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Nonrecurrent Laryngeal Nerve with Bulky Central and Lateral Compartment Lymph Nodes: Too Much to Handle

Chandan Kumar Jha1*, Raouef Ahmed Bichoo2, Sanjay Kumar Yadav2 and Alok Anshu3
1Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Patna- 800023, India
2Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow- 226 014, India
3Department of Surgery, Command Hospital Air Force, Bangalore- 560007, India


*Corresponding author: Chandan Kumar Jha, Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Patna 800023, India


Published: Clinical Image
Cite this article as: Jha CK, Bichoo RA, Yadav SK, Anshu A. Nonrecurrent Laryngeal Nerve with Bulky Central and Lateral Compartment Lymph Nodes: Too Much to Handle. Clin Surg. 2017; 2: 1732.

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A nonrecurrent laryngeal nerve is an embryological error that has to be always kept in mind to prevent accidental injury to it during surgery. A right sided Nonrecurrent Laryngeal (NRLN) nerve is a rare occurrence (0.5% to 1.6%), and even rarer (0.04%) is its presence on the left side [1]. A NRLN is more prone to injury than a Recurrent Nerve (RLN) and this risk is magnified when the Central Compartment (CC) is studded with bulky lymph nodes.
It was a case of papillary carcinoma of thyroid with large, matted lymph nodes in the CC and the lymph node mass in the CC was merging with the lateral compartment lymph node mass (Figure 1). During dissection when we didn’t find the RLN in its usual position we opened the carotid sheath and identified the vagus nerve which then was retracted with elastic sling. This made the identification of a NRLN possible despite being entrapped in the LN mass and it was then traced up to its insertion (Figure 2). It must be stressed here that we routinely follow the recommended practice of “not cutting any transverse band between the carotid sheath and larynx, other than middle thyroid vein” as suggested by Liu et al. [2].

Figure 1

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Figure 1
Postoperative total thyroidectomy with central and bilateral selective neck dissection specimen: Bulky lymph nodes in central and lateral compartments of neck.

Figure 2

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Figure 2
A right nonrecurrent laryngeal nerve arising from right vagus and inserting into the larynx.

References

  1. Henry JF, Audiffret J, Denizot A, Plan M. The nonrecurrent inferior laryngeal nerve: review of 33 cases, including two on the left side. Surgery. 1988;104(6):977-84.
  2. Liu LX, Wu LF, Xue DB, Meng XZ, Zhang WH, Jiang HC. The importance of nonrecurrent laryngeal nerve in thyroid surgery. Zhonghua Wai Ke Za Zhi. 2006;44(13):904-6.