Characteristics of lymph node metastasis of right recurrent laryngeal nerve in thoracic esophageal squamous cell carcinoma / 中华肿瘤杂志

Objective: To understand the characteristics and influencing factors of lymph node metastasis of the right recurrent laryngeal nerve in thoracic esophageal squamous cell carcinoma (ESCC), and to explore the reasonable range of lymph node dissection and the value of right recurrent laryngeal nerve lymph node dissection. Methods: The clinicopathological data with thoracic ESCC were retrospectively analyzed, and the characteristics of lymph node metastasis along the right recurrent laryngeal nerve and its influencing factors were explored. Results: Eighty out of 516 patients had lymph node metastasis along the right recurrent laryngeal nerve, the metastasis rate was 15.5%. Among 80 patients with lymph node metastasis along the right recurrent laryngeal nerve, 25 cases had isolated metastasis to the right recurrent laryngeal nerve lymph node but no other lymph nodes. The incidence of isolated metastasis to the recurrent laryngeal nerve lymph node was 4.8% (25/516). A total of 1 127 lymph nodes along the right recurrent laryngeal nerve were dissected, 115 lymph nodes had metastasis, and the degree of lymph node metastasis was 10.2%. T stage, degree of tumor differentiation and tumor location were associated with right paraglottic nerve lymph node metastasis (all P<0.05). The lymph node metastasis rate along the right recurrent laryngeal in patients with upper thoracic squamous cell carcinoma (23.4%, 26/111) was higher than that of patients with middle (13.5%, 40/296) and lower (12.8%, 14/109) thoracic squamous cell carcinoma (P=0.033). In patients with poorly differentiated ESCC (20.6%, 37/180) the metastasis rate was higher than that of patients with moderately (14.6%, 39/267) and well-differentiated (5.8%, 4/69; P<0.05). The lymph node metastasis rate of patients with stage T4 (27.3%, 3/11) was higher than that of patients with stage T1 (9.6%, 19/198), T2 (19.0%, 16/84) and T3 (18.8%, 42/1 223; P<0.05). Multivariate regression analysis showed that tumor location (OR=0.61, 95% CI: 0.41-0.90, P=0.013), invasion depth (OR=1.46, 95% CI: 1.11-1.92, P=0.007), and differentiation degree (OR=1.67, 95% CI: 1.13-2.49, P=0.011) were independent risk factors for lymph node metastasis along right recurrent laryngeal nerve of ESCC. Conclusions: The lymph node along the right recurrent laryngeal nerve has a higher rate of metastasis and should be routinely dissected in patients with ESCC. Tumor location, tumor invasion depth, and differentiation degree are risk factors for lymph node metastasis along right recurrent laryngeal nerve in patients with ESCC.

Utilidad de la neuromonitorización vagal continua en cirugía tiroidea: experiencia y resultados en un hospital de tercer nivel / The role of continuous vagal intraoperative nerve monitoring in thyroid surgery: experience and results in a third-level hospital

Resumen Objetivo: La lesión del nervio laríngeo recurrente es una grave complicación en cirugía tiroidea. El propósito del presente estudio es analizar la utilidad de la neuromonitorización vagal continua intraoperatoria en un hospital terciario. Materiales y Método: Estudio observacional, analítico y retrospectivo que recoge pacientes intervenidos de cirugía tiroidea con neuromonitorización en un período de 14 meses. La pérdida de señal se define como amplitud final nerviosa < 100 ^V, realizándose laringoscopia postquirúrgica ante la sospecha de lesión nerviosa. El análisis estadístico se realizó con el programa SPSS® V25,0, con p < 0,05. Resultados: Se incluyeron 120 pacientes intervenidos, registrándose en el 24,2% pérdida de señal. Factores de riesgo para lesión fueron bocio intratorácico (OR 5,31; IC 95% 1,56-17,99; p = 0,007), cirugía cervical previa (OR 5,76; IC 95% 0,64-51,97; p = 0,119) y patología maligna (OR 1,44; IC 95% 0,16-12,79; p = 0,743). Fue posible el cambio de estrategia quirúrgica en 7 casos. En el seguimiento posterior se cuantificó parálisis recurrencial transitoria en 27 pacientes y permanente en 4. Discusión: La neuromonitorización parece reducir la incidencia de parálisis laríngea porque aumenta la seguridad en la identificación del nervio recurrente y reduce su manipulación durante la cirugía. Conclusiones: La neuromonitorización intraoperatoria es útil para identificar el nervio laríngeo recurrente y advierte del riesgo potencial de lesión, permitiendo cambiar la estrategia quirúrgica para evitar la parálisis bilateral de cuerdas vocales.

