Recurrent Laryngeal Nerve Involvement Research Articles

Surgical treatment for well-differentiated thyroid carcinoma invading the larynx,trachea,esophagus and hypopharynx

Objective:To explore the surgical treatment for well-differentiated thyroid carcinoma(WDTC) invading the larynx,trachea,esophagus and hypopharynx. Methods: Primary tumor resection was performed in 17 patients with advanced WDTC.All the 17 cases had laryngotracheal involvement and received different kinds of surgical treatment: including 14 receiving local shaving-off,wedge tracheal resection with direct suture,window tracheal resection with sternocleidomastoid myoperiosteous flap reconstruction,sleeve tracheal resection with tracheal anastomosis or tracheal reconstruction by forearm free skin flap,and 3 receiving total laryngectomy or near-total laryngectomy. Eleven cases with esophagus and hypopharynx involvement received muscular layer resection or esophageal and hypopharynx partial resection with pectoralis major myocutaneous flap reconstruction. For 12 cases with recurrent laryngeal nerve involvement,9 were treated by nerve decompression,nerve resection combined with one-stage arytenoid within-shift and/or recurrent laryngeal nerve transposition,3 by simple laryngectomy. Results: The patients were followed up for 1 to 12 years. Sixteen patients survived and one died of tumor metastasis. The 5-year survival rate was 93.3%; the post-operation complication rate was 23.5%.Tumor relapses were found in 2 cases who had undergone local shaving-off or partial cervical trachea resection. The voice quality of the 9 patients receiving recurrent laryngeal nerve decompression or voice rehabilitation was greatly improved,and 5 of them had normal voice. Conclusion: The curative rate and quality of life of WDTC patients with extrathyroidal extension can be improved by one-stage resection and reconstruction. Operation modes should be chosen according to the location, involvement of tumor, the invasion of recurrent laryngeal nerve and the disease course. Operation is invasive and reconstruction is a complicated process, with many complications.

True Vocal Fold Immobility in the Setting of Well-Differentiated Thyroid Carcinoma: Unusual Illustrative Cases and Recommendations for Operative Strategy

We present cases of transient true vocal fold (TVF) immobility caused by well-differentiated thyroid carcinoma (WDTC), and review the literature concerning management of WDTC invading the recurrent laryngeal nerve (RLN). A description of the clinical course of 2 patients with WDTC and transient TVF immobility is presented in the context of a review of the literature concerning locally advanced WDTC with extrathyroidal extension and RLN involvement. Both patients had papillary thyroid carcinoma with ipsilateral TVF paralysis that resolved completely before operation. During the operation, the RLN was found to be grossly involved with disease and inseparable from the tumor, necessitating resection. Review of the literature revealed the following points that should be considered when confronting an RLN invaded by WDTC. (1) Benign disease can mimic invasive WDTC and must be ruled out. (2) RLN invasion does not carry the same prognostic implications as other categories of extrathyroidal extension of WDTC. (3) RLN sacrifice does not increase the overall survival rate. (4) There is no evidence that a paralyzed RLN will regain function when preserved. (5) The majority of RLNs that function before operation can be expected to function after the operation if preserved. Resolution of TVF paralysis should not reduce suspicion of RLN involvement by WDTC. When RLN involvement is discovered during operation, every attempt should be made to preserve a functioning RLN.

Effectiveness of Steroid Treatment for Hoarseness Caused by Idiopathic Fibrosing Mediastinitis: Report of a Case

A 65-year-old woman was referred to our department for investigation and treatment of hoarseness. A chest computed tomography (CT) scan showed a mediastinal mass spreading into the aortopulmonary window. This finding and that of flexible laryngoscopy suggested that the hoarseness was being caused by left recurrent nerve involvement resulting in left vocal cord paralysis. Thus, we performed a mediastinoscopic biopsy via a parasternal incision. Pathological examination revealed dense fibrous tissue infiltrated with varied inflammatory cells. Because no etiological pathogen or neoplastic lesion was identified, we diagnosed idiopathic fibrosing mediastinitis and began treating the patient with prednisolone. After a course of treatment, the mediastinal lesion showed a remarkable response. The hoarseness resolved as the lesion became smaller. Laryngoscopy confirmed recuperation of vocal cord function. This report shows that steroid therapy is a treatment option for hoarseness caused by recurrent laryngeal nerve involvement of fibrosing mediastinitis, if administered under close observation.

Thyroid gland tuberculosis with endolaryngeal extension: a case with laryngotracheal dyspnoea

Tuberculosis affecting the thyroid gland is a rare condition. We present the case of a 30-year-old man with thyroid tuberculosis whose presenting complaints were dyspnoea and hoarseness. There was a cystic mass in the posterosuperior right thyroid lobe extending into the paraglottic space. There was also recurrent laryngeal nerve involvement. We performed surgery and administered post-operative antituberculous treatment.

Tuberculous lymphadenopathy of superior mediastinum causing vocal cord paralysis

Vocal cord paralysis because of involvement of recurrent laryngeal nerve by benign and acute inflammatory lymphadenopathy is a rare condition. Presented here is a case of tuberculous lymphadenopathy of superior mediastinum causing left recurrent laryngeal nerve paralysis, which was successfully treated by antituberculosis treatment, with complete recovery of vocal cord function.

Thyroid cancer surgery.

