J Endocr Surg.  2018 Sep;18(3):205-209. 10.16956/jes.2018.18.3.205.

Nonrecurrent Laryngeal Nerve Identification and Preservation during Transoral Robotic Thyroidectomy

• Lee MH
• Kim HY
• Cho J

• KMID: 2420778
• DOI: http://doi.org/10.16956/jes.2018.18.3.205

Abstract

The nonrecurrent laryngeal nerve (NRLN), a rare, anatomic variation of the recurrent laryngeal nerve, is associated with increased injury risk during thyroid surgery. Here, we report a 44-year-old female presenting with right NRLN, receiving transoral robotic thyroidectomy with intraoperative neuromonitoring (IONM). Ultrasonogram of the patient's thyroid gland revealed a solitary nodule, with fine-needle aspiration cytology, indicating papillary carcinoma. Preoperative computed tomography scan revealed an aberrant right subclavian artery arising from the distal aortic arch, suggesting right NRLN. During transoral robotic hemi-thyroidectomy, IONM identified a NRLN emanating from the right vagus nerve and entering the larynx. The post-operative period was uneventful, and laryngoscopic examination demonstrated normal vocal cord movement with no changes observed in patient voice. This is the first report of transoral robotic thyroidectomy in a patient with NRLN. During transoral thyroidectomy, the right NRLN was easily identified and its integrity was preserved utilizing IONM.

Keyword

Thyroidectomy; Recurrent laryngeal nerve; Aberrant subclavian artery

MeSH Terms

Adult
Anatomic Variation
Aorta, Thoracic
Biopsy, Fine-Needle
Carcinoma, Papillary
Female
Humans
Laryngeal Nerves*
Larynx
Recurrent Laryngeal Nerve
Subclavian Artery
Thyroid Gland
Thyroidectomy*
Ultrasonography
Vagus Nerve
Vocal Cords
Voice

Figure

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  Fig. 1 Preoperative CT scan of the patient. Neck CT demonstrated aberrant subclavian artery (arrow), arising from the distal aortic arch. CT = computed tomography.

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  Fig. 2 IONM to identify the NRLN. Intraoperative imaging of the NRLN (arrow) in proximity of the Berry ligament. The IONM revealed an endotracheal signal during stimulation of the NRLN. IONM = Intraoperative nerve monitoring; NRLN = nonrecurrent laryngeal nerve; T = trachea.

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  Fig. 3 NRLN following resection of the right hemi-thyroid. Intraoperative imaging of the NRLN (arrow) following resection of the right hemi-thyroid. The NRLN emanated from the right vagus nerve and entered into the larynx. NRLN = nonrecurrent laryngeal nerve; T = trachea.

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