The aim of the present study was to determine whether immediate revision surgery has benefits for patients with iatrogenic bilateral recurrent laryngeal nerve (RLN) palsy. From January 1, 2004 to January 30, 2011, 29 consecutive patients underwent immediate revision after total thyroidectomy. The cohort comprised 29 patients, 2 males and 27 females, aged 23 to 76 years (median 52 years). Identification of the type and extent of injury of each branch was reported in the protocol, and reconstruction was performed whenever possible. A complete transection of the nerve or one of its branches was found in 14 and 5 nerves, respectively. In three patients, the nerve was completely or partially transected on both sides. Seven anatomically intact nerves were injured by loaded ligature, in one case there was a sign of thermal damage and four nerves showed signs of excessive manipulation (thinning of the nerve trunk). Primary end-to-end anastomosis was performed in seven completely transected RLN and four transected anterior branches of RLN. None of the reconstructed nerve trunks or its branches regained function, although good muscle tone was observed. 23 of 38 intact nerves (61%) regained function, and normal vocalcord mobility on both sides was restored in only four patients. In all cases with regained vocal-cord mobility, functional recovery occurred within 3 months after primary surgery. In conclusion, immediate revision after thyroidectomy may help to indicate the type of RLN damage, which is a predictor of functional recovery and one of major factors influencing future therapeutic management.

Obiettivo del presente studio è stato quello di determinare se la revisione immediata potrebbe essere utile nei pazienti affetti da paralisi ricorrenziale bilaterale dopo chirurgia tiroidea o delle ghiandole paratiroidee. Dal 1° gennaio 2004 al 30 gennaio 2011, 29 pazienti consecutivi sono stati sottoposti a revisione immediata dopo tiroidectomia totale e sono stati inclusi nello studio. La coorte comprendeva 2 maschi e 27 femmine, di età compresa tra 23-76 anni (età mediana 52 anni). L'identificazione del tipo e dell'estensione del danno del nervo ricorrente o di uno dei suoi rami è stata riportata nello studio. Quando possibile è stata eseguita la ricostruzione. Una resezione completa del nervo o di uno dei suoi rami è stata trovata in 14 e 5 casi, rispettivamente. In tre pazienti il nervo è stato tutto o in parte sezionato bilateralmente. In sette casi il nervo anatomicamente intatto è stato danneggiato da legatura in prossimità dello stesso, in un caso erano riconoscibili i segni di danno termico. In quattro nervi sono stati identificati segni di manipolazione eccessiva. Un'anastomosi primaria termino terminale è stata effettuata in sette nervi laringei completamente sezionati e in quattro rami anteriori dello stesso. Nessuno dei nervi ricostruiti ha riguadagnato la sua funzione, benché sia stato conservato un buon tono muscolare. In 23 dei 38 nervi intatti (61%) è stato osservato un buon recupero funzionale. La motilità laringea è stata recuperata bilateralmente solo in quattro pazienti. In tutti i casi la ripresa funzionale del nervo si è verificata entro 3 mesi dalla chirurgia primaria. La revisione chirurgica immediata in caso di sospetta paralisi ricorrenziale bilaterale dopo tiroidectomia può aiutare a precisare il tipo del danno a carico dei ricorrenti, predittivo del recupero funzionale, e fattore principale nel determinare i successivi passi terapeutici.

Charles University Prague 1st Faculty of Medicine Department of Otorinolaryngology Head and Neck Surgery Faculty Hospital Motol Postgraduate Medical School Czech Republic

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A new strategy for the surgical management of RLN infiltrated by well-differentiated thyroid carcinoma

Minimally invasive video-assisted versus minimally invasive nonendoscopic thyroidectomy