L’identification du nerf laryngé pendant l’opération de la thyroïde — la faisabilité d’une nouvelle approche

Abstract

P Pu ur rp po os se e: : Recurrent laryngeal nerve damage remains one of the most devastating complications of thyroid surgery. However, nerve identification is not always easy, and a reliable method to locate nerves intraoperatively is needed.M Me et th ho od ds s: : Thirty consecutive patients were anesthetized for elective thyroid surgery using a standard technique. Indications for surgery covered a broad spectrum of conditions. In the technique described, the airway is secured with a micro laryngeal tube, and a laryngeal mask airway is inserted through which a fibreoptic scope is inserted to view the larynx. Movement of the arytenoids in response to nerve stimulation can be viewed at any time on a television monitor. The airway is secure throughout the procedure and nerve identification is continuously available.R Re es su ul lt ts s: : In our study 30 patients were anesthetized and nerve stimulation used in all of them to identify both superior and recurrent laryngeal nerve. None of them developed intraoperative complications. One patient had temporary postoperative recurrent laryngeal nerve damage, which was not attributable to use of this method.C Co on nc cl lu us si io on n: : On the basis of our results so far, the method described is feasible and provides a safe method of nerve location during surgery. Laryngeal nerve stimulation is likely to become an integral part of thyroid surgery. Objectif : Les dommages du nerf laryngé récurrent demeurent la Conclusion : D'après les résultats obtenus jusqu'à maintenant, la méthode décrite est faisable et permet une identification peropéra-toire du nerf sans danger. La stimulation du nerf laryngé pourrait donc être intégrée à l'opération de la thyroïde.HYROIDECTOMIES continue to produce complications with the most devastating being damage to the recurrent laryngeal nerve. 1 The rate of recurrent laryngeal nerve palsy varies from 2% to 17% and for superior laryngeal nerve from 9% to 14%. 2 Trauma to one of the laryngeal nerves is more likely if there are variations or distortions of anatomy, malignancy, previous radiation or revision surgery.It is standard practice to identify the recurrent laryngeal nerve but this is not always possible. A recent study identifies failure to find the nerve in as many as 18% of cases. 3 Mountain et al. showed that the incidence of nerve paralysis was three to four times greater in cases where the nerve was not exposed than in cases where it was routinely exposed.

Surgical anatomy of the internal branch of the superior laryngeal nerve

“…Routinely the main trunk and posterior descending branch of the ibSLN was preserved in supraglottic laryngectomy by identification of the main trunk in the viscero-vertebral angle medial to the carotid bifurcation [5]. The rate of SLN palsy varies from 9 to 14% in thyroid surgery [10], from 1 to 4.5% in carotid endarterectomy operations [8], and 8% in anterior cervical fusion operations [4]. Injury to the ibSLN results in impairment of the laryngeal cough reflex [12,18].…”

Laryngeal nerve monitoring during thyroid surgery in pregnancy

“…An unsecured airway may lead to aspiration and/or loss of the airway intraoperatively with disastrous consequences, particularly in pregnancy. To circumvent above difficulties, Hillermann et al [8] described the use of the combined technique of LMA and ETT for facilitating laryngeal nerve monitoring during thyroid surgery in nonpregnant subjects. The use of this technique, as described in our case report, assures that the airway is secured from the onset of anesthesia until the parturient is awake, while providing an unhindered and uninterrupted view of vocal cords during the entire procedure.…”

“…The use of this technique, as described in our case report, assures that the airway is secured from the onset of anesthesia until the parturient is awake, while providing an unhindered and uninterrupted view of vocal cords during the entire procedure. Hillermann et al [8] used a 5.0-mm microlaryngeal tube. However, we used a larger 6.5-mm ETT in this parturient, as we felt that a smaller ETT would not provide an adequate seal around the tracheal cuff, hence, predisposing the patient to aspiration in spite of the high cuff inflating volume.…”

“…Trauma to the laryngeal nerves continues to be the most devastating complication of thyroid surgery [2]. Laryngeal nerve monitoring is being used with increasing frequency to decrease the incidence of laryngeal nerve injury during thyroid surgery [3][4][5][6][7][8]. We report the successful use of a laryngeal mask airway (LMA) through which a fiberoptic bronchoscope (FOB) was inserted to view the larynx in the intubated parturient undergoing partial thyroidectomy.…”

Retrospective Analysis of Thyroidectomy Cases That Became Subjects Due to Unintended Consequences

“…22 Yine sinirin anatomik varyasyon ve distorsiyonları, daha önce radyasyona maruz kalma ve reoperasyon sinir yaralanması için risk oluşturmaktadır. 33 RLS yaralanmasının azaltıl-masında sinirin anatomik seyrinin aranması gereken noktaların bilinmesi önem taşımaktadır. 34,35 Ses kısıklığı altı aya kadar uzarsa tek taraflı RLS hasarı düşünülür.…”