Recurrent and superior laryngeal nerve injury in thyroid surgery: literature review

Abdullatif Mahyoub, Alaa A. Aljohani, Abdullah J. Althobaiti, Sami S. Alharbi, Abdulaziz A. Alahmary, Raeed S. Algarni, Sultanah K. Alamoudi, Munirah S. Alshahrani, Turki M. Alkhaldi, Abdulhakim H. Alqubaishi, Kaled A. Marzogi


Laryngeal nerve injury is considered one of the most common complications after thyroidectomy. It is associated with decreased quality of life because it will result in hoarseness of voice and aspiration. Identification of the risk factors and procedures to decrease the injury is crucial for handling laryngeal nerve injury. We searched the MEDLINE database using PubMed. Two independent reviewers reviewed the resulting papers and reviewed them based on our inclusion criteria. Based on the review results, the incidence of recurrent laryngeal nerve injury is higher than the external branch of the superior laryngeal nerve, but it is mainly due to under-reporting of the external branch of superior laryngeal nerve injury. Cancer surgery, surgeon experience, workload, re-operative procedures, and extent of surgery increased the incidence of the laryngeal nerve injury. Handling of these risk factors combined with visual dissection and inspection and/or intraoperative nerve monitoring decreased the incidence of the nerve injury. In conclusion, laryngeal nerve injury is a common post thyroidectomy complication. Anatomical dissection and visual inspection combined with intraoperative nerve monitoring is the most suitable option in high-risk thyroid surgeries.


Recurrent laryngeal nerve, Thyroidectomy, Superior laryngeal nerve, Intraoperative nerve monitoring

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Brito JP, Morris JC, Montori VM. Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours. BMJ. 2013;347:f4706.

Hu J, Zhao N, Kong R, Wang D, Sun B, Wu L. Total thyroidectomy as primary surgical management for thyroid disease: surgical therapy experience from 5559 thyroidectomies in a less-developed region. World J Surg Oncol. 2016;14(1):20.

Karamanakos SN, Markou KB, Panagopoulos K. Complications and risk factors related to the extent of surgery in thyroidectomy. Results from 2,043 procedures. Hormones (Athens, Greece). 2010;9(4):318-25.

Horne SK, Gal TJ, Brennan JA. Prevalence and patterns of intraoperative nerve monitoring for thyroidectomy. Otolaryngol Head Neck Surg. 2007;136(6):952-6.

Myssiorek D. Recurrent laryngeal nerve paralysis: anatomy and etiology. Otolaryngol Clin North Am. 2004;37(1):25-44.

Morton RP, Whitfield P, Al-Ali S. Anatomical and surgical considerations of the external branch of the superior laryngeal nerve: a systematic review. Clin Otolaryngol.2006;31(5):368-74.

Zakaria HM, Al Awad NA, Al Kreedes AS. Recurrent laryngeal nerve injury in thyroid surgery. Oman Med J. 2011;26(1):34-8.

Aluffi P, Policarpo M, Cherovac C, Olina M, Dosdegani R, Pia F. Post-thyroidectomy superior laryngeal nerve injury. Eur Arch Oto-rhino-Laryngol. 2001;258(9):451-4.

Uludag M, Aygun N, Kartal K. Contribution of intraoperative neural monitoring to preservation of the external branch of the superior laryngeal nerve: a randomized prospective clinical trial. Langenbeck's Arch Surg. 2017;402(6):965-76.

Yarbrough DE, Thompson GB, Kasperbauer JL, Harper CM, Grant CS. Intraoperative electromyographic monitoring of the recurrent laryngeal nerve in reoperative thyroid and parathyroid surgery. Surgery. 2004;136(6):1107-15.

Barczyński M, Konturek A, Stopa M, Honowska A, Nowak W. Randomized controlled trial of visualization versus neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy. World J Surg. 2012;36(6):1340-7.

Lo CY, Kwok KF, Yuen PW. A prospective evaluation of recurrent laryngeal nerve paralysis during thyroidectomy. Arch Surg. 2000;135(2):204-7.

Thomusch O, Sekulla C, Walls G, Machens A, Dralle H. Intraoperative neuromonitoring of surgery for benign goiter. Am J Surg. 2002;183(6):673-8.

Dionigi G, Boni L, Rovera F, Rausei S, Castelnuovo P, Dionigi R. Postoperative laryngoscopy in thyroid surgery: proper timing to detect recurrent laryngeal nerve injury. Langenbecks Arch Surg. 2010;395(4):327-31.

