Managing the involved recurrent laryngeal nerve in thyroid cancer.

Background: Recurrent laryngeal nerve palsy (RLNP) is not uncommon after thyroid surgery and can be debilitating. This is a retrospective cohort analysis of outcomes in patients with RLNP post-thyroidectomy for differentiated thyroid malignancy.

Method: Clinicopathological details as well as outcomes of thyroidectomies for differentiated thyroid cancer in 862 patients performed over a period of 22 years (2001-2023) for nerve palsy were collected. The patients were stratified into two groups based on whether the recurrent laryngeal nerve (RLN) was amputated or preserved.

Results: Of the 1520 nerves in 862 patients at risk during thyroidectomy, a total of 71 (8.2%) (20M:51F) patients, with a median age of 54 (range: 19 - 83) suffered RLNP, which was temporary in 14 (1.6%), unilateral in 51 (5.9%) and bilateral in 6 (0.7%) patients. The RLN was amputated in 31 of 62 patients (50%). In 29 of 71(41%) patients the nerve was intentionally sacrificed due to gross disease infiltration while the RLN was inadvertently severed during dissection in 2 (3%) patients. Among cases with recurrent laryngeal nerve (RLN) transection, only five underwent primary repair or ansa cervicalis to RLN anastomosis. The only factor associated with amputation of the RLN was a larger tumour size (40.4 vs 24.7mm, p = 0.007). Preservation of voice quality was higher in the shave group in comparison to the amputation group ((93.5% vs 71.0%, p = 0.0426).

Conclusion: Preservation of nerve or reconstruction in transectional injuries should be considered where possible to improve voice outcomes except in cases when the laryngotracheal complex is involved.