RESUMO
PURPOSE: The aim of this systematic review and meta-analysis was to systematically review and perform a meta-analysis on the anatomical variations of the RLN. METHODS: We performed online research for studies that addressed anatomical variations of the RLN and laterality, published between 2015 and 2021. We found 230 articles, and nine were included. RESULTS: Eight variations were found, with Type I prevailing (41.17%; 95% CI 19.44-64.88), extra laryngeal divergence of the RLN. The other types were: II-fan shape; III-distance greater than 5 mm to the cricothyroid joint; IV-thickening and adipopexy in the elderly; V-non-recurrent laryngeal nerve; VI-intracranial branch; VII-tortuous ascending RLN; and VIII-combination between the inferior branch of the NV and the ascending trunk of the RLN. Types I (p = 0) and III (p < 0.01) prevailed on the left and types II (p < 0.01) and V (p < 0.01) on the right. CONCLUSIONS: It was observed that variations occurred due to the path of the RLN to the entrance to the larynx, its shape, and the age of the evaluated individual. The most frequent variation and side were, respectively, Type I, extra laryngeal divergence and left.
Assuntos
Variação Anatômica , Nervo Laríngeo Recorrente , Humanos , Nervo Laríngeo Recorrente/anatomia & histologia , Laringe/anatomia & histologiaRESUMO
BACKGROUND: Recurrent laryngeal nerve (RLN) injury after thyroidectomy is relatively common. Locating the RLN prior to thyroid dissection is paramount to avoid injury. We developed a fluorescence imaging system that permits nerve autofluorescence. We aimed to determine the sensitivity and specificity of fluorescence imaging at detecting the RLN relative to thyroid and other background tissue and compared it to white light. METHODS: In this prospective study, 65 patients underwent thyroidectomy from January to April 2022 (16 bilateral thyroid resections) using white and fluorescent light. Fluorescence intensity [relative fluorescence units (RFU)] was recorded for RLN, thyroid, and background. RFU mean, minimum, and maximum values were calculated using Image J software. Thirty randomly selected pairs of white and fluorescent light images were independently reviewed by two examiners to compare RLN detection rate, number of branches, and length and minimum width of nerves visualized. Parametric and nonparametric statistical analysis was performed. RESULTS: All 81 RNLs observed were visualized more clearly under fluorescence (mean intensity, µ = 134.3 RFU) than either thyroid (µ = 33.7, p < 0.001) or background (µ = 14.4, p < 0.001). Forest plots revealed no overlap between RLN intensity and that of either other tissue. Sensitivity and specificity for RLN were 100%. All 30 RLNs and all 45 nerve branches were clearly visualized under fluorescence, versus 17 and 22, respectively, with white light (both p < 0.001). Visible nerve length was 2.5 × as great with fluorescence as with white light (µ = 1.90 vs. 0.76 cm, p < 0.001). CONCLUSIONS: In 65 patients and 81 nerves, RLN detection was markedly and consistently enhanced with autofluorescence neuro-imaging during thyroidectomy, with 100% sensitivity and specificity.
Assuntos
Traumatismos do Nervo Laríngeo Recorrente , Tireoidectomia , Humanos , Tireoidectomia/efeitos adversos , Tireoidectomia/métodos , Estudos Prospectivos , Nervo Laríngeo Recorrente/diagnóstico por imagem , Nervo Laríngeo Recorrente/cirurgia , Glândula Tireoide , Traumatismos do Nervo Laríngeo Recorrente/etiologia , Traumatismos do Nervo Laríngeo Recorrente/prevenção & controleRESUMO
Objective: The recurrent laryngeal nerve (RLN) may be involved by papillary thyroid carcinoma ≤ 1 centimeter (PTC ≤ 1 cm). Current study investigated the predictive factors of RLN invasion in PTC ≤ 1 cm, the risk factors of disease recurrence in RLN invaded cases and the results of surgical management for RLN invasion. Materials and methods: Data of 374 PTC ≤ 1 cm patients were retrospectively collected. We performed univariate and multivariate analysis to identify predictive factors of RLN invasion and risk factors of disease recurrence. The abilities of factors in predicting RLN invasion were evaluated. Surgical outcomes and recurrence free survival (RFS) of patients were analyzed. Results: A total of 28 patients suffered RLN invasion, among which seven had disease recurrence. Preoperative vocal cord palsy (VCP), gross extrathyroidal extension, larger tumor size and tumor on the dorsal side of thyroid were verified as predictive factors of RLN invasion. RLN involved patients had poorer RFS, but better than those who also had upper-aerodigestive tract invasion. Upper-aerodigestive tract invasion, lateral neck lymph nodes metastasis (LNM) and BRAF V600E mutation were independent risk factors of disease recurrence in RLN invaded cases. Tumor shaving showed better RLN function preservation without increasing recurrent risk. Conclusion: Current study confirmed the rarity of RLN invasion in PTC ≤ 1 cm. Various aggressive features were verified as predictive factors of RLN invasion. Tumor shaving showed superiority in preserving nerve function without increasing recurrent risk. Special attentions should be paid for disease recurrence when RLN invasion accompanied by upper-aerodigestive tract invasion, lateral neck LNM or BRAF V600E mutation.