The surgical management of thyroid cancer is complex, controversial, and categorized by divergent opinions based upon retrospective, self-fulfilling data. This chapter will review the role of the surgeon in the evaluation of thyroid nodules and the management of malignant thyroid disease. Patients who ultimately prove to have thyroid cancer generally present with 1) a thyroid nodule with or without preoperative cytologic evidence of malignancy, 2) a rapidly enlarging neck mass with or without symptoms and signs associated with local invasion, or 3) a positive history of familial thyroid cancer with or without a positive calcitonin stimulation test, or more likely, a positive RET protooncogene screening examination for medullary carcinoma of the thyroid. The initial surgical evaluation is focused on evaluating risk factors. A history of head or neck irradiation in childhood or a familial history of medullary carcinoma of the thyroid significantly impact surgical management. The physical examination needs to focus on evidence of local invasion, fixation to surrounding structures, recurrent laryngeal nerve involvement, regional nodal metastases, and systemic disease. In addition, it is the surgeon’s obligation to screen for nonthyroidal disease that could impact perioperative management. This includes a history of bleeding disorders, cardiac, pulmonary, hepatic or renal disease, a potentially difficult airway, as well as potential endocrinopathies including thyrotoxicosis, Addisonian crisis and pheochromocytoma. It is also important to perform a laryngeal examination in every surgical candidate to evaluate recurrent laryngeal nerve integrity by the demonstration of vocal cord function. Surgery is an important, but not the only essential component in the management of patients with thyroid cancer. It is a requisite that each surgeon who manages these patients has an integrated plan that operates in concert with cytopathologists, endocrinologists, and radiation oncologists. The sensitivity and specificity of fine needle aspiration (FNA) varies between institutions and even among individual cytopathologists. Since FNA is the single most important preoperative diagnostic procedure for the majority of patients with dominant thyroid nodules, every thyroid surgeon must be able to evaluate the reliability and accuracy of the FNA findings upon which critical clinical decisions are based.

Painless aortic dissection presenting as hoarseness of voice: Cardiovocal syndrome: Ortner's syndrome

Most of the neurological manifestations of the aortic dissection are due to neuronal ischemia secondary to either extension of the dissection process into a branch artery, or compression of an artery by the false lumen of the dissecting aortic hematoma. However, the enlarging false lumen may directly compress on an adjacent nerve, causing neuronal injury resulting in neurological symptoms. This may particularly take place when a distal intimal tear does not decompress the false lumen, resulting in formation of an expanding blind pouch. About 10% of aortic dissections are painless and may present with symptoms secondary to the complications of the dissection. Although cardiovocal syndrome, or Ortner's syndrome (hoarseness of voice due to involvement of recurrent laryngeal nerve in cardiovascular diseases) has been described with aortic dissection, it has not been reported as an initial presenting feature of this disorder. This report describes the first case of painless aortic dissection presenting with hoarseness of voice, the cardiovocal syndrome. The hoarseness remained the only symptom throughout the entire course of the disease. The aortic dissection was not suspected initially. During surgical exploration, the recurrent laryngeal nerve was found compressed by the false lumen at the level of aortic arch. Aortic root replacement was performed successfully, resulting in complete resolution of the hoarseness. The neurological manifestations of aortic dissection, and the cardiovocal syndrome, are discussed.

Brachial plexus injury and hypoglossal paralysis

Two neonates born after traumatic deliveries presented with injuries of the upper brachial plexus and ipsilateral hypoglossal nerve. In addition, 1 patient presented with paresis of the diaphragm after breech delivery; the other patient presented with signs of recurrent laryngeal nerve involvement after vertex delivery. Both infants recovered spontaneously.

Histopathologic study of carcinoma of the hypopharynx: implications for conservation surgery.

A total of 38 specimens obtained by laryngopharyngectomy were subjected to a whole organ section study. Of the 38, 31 were pyriform sinus (PS), three were postcricoid (PC), and four were posterior wall (PW) carcinomas. The results were as follows. 1) The thyroid cartilage was involved much more frequently than the other laryngeal cartilages. 2) Joint involvements were infrequent. 3) The interarytenoid, thyroarytenoid, and lateral cricoarytenoid muscles frequently were invaded by PS carcinomas, whereas PC carcinomas frequently involved the interarytenoid and posterior cricoarytenoid muscles. 4) The recurrent laryngeal nerve (RLN) was involved in all PC T3 cases, but RLN involvement was rare in PS cases. 5) Involvements of the paraglottic space and periarytenoid region were closely related to fixation of the larynx on the affected side (hemilarynx) in PS carcinomas. 6) Neither hemilarynx fixation nor PS apex involvement was a reliable landmark for determining the exact extent of laryngeal involvement. 7) Conservation surgery could have been employed in 18 of the 38 cases.

Thyroid carcinoma.

Differentiated thyroid carcinoma was studied with regard to mode of presentation, initial findings, treatment and survival. The classic signs, symptoms, physical and scan findings were found to be present in approximately 70% of the patients. Thirty percent of the patients had either unusual presentations or findings. Prognosis was found to be dependent on age of presentation more than any other factor. The effects of neck metastasis, extracapsular invasion and recurrent laryngeal nerve involvement on long-term survival are studied in detail. patients with prior exposure to radiation were found to have more extensive disease and require more extensive surgery but ultimately had the same prognosis for 15-year cure. Treatment for distant metastatic disease by surgery, radioactive iodine and external radiation all resulted in long-term survival in certain cases.