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Nonrecurrent Laryngeal Nerve Predicted Before Thyroidectomy By Preoperative Imaging.

G. Materazzi, P. Berti, P. Iacconi, P. Miccoli
Published 2000 · Medicine

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A 48-year-old woman, complaining of dyspnea on exercise and dysphagia, was referred to us for a multinodular goiter. A CT scan excluded a substernal thyroid mass but demonstrated the abnormal course of the brachiocephalic artery in a very posterior position behind the esophagus. The angio-MRI (A) confirmed the presence of an abnormal right brachiocephalic artery, arising from the aortic arch beyond the left subclavian artery and crossing to the right behind the trachea and esophagus, just in front of the vertebrae (arteria lusoria). On the basis of preoperative imaging, the right nonrecurrent laryngeal nerve was predicted. The usual collar incision was made, the right lobe mobilized, and the upper pole vessels ligated. The tracheoesophageal groove was explored, and the nonrecurrent laryngeal nerve (B, arrowhead) was found crossing transversally from the carotid sheath and entering the larynx under the inferior border of the inferior constrictor muscle. A total thyroidectomy was carried out, the postoperative course was uneventful, and the patient was discharged 2 days after operation. The nonrecurrent inferior laryngeal nerve is a rare occurrence in thyroid surgery (0.6%); the risk of injury in the presence of this anatomic variant is high, even for experienced endocrine surgeons. The right nonrecurrent laryngeal nerve is strictly associated with an aberrant brachiocephalic artery that sometimes is symptomatic (dysphagia). Preoperative imaging, such as barium swallow, CT, or angio-MRI, easily predicts this rare anomaly. Careful, complete dissection of the nerve is always advocated during cervicotomy.
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