Assuntos
Carcinoma Papilar , Neoplasias da Glândula Tireoide , Humanos , Câncer Papilífero da Tireoide/patologia , Neoplasias da Glândula Tireoide/patologia , Carcinoma Papilar/cirurgia , Nervo Laríngeo Recorrente/patologia , Nervo Laríngeo Recorrente/cirurgia , Estudos Retrospectivos , Proteínas Proto-Oncogênicas B-raf/genética , Tireoidectomia/efeitos adversos , Metástase Linfática , Recidiva Local de Neoplasia/patologia , Fatores de Risco , Medição de RiscoRESUMO
Resumen Objetivo: La lesión del nervio laríngeo recurrente es una grave complicación en cirugía tiroidea. El propósito del presente estudio es analizar la utilidad de la neuromonitorización vagal continua intraoperatoria en un hospital terciario. Materiales y Método: Estudio observacional, analítico y retrospectivo que recoge pacientes intervenidos de cirugía tiroidea con neuromonitorización en un período de 14 meses. La pérdida de señal se define como amplitud final nerviosa < 100 ^V, realizándose laringoscopia postquirúrgica ante la sospecha de lesión nerviosa. El análisis estadístico se realizó con el programa SPSS® V25,0, con p < 0,05. Resultados: Se incluyeron 120 pacientes intervenidos, registrándose en el 24,2% pérdida de señal. Factores de riesgo para lesión fueron bocio intratorácico (OR 5,31; IC 95% 1,56-17,99; p = 0,007), cirugía cervical previa (OR 5,76; IC 95% 0,64-51,97; p = 0,119) y patología maligna (OR 1,44; IC 95% 0,16-12,79; p = 0,743). Fue posible el cambio de estrategia quirúrgica en 7 casos. En el seguimiento posterior se cuantificó parálisis recurrencial transitoria en 27 pacientes y permanente en 4. Discusión: La neuromonitorización parece reducir la incidencia de parálisis laríngea porque aumenta la seguridad en la identificación del nervio recurrente y reduce su manipulación durante la cirugía. Conclusiones: La neuromonitorización intraoperatoria es útil para identificar el nervio laríngeo recurrente y advierte del riesgo potencial de lesión, permitiendo cambiar la estrategia quirúrgica para evitar la parálisis bilateral de cuerdas vocales.
