Recurrent Laryngeal Nerve Palsy Management and Features

Clinical Presentation

The American Academy of Otolaryngology-Head and Neck Surgery notes that hoarseness is the most common symptom of unilateral RLN palsy, occurring in 1.2%-5.0% of cases following procedures like thyroid surgery 2
Bilateral RLN palsy presents with stridor and acute airway obstruction requiring immediate intervention, and is associated with a definitive biological damage rate of 25% according to Italian health parameters 1
Aspiration of food and liquids into the trachea due to impaired airway protection during swallowing is a potential complication of unilateral RLN palsy 3
The American Academy of Otolaryngology-Head and Neck Surgery reports that bilateral RLN palsy is a medical emergency due to potential complete airway obstruction 3

The American Academy of Otolaryngology-Head and Neck Surgery states that thyroid surgery is a common cause of RLN paralysis, occurring in up to 2.1% of thyroidectomy patients 4
Anterior cervical spine surgery may result in hoarseness in up to 50% of patients immediately following surgery 4
Carotid endarterectomy is associated with RLN damage in up to 6% of patients 4
Cardiac surgery may result in hoarseness in 17% to 31% of patients, with RLN injury in about 1.4% 4

The International Journal of Surgery notes that the RLN is a mixed nerve with sensory and motor fibers, originating from the thoracic portion of the vagus nerve 1
The right RLN lies in a more superficial plane along the lateral esophageal edge and is traditionally considered at higher risk of injury 1
The left RLN surrounds the aortic arch and is located more deeply in the tracheoesophageal groove 1
The American Academy of Otolaryngology-Head and Neck Surgery reports that the RLN innervates all intrinsic laryngeal muscles except the cricothyroid muscle 6

The International Journal of Surgery states that transection, clamping, stretching, electrocoagulation, ligature entrapment, or ischemia are the main causes of RLN injury 1
The American Academy of Otolaryngology-Head and Neck Surgery notes that the left recurrent laryngeal nerve is damaged more commonly than the right during cardiac surgery as it extends into the chest and loops under the arch of the aorta 4

The American Academy of Otolaryngology-Head and Neck Surgery recommends that laryngoscopy is essential for diagnosis and should be performed in patients with persistent voice changes 6
Routine laryngeal exam after surgery can detect vocal fold paralysis in twice as many patients as laryngoscopy performed only in patients with persistent and severe voice changes 6

The American Academy of Otolaryngology-Head and Neck Surgery notes that most unilateral RLN injuries show compensation from the opposite vocal cord over time 3
Administering steroids to reduce swelling and inflammation and providing neurotrophic drugs can be considered for transient voice alterations 2
Recovery from RLN injury usually occurs within 1-3 months 2

The International Journal of Surgery recommends that capsular dissection, visual identification, and intraoperative nerve monitoring can reduce the definitive RLN injury rate to 0.3-3% and transient forms to 6-8% 1

The International Journal of Surgery states that permanent vocal cord paralysis is exceedingly rare, with rates ranging from 0.04% to 0.17% 2