Aim: Recurrent laryngeal nerve injury is a serious complication in thyroid surgery. The purpose of the present study is to analyze the use of intraoperative continuous vagal neuromonitoring in a tertiary hospital. Materials and Method: Observational, analytical and retrospective study that includes patients who underwent thyroid surgery with neuromonitoring in a period of 14 months. Loss of signal is defined as final nerve amplitude < 100 ^V, and postsurgical laryngoscopy is performed due to suspicion of nerve injury. Statistical analysis was performed with the SPSS® V25.0 program, with p < 0.05. Results: 120 operated patients were included, registering loss of signal in 24.2%. Risk factors for injury were intrathoracic goiter (OR 5.31; 95% CI 1.56-17.99; p = 0.007), previous cervical surgery (OR 5.76; 95% CI 0.64-51.97; p = 0.119) and malignant pathology (OR 1.44; 95% CI 0.16-12.79; p = 0.743). A change in surgical strategy was possible in 7 cases. In the subsequent follow-up, transient recurrent paralysis was quantified in 27 patients and permanent in 4. Discussion: Neuromonitoring seems to reduce the incidence of laryngeal paralysis because it increases the security in the identification of the recurrent nerve and reduces its manipulation during surgery. Conclusions: Intraoperative neuromonitoring is useful to identify the recurrent laryngeal nerve and warns of the potential risk of injury, allowing to change the surgical strategy to avoid bilateral vocal cord paralysis.

The value and related complications of lymph node dissection along bilateral recurrent laryngeal nerves in esophageal cancer patients / 中华肿瘤杂志

Esophageal cancer is one of the most common malignant tumors of digestive tract, lymph node metastasis is a frequently encountered metastasis in the esophageal cancer patients. The number of lymph node metastasis is reported as an important prognostic factor, and it also affects the choice of postoperative treatments in the esophageal cancer. It was reported that the recurrent laryngeal nerve lymph nodes are the most common sites of nodal metastasis and need to be completely dissected during the esophagectomy for thoracic esophageal cancers. Dissection of the lymph nodes along bilateral recurrent laryngeal nerves not only improves the accuracy of staging, but also improves postoperative survival of esophageal cancer patients due to reducing the local recurrence. However, it also brings problems such as injury of laryngeal recurrent nerves, and increases postoperative complications such as pulmonary complications and malnutrition due to aspiration and coughing. Therefore, it is necessary to preserve the structure and function of bilateral recurrent laryngeal nerves during esophagectomy through careful manipulations, and minimize the impact of complications in prognosis and quality of life from injury to the recurrent laryngeal nerve.

Lesión del nervio laríngeo recurrente en cirugía tiroidea / Recurring laryngeal nerve injury in thyroid surgery

La lesión del nervio laríngeo recurrente (NLR) es una de las complicaciones más severas en las tiroidectomías. La lesión unilateral genera trastornos disfónicos que se manifiesta por voz débil y una posición paramedial de la cuerda vocal afectada, mientas que la bilateral genera trastornos respiratorios, incluyendo la asfixia. Se ha estimado que la lesión del NLR en las tiroidectomías se encuentra entre un rango de 0.3%- 18.9%. Se ha visto que con el neuromonitoreo intraoperatorio ha disminuido la incidencia de lesión, aunque debemos tener en cuenta un factor muy importante a la hora de solicitarlo y utilizarlo, el económico. La tasa de lesión permanente del nervio laríngeo recurrente debe permanecer por debajo de 1 a 2 %. Sin embargo, existen circunstancias en las cuales los nervios están expuestos a un mayor riesgo y son muchos los factores involucrados en su mecanismo de lesión. Este artículo pretende hacer una revisión del tema enfatizando en la importancia de la preservación de la funcionalidad e integridad de ambos nervios laríngeos recurrentes.

Recurrent laryngeal nerve injury (RLN) is one of the most severe complications in thyroidectomies. Unilateral injury generates dysphonic disorders manifested by weak voice and a paramedial position of the affected vocal cord, while bilateral injury generates respiratory disorders, including suffocation. RLN injury in thyroidectomies has been estimated to be in the range of 0.3% - 18.9%. It has been seen that with intraoperative neuromonitoring the incidence of injury has decreased, although we must take into account a very important factor when requesting and using it, the economic one. The rate of permanent injury to the recurrent laryngeal nerve should remain below 1% to 2%. However, there are circumstances in which the nerves are exposed to greater risk and many factors are involved in their mechanism of injury. This article aims to review the subject, emphasizing the importance of preserving the functionality and integrity of both recurrent laryngeal nerves

The Clinical Significance of the Right Para-Oesophageal Lymph Nodes in Papillary Thyroid Cancer