Aim: Recurrent laryngeal nerve injury is a serious complication in thyroid surgery. The purpose of the present study is to analyze the use of intraoperative continuous vagal neuromonitoring in a tertiary hospital. Materials and Method: Observational, analytical and retrospective study that includes patients who underwent thyroid surgery with neuromonitoring in a period of 14 months. Loss of signal is defined as final nerve amplitude < 100 ^V, and postsurgical laryngoscopy is performed due to suspicion of nerve injury. Statistical analysis was performed with the SPSS® V25.0 program, with p < 0.05. Results: 120 operated patients were included, registering loss of signal in 24.2%. Risk factors for injury were intrathoracic goiter (OR 5.31; 95% CI 1.56-17.99; p = 0.007), previous cervical surgery (OR 5.76; 95% CI 0.64-51.97; p = 0.119) and malignant pathology (OR 1.44; 95% CI 0.16-12.79; p = 0.743). A change in surgical strategy was possible in 7 cases. In the subsequent follow-up, transient recurrent paralysis was quantified in 27 patients and permanent in 4. Discussion: Neuromonitoring seems to reduce the incidence of laryngeal paralysis because it increases the security in the identification of the recurrent nerve and reduces its manipulation during surgery. Conclusions: Intraoperative neuromonitoring is useful to identify the recurrent laryngeal nerve and warns of the potential risk of injury, allowing to change the surgical strategy to avoid bilateral vocal cord paralysis.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Nervo Laríngeo Recorrente/patologia , Glândula Tireoide/cirurgia , Nervo Vago , Análise Multivariada , Estudos Retrospectivos , Monitorização IntraoperatóriaRESUMO
La lesión del nervio laríngeo recurrente (NLR) es una de las complicaciones más severas en las tiroidectomías. La lesión unilateral genera trastornos disfónicos que se manifiesta por voz débil y una posición paramedial de la cuerda vocal afectada, mientas que la bilateral genera trastornos respiratorios, incluyendo la asfixia. Se ha estimado que la lesión del NLR en las tiroidectomías se encuentra entre un rango de 0.3%- 18.9%. Se ha visto que con el neuromonitoreo intraoperatorio ha disminuido la incidencia de lesión, aunque debemos tener en cuenta un factor muy importante a la hora de solicitarlo y utilizarlo, el económico. La tasa de lesión permanente del nervio laríngeo recurrente debe permanecer por debajo de 1 a 2 %. Sin embargo, existen circunstancias en las cuales los nervios están expuestos a un mayor riesgo y son muchos los factores involucrados en su mecanismo de lesión. Este artículo pretende hacer una revisión del tema enfatizando en la importancia de la preservación de la funcionalidad e integridad de ambos nervios laríngeos recurrentes.
Recurrent laryngeal nerve injury (RLN) is one of the most severe complications in thyroidectomies. Unilateral injury generates dysphonic disorders manifested by weak voice and a paramedial position of the affected vocal cord, while bilateral injury generates respiratory disorders, including suffocation. RLN injury in thyroidectomies has been estimated to be in the range of 0.3% - 18.9%. It has been seen that with intraoperative neuromonitoring the incidence of injury has decreased, although we must take into account a very important factor when requesting and using it, the economic one. The rate of permanent injury to the recurrent laryngeal nerve should remain below 1% to 2%. However, there are circumstances in which the nerves are exposed to greater risk and many factors are involved in their mechanism of injury. This article aims to review the subject, emphasizing the importance of preserving the functionality and integrity of both recurrent laryngeal nerves
Assuntos
Humanos , Nervo Laríngeo Recorrente/patologia , Tireoidectomia , Neoplasias da Glândula Tireoide/complicações , Monitorização IntraoperatóriaRESUMO
BACKGROUND: Intermittent intraoperative neuromonitoring of the recurrent laryngeal nerve is the ideal complement in thyroid surgeries, decreasing thyroid injuries. OBJECTIVE: To analyze the prevalence of recurrent laryngeal nerve injuries with the use and without the use of neuromonitoring in thyroid surgery. METHOD: Observational, descriptive and retrospective study, in which a total of 571 patients were included between the years 2012-2018. Of which 180 neuromonitoring was used and 391 were not used. RESULTS: Of the 180 patients who underwent total thyroidectomy with the use of neuromonitoring, we had a total of 8 (4.4%) transient paralysis and 2 (1.1%) definitive. Without the use of neuromonitoring we obtain 12 (3%) transient paralysis and 7 (1.85%) definitive. CONCLUSIONS: We believe that the use of neuromonitoring complementary to surgery should be used routinely to the usual technique. And we also obtain significant results regarding the reduction of recurrent laryngeal nerve injuries with the use of intraoperative neuromonitoring.