Serpell JW. New operative surgical concept of two fascial layers enveloping the recurrent laryngeal nerve. Ann Surg Oncol. 2010;17(6):1628-36.

Reeve T, Thompson NW. Complications of thyroid surgery: how to avoid them, how to manage them, and observations on their possible effect on the whole patient. World J Surg. 2000;24(8):971-5.

El-Guindy A, Abdel-Aziz M. Superior laryngeal nerve preservation in peri-apical surgery by mobilization of the viscerovertebral angle. J Laryngol Otol. 2000;114(4):268-73.

Hunt CJ. The superior and inferior laryngeal nerve as related to thvroid surgery. Am Surgeon. 1961;27:548-52.

Jatzko GR, Lisborg PH, Müller MG, Wette VM. Recurrent nerve palsy after thyroid operations--principal nerve identification and a literature review. Surgery. 1994;115(2):139-44.

Levin KE, Clark AH, Duh QY, Demeure M, Siperstein AE, Clark OH. Reoperative thyroid surgery. Surgery. 1992;111(6):604-9.

Thomusch O, Machens A, Sekulla C. Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany. World J Surg. 2000;24(11):1335-41.

Dralle H, Sekulla C, Haerting J. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery. 2004;136(6):1310-22.

Godballe C, Madsen AR, Sørensen CH. Risk factors for recurrent nerve palsy after thyroid surgery: a national study of patients treated at Danish departments of ENT Head and Neck Surgery. Eur Arch Otorhinolaryngol. 2014;271(8):2267-76.

Bilimoria KY, Bentrem DJ, Ko CY. Extent of surgery affects survival for papillary thyroid cancer. Ann Surg. 2007;246(3):375-81.

Acun Z, Comert M, Cihan A, Ulukent SC, Ucan B, Cakmak GK. Near-total thyroidectomy could be the best treatment for thyroid disease in endemic regions. Arch Surg. 2004;139(4):444-7.

Bothra S, Sabaretnam M, Kannujia A. Patient, thyroid, and surgeon related factors that make thyroidectomy difficult-cohort study. Ann Med Surg. 2020;49:14-8.

D'Orazi V, Sacconi A, Trombetta S. May predictors of difficulty in thyroid surgery increase the incidence of complications? Prospective study with the proposal of a preoperative score. BMC Surgery. 2019;18(1):1-8.

Godballe C, Madsen AR, Sørensen CH. Risk factors for recurrent nerve palsy after thyroid surgery: a national study of patients treated at Danish departments of ENT Head and Neck Surgery. Eur Arch Oto-rhino-laryngol.2014;271(8):2267-76.

Tsai SH, Chien SC, Nguyen PA. Incidences of hypothyroidism associated with surgical procedures for thyroid disorders: A nationwide population-based study. Front Pharmacol. 2019;10:1-8.

Hermann M, Alk G, Roka R, Glaser K, Freissmuth M. Laryngeal Recurrent Nerve Injury in Surgery for Benign Thyroid Diseases: Effect of Nerve Dissection and Impact of Individual Surgeon in More Than 27,000 Nerves at Risk. Ann Surg. 2002;235:261-8.

Beneragama T, Serpell JW. Extralaryngeal bifurcation of the recurrent laryngeal nerve: a common variation. ANZ J Surg. 2006;76(10):928-31.

Bai B, Chen W. Protective Effects of Intraoperative Nerve Monitoring (IONM) for Recurrent Laryngeal Nerve Injury in Thyroidectomy: Meta-analysis. Scientific Rep. 2018;8(1):1-11.

Chiang F-Y, Lee K-W, Chen H-C. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation. World J Surg. 2010;34(2):223-9.

Hurtado-López L-M, Díaz-Hernández PI, Basurto-Kuba E, Zaldívar-Ramírez FR, Pulido-Cejudo A. Efficacy of Intraoperative Neuro-Monitoring to Localize the External Branch of the Superior Laryngeal Nerve. Thyroid. 2016;26(1):174-8.

Masuoka H, Miyauchi A, Higashiyama T. Prospective randomized study on injury of the external branch of the superior laryngeal nerve during thyroidectomy comparing intraoperative nerve monitoring and a conventional technique. Head Neck. 2015;37(10):1456-60.