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

Novel surgical methods for reconstruction of the recurrent laryngeal nerve: Microscope-guided partial layer resection and intralaryngeal reconstruction of the recurrent laryngeal nerve

BACKGROUND

The optimal strategy for surgical management of papillary thyroid carcinoma invasion of the recurrent laryngeal nerve remains controversial. Our aim was to evaluate the efficacy of 2 surgical methods and provide detailed descriptions of microscope-guided partial layer resection and intralaryngeal reconstruction of the recurrent laryngeal nerve.

METHODS

This retrospective study enrolled 85 patients with papillary thyroid carcinoma who underwent initial surgical excision for invasion of the recurrent laryngeal nerve. Twenty-seven patients (28 recurrent laryngeal nerve sites) underwent partial layer resection, and 11 patients (11 recurrent laryngeal nerve sites) underwent intralaryngeal reconstruction of the recurrent laryngeal nerve. The remaining patients underwent either only resection or resection with immediate reconstruction of the recurrent laryngeal nerve. Pre and postoperative phonetic function and rates of locoregional recurrence were extracted from medical charts for analysis.

RESULTS

Isolated locoregional recurrence specific to the aerodigestive tract was identified in 1 patient (3.7%) in the partial layer resection group and 1 patient (9.1%) in the intralaryngeal reconstruction group. Seventy-five percent of patients in the partial layer resection group recovered or had preserved vocal cord function, and the mean maximum phonation time of the patients with postoperative complete vocal cord palsy was 15.3 seconds. The mean maximum phonation time of the patients, excluding 4 patients with permanent stoma in the intralaryngeal reconstruction group, was 22.3 seconds. The mean maximum phonation time of either group was longer than that of patients with recurrent laryngeal nerve resection only and comparable with that of patients with recurrent laryngeal nerve resection and immediate reconstruction.

CONCLUSION

Patients who underwent either partial layer resection or intralaryngeal reconstruction had low rates of locoregional recurrence specific to the aerodigestive tract and good postoperative functional outcomes.

Impact of lymph node metastases with recurrent laryngeal nerve invasion on patients with papillary thyroid carcinoma

BACKGROUND

Although rare, invasion by papillary thyroid carcinoma (PTC) of the upper aerodigestive tract significantly affects patients' prognosis and quality of life. Within the central compartment, the recurrent laryngeal nerve (RLN) is most frequently invaded by lymph node metastases (LNM). However, such an invasion has not been described in the literature, although reports on RLN invasion by primary tumors have been published. The present study aimed to characterize LNM with RLN invasion in patients with PTC.

METHODS

The participants of this retrospective investigation were selected from 629 PTC patients who received initial surgical treatment at our institution between January 1981 and December 2012. They included 38 (6%) patients with 40 cases of RLN invasion by LNM (LNM invasion group) and 112 (17.8%) patients with 117 cases of RLN invasion by the primary tumor (primary invasion group).

RESULTS

In the LNM invasion group, 70% of the RLN invasion cases occurred on the right side, whereas those in the primary invasion group were almost equally distributed. RLN invasion caused vocal cord paralysis, affecting 13 nerves (32.5%) in the LNM invasion group and 68 nerves (58%) in the primary invasion group. Significant differences in laterality and preoperative vocal cord paralysis were observed between the two groups. In the LNM invasion group, the longest diameter of metastatic lymph nodes (mean±standard deviation) of patients with RLN paralysis was 21±8 mm, whereas it was significantly different at 14±7 mm in those without RLN paralysis.

CONCLUSIONS

Our results indicate that most patients with RLN invasion by LNM did not experience preoperative vocal cord paralysis. LNM invasion of the RLN (70%) more often occurred on the right side as expected given the complexity and three-dimensional anatomy of the RLN in the right paratracheal region compared to the left. RLN invasion by LNM should be considered if preoperative paratracheal nodal disease, especially when bulky, is noted in the right paratracheal region.