ANTECEDENTES: La neuromonitorización intraoperatoria intermitente del nervio laríngeo recurrente es el complemento ideal en las cirugías tiroideas, ya que disminuye las lesiones. OBJETIVO: Analizar la prevalencia de lesiones del nervio laríngeo recurrente con y sin el uso de neuromonitorización en cirugía de tiroides. MÉTODO: Estudio observacional, descriptivo y retrospectivo, en el que se incluyeron 571 pacientes entre los años 2012 y 2018. De ellos, en 180 se utilizó neuromonitorización y en 391 no. RESULTADOS: De los 180 pacientes que se sometieron a tiroidectomía total con neuromonitorización hubo 8 (4.4%) parálisis transitorias y 2 (1.1%) parálisis definitivas. Sin el uso de neuromonitorización hubo 12 (3%) parálisis transitorias y 7 (1.85%) definitivas. CONCLUSIONES: Creemos que la neuromonitorización debe usarse sistemáticamente con la técnica habitual. Obtenemos resultados significativos con respecto a la reducción de las lesiones del nervio laríngeo recurrente con el uso de neuromonitorización intraoperatoria.
Assuntos
Traumatismos do Nervo Laríngeo Recorrente , Humanos , Nervo Laríngeo Recorrente , Traumatismos do Nervo Laríngeo Recorrente/epidemiologia , Traumatismos do Nervo Laríngeo Recorrente/prevenção & controle , Estudos Retrospectivos , TireoidectomiaRESUMO
Inferior laryngeal nerve palsy is a relatively common entity. Nevertheless, an occurrence as a result of a cardiovascular pathology is rare. In this case, it is called Ortner's syndrome (OS). Aortic diseases are responsible for more than half of cases. Supraaortic vessels disorders are rare causes of OS. In our new report, a non-smoker and non-drinker 70-year-old woman presented with a history of dysphonia since childhood. On direct laryngoscopy, a left vocal cord paralysis was detected and a contrast-enhanced computed tomography showed an aberrant right subclavian artery originating from the left portion of the aortic arch. Its course to its usual site runs behind the esophagus, being also called arteria lusoria. In this particular case, two unusual situations appear together, which contributes to the rarity of the event.(AU)
Assuntos
Humanos , Feminino , Idoso , Nervo Laríngeo Recorrente , Artéria Subclávia , Rouquidão , Aorta Torácica , Disfonia , não FumantesRESUMO
Introdução: A tuberculose (TB) acomete especialmente os pulmões, no entanto, também se tem conhecimento das formas extrapulmonares. Dentre essas, buscamos relatar um caso raro de TB mediastinal localizada em trajeto de nervo laríngeo recorrente (NLR), a qual se manifestou com paralisia de prega vocal (PPV). Relato de Caso: Paciente masculino, 58 anos, apresentando quadro de disfonia. Histórico de exérese de testículo esquerdo e anatomopatológico evidenciando orquiepididimite crônica granulomatosa sugestiva de etiologia tuberculosa. Ex-tabagista e ex-etilista. Realizou, há 15 anos, um tratamento por 6 meses para TB pulmonar. Contactante de paciente bacilífero há três anos. A videolaringoscopia identificou PPV esquerda paramediana. A tomografia computadorizada (TC) de pescoço evidenciou linfonodos calcificados no mediastino superior, fossas supraclaviculares e espessamento de corda vocal à direita. A TC de Tórax apresentou conglomerados sequelares linfonodais calcificados no mediastino e sequela de processo granulomatoso crônico tipo TB em ápices pulmonares. Sorologia de HIV não reagente. Baciloscopia negativa, com amostra insuficiente. Cultura de escarro negativa. Discussão: A PPV esquerda encontrada na videolaringoscopia e TC de pescoço e os achados de TB mediastinal indicaram acometimento do NLR esquerdo pelo processo granulomatoso em seu trajeto, sendo esse, uma reativação de TB ganglionar mediastinal. Fora realizado esquema básico de tratamento para TB, com posterior resolução do quadro de disfonia. Embora a TB torácica seja uma condição comum, a rouquidão devido à PPV é uma complicação raramente associada. Conclusão: Salientamos a importância de estender a investigação ao mediastino na vigência de PPV unilateral, uma vez que a disfunção do NLR pode justificar o quadro.