PURPOSE: Although guidelines indicate that routine dissection of the central lymph nodes in patients with thyroid carcinoma should include the right para-oesophageal lymph nodes (RPELNs), located between the right recurrent laryngeal nerve and the cervical oesophagus and posterior to the former, RPELN dissection is often omitted due to high risk of injuries to the recurrent laryngeal nerve and the right inferior parathyroid gland. MATERIALS AND METHODS: We retrospectively identified all patients diagnosed with papillary thyroid carcinoma who underwent total thyroidectomy with central lymph node dissection, including the RPELNs, between January 1, 2009 and December 31, 2013 at the Thyroid Cancer Center of Yonsei University College of Medicine, Seoul, Korea. RESULTS: Of 5556 patients, 148 were positive for RPELN metastasis; of the latter, 91 had primary tumours greater than 1 cm (p<0.001). Extrathyroidal extension by the primary tumour (81.8%; p<0.001), bilaterality, and multifocality were more common in patients with than without RPELN metastasis; however, there were no significant differences in age and sex between groups. A total of 95.9% of patients with RPELN metastasis had central node (except right para-oesophageal lymph node) metastasis, and the incidence of lateral neck node metastasis was significantly higher in patients with than without RPELN metastasis (63.5% vs. 14.3%, p<0.001). Forty-one patients underwent mediastinal dissection, with 11 patients confirmed as having mediastinal lymph node metastasis with RPELN metastasis on pathological examination. CONCLUSION: RPELN metastasis is significantly associated with lateral neck and mediastinal lymph node metastasis.

Risk factors for posterior to right recurrent laryngeal nerve lymph node metastasis in papillary thyroid carcinoma

To identify the risk factors for posterior right recurrent laryngeal nerve lymph node metastasis [PRRLN-LNM] in papillary thyroid carcinoma [PTC]. We conducted a retrospective study of 389 patients with primary PTC who underwent right lobectomy or total thyroidectomy, and comprehensive right or bilateral central compartment dissection [CCD] with or without lateral neck dissection [LND] between January 2010 and May 2013 at the Department of Head and Neck Surgery, Institute of Micro-Invasive Surgery of Zhejiang University, Zhejiang, China. The clinicopathological findings were investigated, and relative risk factors for PRRLN-LNM were analyzed. Central compartment LNM were present in 50.9% [198/389], and PRRLN-LNM were present in 12.6% [49/389] of patients, wherein 3.1% [12/389] had PRRLN-LNM only. A multivariate analysis revealed that younger age [

Maniobra digital para localización del nervio recurrente descripción de la técnica Montezuma y Wilper / Digital maneuver for the localization of recurrent nerve Wilper and Montezuma technique description

En el siguiente trabajo tratamos de dar a conocer una maniobra que desde hace varios años venimos utilizando en el servicio de cabeza y cuello, con lo que respecta a la localización del nervio laríngeo recurrente en la cirugía del tiroides tanto en los casos malignos como benigno y en aquellos casos de bocio grado II, III o bocios voluminosos, y carcinoma tiroideos, lo cuales cambian la localización anatómica en el trayecto del nervio de igual manera la disposición anatómica de no recurrir. Se realiza un estudio en una muestra descriptiva tomada para este trabajo de 80 casos solamente, durante 10 años en lo que venimos practicamos la técnica, con pacientes de ambos sexos y diferentes edades. Se procedió a realizar la incisión clásica de cervicotomía anterior, se hace la diéresis hasta liberar los lóbulos tiroideos luego se localiza con palpación digital la escotadura crico tiroidea de cada lado de la laringe donde se encuentra el ligamento suspensorio tiroideo de Berry y membrana cricotiroidea, se diseca una área de 2 cm x 2 cm dicha zona y se ve la penetración de una o dos ramas del nervio recurrentelaríngeo tanto en los casos que recurre como en los no recurrentes. Concluimos que en todos los casos fueron encontrados el nervio ya sea como único o varias de sus ramas en este punto anatómico de reparo

The damage to the recurrent laryngeal nerve is most feared complication by the surgeon of all those that can affect patients undergoing surgery for thyroid and the parathyroid glands. In this paper we try to give a maneuver known that for several years we have been using the service head and neck, with regard to the location of laryngeal recurrent nerve thyroid surgery in both malignant and benign cases most important in cases of goiter grade II, III or bulky goiter and thyroid carcinoma, which changes the anatomical location on the route of laryngeal recurrent nerve, just as the anatomical disposition of non-use. We were studied in a sample descriptive taken for this study of 80 cases only, for 10 years in what we have practiced the technique, patients of both sexes and different ages. We preceded to perform a cervical incision anterior classic, the umlaut is to release the lobes, then located with palpation cricothyroid notch on each side of the larynx where the suspensor ligament of Berry thyroid and cricothyroid membrane is dissected an area of 2 cm x 2 cm that area and is the penetration of one or two branches of recurrent laryngeal nerve, both in the case used as non-recurring. We conclude that in all cases were found either as single recurrent laryngeal nerve or more of its branches at this point anatomical repair

