Clinical impacts of the Sudanese anatomical variations in a relation of the recurrent laryngeal nerve to the inferior thyroid artery

  • Authors

    • Mohamed Elghazali Elhasan Anatomical Lecturer, Almadain College of Medical Sciences and Technology
    • Wael Mohialddin Doush Gastroenterological Surgeon, MD, MRCSEd, Assistant Professor of General Surgery, Department of Surgery, Faculty of Medicine and health sciences, Omdurman Islamic university (Corresponding author)
    2020-10-22
    https://doi.org/10.14419/ijm.v8i2.31070
  • Anatomical Variations, Iatrogenic Injury, Inferior Thyroid Artery, Recurrent Laryngeal Nerve, Sudan, Thyroid Gland.

  • Background: Until recently, the knowledge of the anatomical variations in the relationship between the recurrent laryngeal nerve (RLN) and the inferior thyroid artery (ITA) combined with visual intraoperative RLN identification are essential for the protection of these life-important structures during surgical exposure and the mobilization of thyroid and parathyroid glands. This leads to the proper treatment of patients and improvement of the surgical techniques.

    Aim: To describe anatomical variations in the relationship of the recurrent laryngeal nerve to the inferior thyroid artery in the Sudanese population.

    Patients and methods: Following ethical committee approval, an observational descriptive prospective cross-sectional study in the period between March 2019 and February 2020, for anatomical variations in the relation of the recurrent laryngeal nerve to the inferior thyroid artery in seventy-two cervical sides of thirty-six well-dissected embalmed Sudanese cadavers. The RLN was investigated in three positions: posterior to the ITA main trunk, anterior to the ITA main trunk and between the ITA branches. Then, the results were analyzed according to the gender, age and dissection side.

    Results: We found that the anatomical variations were more frequent in males (97.2%) than females (2.8%). The age of these variations ranged between 31–45 years which represents (61.1%). On the right side of the neck, the commonest position of the RLN is posterior to the ITA (63.9%) followed by in decreasing order of frequency, the RLNs run between the ITA branches (30.6%) and anterior to the ITA (5.6%). On the left side of the neck, the commonest position of the RLN is posterior to the ITA (69.4%). It passed between the ITA branches in (30.6%) of specimens. There was no anterior location of the RLN to the ITA. Variations in a relationship of the RLN to the ITA on one side is significantly different from the opposite side.

    Conclusions: Although the risk of potential damage to the RLN during surgical neck procedures involving the thyroid gland and parathyroid glands is well recognized, pre-operative detailed surgeon’s knowledge for these frequent anatomical variations and the usage of the ITA as an anatomical landmark for intraoperative RLN recognition is important. This will lead to a reduction of iatrogenic RLN injury prevalence. Future studies are recommended to compare the findings on this cadaveric study with a larger sample size in the long-term period.

     

     

  • References

    1. [1] Higgins, C.C., 1927. Surgical anatomy of the recurrent laryngeal nerve with especial reference to thyroid surgery. Annals of surgery, 85(6), p.827–838. https://doi.org/10.1097/00000658-192706000-00004.

      [2] Rimi, K.R. and Bose, B.K., 2010. Position of terminal branches of inferior thyroid arteries in relation to recurrent laryngeal nerve. Dinajpur Med Col J, 3(2), pp.47–54.

      [3] Premachandra, D.J., Radcliffe, G.J. and Stearns, M.P., 1990. Intraoperative identification of the recurrent laryngeal nerve and demonstration of its function. The laryngoscope, 100(1), pp.94–96. https://doi.org/10.1288/00005537-199001000-00019.

      [4] Erbil, Y., Barbaros, U., Işsever, H., Borucu, I., Salmaslıoglu, A., Mete, O., Bozbora, A. and Ozarmagan, S., 2007. Predictive factors for recurrent laryngeal nerve palsy and hypoparathyroidism after thyroid surgery. Clinical otolaryngology, 32(1), pp.32–37. https://doi.org/10.1111/j.1365-2273.2007.01383.x.

      [5] Jeannon, J.P., Orabi, A.A., Bruch, G.A., Abdalsalam, H.A. and Simo, R., 2009. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. International journal of clinical practice, 63(4), pp.624–629. https://doi.org/10.1111/j.1742-1241.2008.01875.x.

      [6] Tang, W.J., Sun, S.Q., Wang, X.L., Sun, Y.X. and Huang, H.X., 2012. An applied anatomical study on the recurrent laryngeal nerve and inferior thyroid artery. Surgical and radiologic anatomy, 34(4), pp.3254–332. https://doi.org/10.1007/s00276-011-0905-8.

