Airway stenosis following immediate bilateral recurrent laryngeal nerve reconstruction: report of two cases successfully treated with laser submucosal intermediate transverse resection of the arytenoid cartilage.

Abstract

Background: While the usefulness of immediate intraoperative reconstruction of the unilateral recurrent laryngeal nerve (RLN) has been reported, there are few reports of bilateral reconstruction. Furthermore, detailed evaluation of laryngeal function before and after surgical treatment for airway compromise caused by bilateral RLN paralysis remains limited. This report aimed to highlight a preventable complication of immediate bilateral RLN reconstruction and a salvage treatment option.

Case description: We report two women who underwent immediate bilateral RLN reconstruction during surgery for benign thyroid tumors at another hospital and subsequently developed airway stenosis. Both patients underwent intraoperative tracheostomy and were referred to our institution for tracheostomy closure. Laryngeal electromyography revealed thyroarytenoid muscle activity during inspiration and reduced activity during phonation, indicating nerve misinnervation. Respiratory, swallowing, and voice functions were evaluated before and after surgery. The laser submucosal intermediate transverse resection of the arytenoid cartilage (LSITRA) technique was performed to enlarge the posterior glottis. In both cases, respiratory function improved after surgery, tracheostomies were successfully closed, and no restenosis was observed during more than 1 year of follow-up after decannulation.

Conclusions: LSITRA was effective for treating airway stenosis caused by bilateral RLN paralysis, with minimal adverse effects on voice and swallowing function. Although immediate RLN reconstruction is effective for unilateral nerve injury, bilateral reconstruction should be avoided because misinnervation may result in airway compromise. In benign thyroid disease, a two-stage surgical approach should be considered when loss of signal is detected on one side.