Introduction: tuberculosis (TB) affects most commonly the lungs; nevertheless, extrapulmonary forms are also known. With that in mind, we intend to report a rare case of mediastinal TB located on the path of the recurrent laryngeal nerve (RLN), manifesting itself with vocal fold paralysis (VFP). Case report: male patient, 58 years old, presenting dysphonia. History of exeresis of the left testicle and anatomopathological showing chronic granulomatous orchiepididimitis, suggestive of tuberculous etiology. Former smoker, ex-alcoholic. Previous treatment for six months due to pulmonary TB, 15 years ago. Bacilli patient contactant for three years. Videolaryngoscopy identified paramedian left VFP. Computed tomography (CT) of the neck showed calcified lymph nodes in the upper mediastinum, supraclavicular fossa, and thickening on the right vocal cord. Chest CT showed calcified lymph node sequels in the mediastinal and Chronic Granulomatous TB-type sequel in pulmonary apices. Non-reactive HIV serology. Negative baciloscopy, insufficient sample. Negative sputum culture. Discussion: the finding of left VFP in videolaryngoscopy and neck CT, associated with the findings of mediastinal TB, indicated that the left RLN's involvement occurred due to the granulomatous process in its path, meaning a reactivation of mediastinal ganglionic TB. A simple treatment schedule for TB had been conducted, with subsequent resolution of the dysphonia. Even though thoracic TB is a common condition, hoarseness due to VFP is a rarely associated complication. Conclusion: we stress the importance of extending the investigation to the mediastinum in case of unilateral VFP since a dysfunction of the RLN is a possible justification of the case.
Assuntos
Masculino , Nervo Laríngeo Recorrente , Tuberculose Laríngea , Disfunção da Prega Vocal , MediastinoRESUMO
OBJECTIVE: to evaluate whether the lateral projection of the thyroid gland, called Zuckerkandl's tubercle (ZT), can assist the surgeon in identifying the inferior laryngeal nerve during conventional open thyroidectomy. METHODS: we conducted a prospective study with 51 patients submitted to thyroidectomy, with a total of 100 resected thyroid lobes, and observed the presence or absence of ZT in sufficient dimensions to be identified without image magnification, its base and height, its location in the gland, and its anatomical relationship with the inferior laryngeal nerve. RESULTS: ZT was present in 68 of the 100 thyroid lobes analyzed (68%). The mean base was 6.7mm on the right side and 7.1mm on the left side, and the average height was 5.7mm on the right side and 6.1mm on the left side. In most of the lobes studied, the tubercle had a minimum height of 5mm (55.9%), with no significant difference between the right and left lobes of the thyroid gland. During surgery, 100% of the identified ZTs were anterior to the inferior laryngeal nerve, just below the nerve entry in the larynx. CONCLUSION: the ZT is a quite frequent entity and large enough to serve as an intraoperative anatomical reference for the inferior laryngeal nerve, next to its entry in the larynx, along with other anatomical references.
OBJETIVO: avaliar se a projeção lateral da glândula tireoide, chamada tubérculo de Zuckerkandl (TZ), pode auxiliar o cirurgião na identificação do nervo laríngeo inferior durante a tireoidectomia convencional aberta. MÉTODOS: estudo prospectivo de 51 pacientes submetidos à tireoidectomia, com um total de 100 lobos tireoidianos ressecados, e observação da presença ou não do TZ em dimensões suficientes para ser identificado sem magnificação de imagem, suas dimensões de base e altura, sua localização na glândula e sua relação anatômica com o nervo laríngeo inferior. RESULTADOS: o TZ estava presente em 68 dos 100 lobos de tireoide analisados (68%). A dimensão média da base foi 6,7mm no lado direito e 7,1mm no lado esquerdo, e a altura média foi 5,7mm no lado direito e 6,1mm no lado esquerdo. Na maioria dos lobos estudados, o tubérculo tinha altura mínima de 5mm (55,9%) sem diferença significativa entre o lobo direito e esquerdo da glândula tireoide. Durante a cirurgia, 100% dos TZ identificados estavam anteriores ao nervo laríngeo inferior, imediatamente abaixo da entrada do nervo na laringe. CONCLUSÃO: o TZ é bastante frequente e em dimensões suficientes para ser usado como referência anatômica na localização intraoperatória do nervo laríngeo inferior, próximo à sua entrada na laringe, junto com as demais referências anatômicas.