      [7] Kaisha, W., Wobenjo, A. and Saidi, H., 2011. Topography of the recurrent laryngeal nerve in relation to the thyroid artery, Zuckerkandl tubercle, and Berry ligament in Kenyans. Clinical anatomy, 24(7), pp.853–857. https://doi.org/10.1002/ca.21192.

      [8] Gremillion, G., Fatakia, A., Dornelles, A. and Amedee, R.G., 2012. Intraoperative recurrent laryngeal nerve monitoring in thyroid surgery: is it worth the cost?. Ochsner Journal, 12(4), pp.363–366.

      [9] Dionigi, G., Wu, C.W., Kim, H.Y., Rausei, S., Boni, L. and Chiang, F.Y., 2016. Severity of recurrent laryngeal nerve injuries in thyroid surgery. World journal of surgery, 40(6), pp.1373–1381. https://doi.org/10.1007/s00268-016-3415-3.

      [10] Cannizzaro, M.A., 2004. Zuckerkandl's tuberculum: could it be useful in thyroid surgery? Chir Ital, 56(5), pp.611–615.

      [11] Akil, F., Yollu, U., Ayral, M., Turgut, F. and Yener, M., 2017. The anatomical relationship between recurrent laryngeal nerve and first tracheal ring in males and females. Clinical and experimental otorhinolaryngology, 10(1), p.104–108. https://doi.org/10.21053/ceo.2015.01746.

      [12] Sasaki, C.T. and Mitra, S., 2001. Recurrent laryngeal nerve monitoring by cricopharyngeus contraction. The laryngoscope, 111(4), pp.738–739. https://doi.org/10.1097/00005537-200104000-00032.

      [13] Arrangoiz, R., Cordera, F., Caba, D., Muñoz, M., Moreno, E. and de Leon, E.L., 2018. Comprehensive review of thyroid embryology, anatomy, histology, and physiology for surgeons. International Journal of otolaryngology and head & neck surgery, 7(4), pp.160–188. https://doi.org/10.4236/ijohns.2018.74019.

      [14] Zada, B., Anwar, K., Malik, S.A., Khan, N. and Salam, F., 2014. Anatomical relationship between recurrent laryngeal nerve and inferior thyroid artery in thyroidectomy patients. Journal of ayub medical college abbottabad, 26(3), pp.380–383.

      [15] Katz, A.D. and Nemiroff, P., 1993. Anastamoses and bifurcations of the recurrent laryngeal nerve--report of 1177 nerves visualized. The American surgeon, 59(3), pp.188-191.

      [16] Cetin, F., Gurleyik, E. and Dogan, S., 2016. Morphology and functional anatomy of the recurrent laryngeal nerve with extralaryngeal terminal bifurcation. Anatomy research international, 2016, pp.1–5. https://doi.org/10.1155/2016/9503170.

      [17] Nyeki, A.R.N., Njock, L.R., Miloundja, J., Vokwely, J.E.E. and Bengono, G., 2015. Recurrent laryngeal nerve landmarks during thyroidectomy. European annals of otorhinolaryngology, head and neck diseases, 132(5), pp.265–269. https://doi.org/10.1016/j.anorl.2015.08.002.

      [18] Sasou, S., Nakamura, S.I. and Kurihara, H., 1998. Suspensory ligament of Berry: its relationship to recurrent laryngeal nerve and anatomic examination of 24 autopsies. Head & neck: journal for the sciences and specialties of the head and neck, 20(8), pp.695–698. https://doi.org/10.1002/(SICI)1097-0347(199812)20:8<695::AID-HED6>3.0.CO;2-3.

      [19] Konschake, M., Zwierzina, M.E., Pechriggl, E.J., Moriggl, B., Brenner, E., Hormann, R. and Prommegger, R., 2016. The nonrecurrent laryngeal nerve: a clinical anatomic mapping with regard to intraoperative neuromonitoring. Surgery, 160(1), pp.161–168. https://doi.org/10.1016/j.surg.2015.12.021.

      [20] Sanders, G., Uyeda, R.Y. and Karlan, M.S., 1983. Nonrecurrent inferior laryngeal nerves and their association with a recurrent branch. The American journal of surgery, 146(4), pp.501–503. https://doi.org/10.1016/0002-9610(83)90240-4.

