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Variant anatomy of non-recurrent laryngeal nerve: when and how should it be taught in surgical residency?

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Abstract

Introduction

While the performance of a thyroidectomy is generally associated with a low risk of injury to the recurrent laryngeal nerve (RLN), the presence of a non-recurrent nerve (NRLN) increases the risk of this complication. Generally, the intraoperative detection via visual appreciation of variant anatomy of the RLN has been regarded as poor, possibly due to a lack of knowledge of both the normal and aberrant anatomy of the RLN.

Materials and methods

Articles for the review were searched through PubMed using the search terms and their combinations: “non-recurrent laryngeal nerve,” “thyroidectomy,” “injury,” “palsy,” “variant anatomy,” and “residency,” from January 1, 2000, to December 2022. Papers considered for the review were the articles published in English, with additional classic and articles of surgical importance retrieved from the reference list of papers. Only papers relevant to the scope of the review were considered for this review.

Findings

The NRLN has been found to be associated with concurrent vascular abnormalities, such as the presence of an aberrant right subclavian artery (ARSA) or an arteria lusoria originating from the aortic arch. However, it seems that both the normal as well as aberrant anatomy of the RLN is currently not emphasized enough during postgraduate surgical training. With the increased use of intraoperative neuromonitoring (IONM), detection of NRLN has become possible through appropriate neural mapping during thyroid surgery, besides other pointers such as visualization during surgery, computerised tomography, and duplex ultrasound scans to visualize the variant vascular anatomy. There is also a possible role for cadaveric courses, either during medical school or in a post-graduate setting—adapted to the student’s level to teach the variant anatomy. With the development of newer techniques such as artificial intelligence, there are potential new options for teaching and training anatomy in the near future.

Conclusions and relevance

Adequate knowledge of the normal and aberrant anatomy of the RLN remains essential for the best outcomes in thyroid surgery, even in the era of the IONM. Moving forward, the knowledge of (aberrant) anatomy should be made an integral part of the core competencies of both medical students and surgical trainees. It is imperative that leaders of the different field work closely together to combine their knowledge towards providing their trainees with the best possible training options.

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Authors and Affiliations

  1. Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Victoria Zheng

  2. University of Buckingham Medical School, Buckingham, UK

    Reshma Rajeev

  3. Division of Endocrine Surgery, National University Hospital, Lower Kent Ridge Road, Buckingham, Singapore

    Diluka Pinto & Rajeev Parameswaran

  4. Division of Endocrine Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK

    Mechteld Christine de Jong

  5. Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Dinesh Kumar Sreenivasan

  6. Department of Surgery, Yong Loo Lin School of Medicine, Medical Drive, Singapore, Singapore

    Rajeev Parameswaran

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  1. Victoria Zheng
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  2. Reshma Rajeev
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  3. Diluka Pinto
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  4. Mechteld Christine de Jong
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Contributions

Rajeev Parameswaran: Conceptualization, review and revision of the manuscript. Victoria Meijia Zheng, Reshma Rajeev, and Dinesh Kunar Sreenivasan—literature review of variant anatomy and draft of the manuscript. Mechteld Christine de Jong and Diluk Pinto—review of teaching and assessment of variant anatomy, evaluation of pointers to help detect NRLN, and draft of manuscript.

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Correspondence to Rajeev Parameswaran.

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Zheng, V., Rajeev, R., Pinto, D. et al. Variant anatomy of non-recurrent laryngeal nerve: when and how should it be taught in surgical residency?. Langenbecks Arch Surg 408, 185 (2023). https://doi.org/10.1007/s00423-023-02928-y

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