CT Evaluation of Vocal Cord Paralysis due to Thoracic Diseases: A 10-Year Retrospective Study

PURPOSE: To discuss computed tomography (CT) evaluation of the etiology of vocal cord paralysis (VCP) due to thoracic diseases. MATERIALS AND METHODS: From records from the past 10 years at our hospital, we retrospectively reviewed 115 cases of VCP that were evaluated with CT. Of these 115 cases, 36 patients (23 M, 13 F) had VCP due to a condition within the thoracic cavity. From these cases, we collected the following information: sex, age distribution, side of paralysis, symptom onset date, date of diagnosis, imaging, and primary disease. The etiology of VCP was determined using both historical information and diagnostic imaging. Imaging procedures included chest radiograph, CT of neck or chest, and esophagography or esophagoscopy. RESULTS: Thirty-three of the 36 patients with thoracic disease had unilateral VCP (21 left, 12 right). Of the primary thoracic diseases, malignancy was the most common (19, 52.8%), with 18 of the 19 malignancies presenting with unilateral VCP. The detected malignant tumors in the chest consisted of thirteen lung cancers, three esophageal cancers, two metastatic tumors, and one mediastinal tumor. We also found other underlying etiologies of VCP, including one aortic arch aneurysm, five iatrogenic, six tuberculosis, one neurofibromatosis, three benign nodes, and one lung collapse. A chest radiograph failed to detect eight of the 19 primary malignancies detected on the CT. Nine patients with lung cancer developed VCP between follow-ups and four of them were diagnosed with a progression of malignancy upon CT evaluation of VCP. CONCLUSION: CT is helpful for the early detection of primary malignancy or progression of malignancy between follow-ups. Moreover, it can reveal various non-malignant causes of VCP.

Laryngeal nerves monitoring versus non-monitoring in thyroid surgery

Thyroid surgery is the most common cause of recurrent nerve [RLN] injury. Deliberate identification of the RLN minimizes the risk of injury. When the nerve is identified and dissected, the reported RLN injury rate during thyroidectomy is 0-2.1%. Continuous intra-operative nerve monitoring during surgery remains a controversial issue. The basic technique involves a skin surface electrode or muscle electrode used to make electromyography [EMG] recordings, which have an audible alarm to alert the surgeon if passive [e.g.stretch during traction] or active nerve stimulation has occurred. We aim to evaluate the use of intra-operative nerve monitoring [IONM] to preserve the laryngeal nerves that may be at risk for injury during thyroid surgery and show the merits of using electrophysiologic laryngeal nerve monitoring during thyroid surgery. This study was conducted as a prospective study on 28 patients whom are thyroidectomy candidates; we elected 14 thyroidectomy candidates in whom we don't use NIM during surgery [Control group A]. These patients were chosen to be evenly matched with another 14 thyroidectomy candidates to monitor the recurrent laryngeal [RLN] and external branch of superior laryngeal [EBSLN] throughout thyroidectomy procedures [NIM group B] to compare the laryngeal nerves risk of injury with and without the use of nerve monitor. Four patients [2 patients in-group A and 2 patients in-group B] were dysphonic after operation. Laryngoscopy revealed unilateral recurrent laryngeal nerve palsy in all except one bilateral in group A. There were no significant differences in RLN paralysis, paresis, or total injury rates between both groups. The number of patients in the presented study was limited to draw a statistical conclusion for significance. The routine application of IONM cannot prevent or reduce recurrent laryngeal nerve injury. However the study signifies the trend towards the use of INOM in expectedly difficult cases and in revision surgery with distorted anatomical relationships and fibrous adhesions

Recurrent laryngeal nerve paralysis secondary to benign thyroid disease

Recurrent laryngeal nerve paralysis in the presence of a thyromegaly is considered to be caused by a thyroid malignancy unless proven otherwise. There are very few case reports of non-malignant thyroid lesions causing vocal cord paralysis. The authors present their experience with a patient with benign thyroid disease presenting as vocal cord paralysis. The relevant literature is reviewed

Parálisis cordal y alcoholismo / Vocal cord paralysis and alcoholism

La parálisis recurrencial por alcoholismo es un hallazgo muy raro, si bien la literatura mundial menciona algunos casos. La inercia de las cuerdas vocales es debido a una neuropatía por probable déficit de vitamina B1 (tiamina). El siguiente trabajo relata una interesante manifestación clínica en un paciente alcohólico quien presentó disfonía, diagnosticándose paresia recurrencial izquierda cuya etiología, luego de descartar las causas más frecuentes y considerando que evolucionó favorablemente con vitamina B1, resultó ser una neuritis recurrencial alcohólica.