extubation may be performed after several days. Intravenous steroids may be beneficial in this situation. Remove the tube over a Cook catheter and in a controlled setting in case reintubation is necessary. Be ready to perform emergent tracheotomy. If nerve function has not recovered after a second trial of extubation, tracheotomy is certainly warranted.

The principal goal for surgery in bilateral vocal-fold paralysis is to improve airway patency. Cordotomy and arytenoidectomy are the most common procedures. These procedures enlarge the airway and may permit decannulation of a tracheostomy. However, the patient must be counseled that his or her voice will likely worsen after surgery. Transfer of a neuromuscular pedicle is reported to improve the airway in cases of bilateral true vocal-fold paralysis. However, again, these reports are limited, and this treatment is not a widely accepted.


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