      [21] Randolph, G.W., 2003. Surgical anatomy of the recurrent laryngeal nerve. Surgery of the thyroid and parathyroid glands, pp.300–302.

      [22] Ozguner, G. and Sulak, O., 2014. Arterial supply to the thyroid gland and the relationship between the recurrent laryngeal nerve and the inferior thyroid artery in human fetal cadavers. Clinical anatomy, 27(8), pp.1185–1192. https://doi.org/10.1002/ca.22448.

      [23] Campos, B.A. and Henriques, P.R.F., 2000. Relationship between the recurrent laryngeal nerve and the inferior thyroid artery: a study in corpses. Revista do Hospital das Clínicas, 55(6), pp.195–200. https://doi.org/10.1590/S0041-87812000000600001.

      [24] Dralle, H., Sekulla, C., Haerting, J., Timmermann, W., Neumann, H.J., Kruse, E., Grond, S., Mühlig, H.P., Richter, C., Voß, J. and Thomusch, O., 2004. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery, 136(6), pp.1310–1322. https://doi.org/10.1016/j.surg.2004.07.018.

      [25] Hirata, K., 1992. Relationship between the recurrent laryngeal nerve and the inferior thyroid artery in Japanese. Kaibogaku zasshi. Journal of anatomy, 67(5), pp.634–641.

      [26] Roshan, S., Bhivate, V.R., Pandey, N. and Shinde, S.B., 2017. Study on recurrent laryngeal nerve: its position and relationship with inferior thyroid artery. Int J Anat Res, 5(1), pp.3404–3409. https://doi.org/10.16965/ijar.2016.490.

      [27] Lekacos, N.L., Tzardis, P.J., Sfikakis, P.G., Patoulis, S.D. and Restos, S.D., 1992. Course of the recurrent laryngeal nerve relative to the inferior thyroid artery and the suspensory ligament of Berry. International surgery, 77(4), p.287–288.

      [28] Kulekci, M., Batıoglu-Karaaltın, A., Saatci, O. and Uzun, I., 2012. Relationship between the branches of the recurrent laryngeal nerve and the inferior thyroid artery. Annals of otology, rhinology & laryngology, 121(10), pp.650–656. https://doi.org/10.1177/000348941212101005.

      [29] Page, C., Foulon, P. and Strunski, V., 2003. The inferior laryngeal nerve: surgical and anatomic considerations. Report of 251 thyroidectomies. Surgical and radiologic anatomy, 25(3-4), pp.188–191. https://doi.org/10.1007/s00276-003-0129-7.

      [30] Polednak, A.P., 2006. Anatomic configurations of the recurrent laryngeal nerve and inferior thyroid artery with statistical considerations. Surgery, 140(3), pp.481–482. https://doi.org/10.1016/j.surg.2006.02.016.

      [31] Beneragama, T. and Serpell, J.W., 2006. Extralaryngeal bifurcation of the recurrent laryngeal nerve: a common variation. ANZ journal of surgery, 76(10), pp.928–931. https://doi.org/10.1111/j.1445-2197.2006.03899.x.

      [32] Shao, T., Yang, W., Zhang, T., Wang, Y., Jin, X., Li, Q., Kuang, J., Qiu, W., Chu, P.G. and Yen, Y., 2010. A newly identified variation at the entry of the recurrent laryngeal nerve into the larynx. Journal of investigative surgery, 23(6), pp.314–320. https://doi.org/10.3109/08941939.2010.509465.

      [33] Skandalakis, J.E., Droulias, C., Harlaftis, N., Tzinas, S., Gray, S.W. and Akin Jr, J.T., 1976. The recurrent laryngeal nerve. The American surgeon, 42(9), pp.629–634.

      [34] Bhargav, P.R.K., 2014. Salient anatomical landmarks of thyroid and their practical significance in thyroid surgery: a pictorial review of thyroid surgical anatomy. Indian journal of surgery, 76(3), pp.207–211. https://doi.org/10.1007/s12262-013-0856-x.

      [35] Reed, A.F., 1943. The relations of the inferior laryngeal nerve to the inferior thyroid artery. The Anatomical record, 85(1), pp.17–23. https://doi.org/10.1002/ar.1090850103.

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    Elghazali Elhasan, M., & Mohialddin Doush, W. (2020). Clinical impacts of the Sudanese anatomical variations in a relation of the recurrent laryngeal nerve to the inferior thyroid artery. International Journal of Medicine, 8(2), 25-30. https://doi.org/10.14419/ijm.v8i2.31070