Skip to main content

Advertisement

SpringerLink
Log in

The weepy nerve—different sensitivity of left and right recurrent laryngeal nerves under tensile stress in a porcine model

  • ORIGINAL ARTICLE
  • Published:
Langenbeck's Archives of Surgery Aims and scope Submit manuscript

Abstract

Purpose

Recurrent laryngeal nerve palsy in thyroid surgery is still a threatening complication. Our aim was to analyze the impact of prolonged tensile stress on the recurrent laryngeal nerve (RLN) in an animal model using continuous intraoperative neuromonitoring (C-IONM).

Methods

Constant tensile stress was applied to left and right RLNs in 20 pigs (40 RLN). In a pilot study, five animals were subjected to a tensile force of 0.34 ± 0.07 N for 10 min and changes in amplitude were documented using C-IONM. In the main study, a force of 1.2 N was applied until the signal amplitude was reduced by 85 %, in 15 pigs. Nerve conductivity was analyzed by threshold current measurements.

Results

Good correlation was found between stress and amplitude decrease in the pilot study as well as between signal decrease and duration of trauma in the main study. Great variations were found inter- and intra-individually. These variations were most prominent at 85 % signal reduction (median 36 min, range 0.3–171 min). There was no side specificity (left 0.3–171 min, right 0.3–168 min, respectively, p = 0.19). However, in each individual animal, there was a sensitive (0.3–98.9 min) and less sensitive nerve (26.8–171 min). These differences became highly significant at 85 % of signal reduction (p = 0.008), where the vulnerability is 1.4 to 146.4 times higher on one side (mean 4.3).

Conclusions

Our study demonstrates the presence of a sensitive RLN that was 4.3 times more vulnerable than the contralateral nerve (range 1.4–146.4 times, p = 0.008). Thus, the right and the left nerves cannot be assumed to be of equal sensitivity to trauma. In our data, the more sensitive nerve does not occur predominantly on one side and was named the “weepy nerve.”

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10

Similar content being viewed by others

References

  1. Serpell JW, Lee JC, Yeung MJ, Grodski S, Johnson W, Bailey M (2014) Differential recurrent laryngeal nerve palsy rates after thyroidectomy. Surgery 156:1157–66. doi:10.1016/j.surg.2014.07.018

    Article  PubMed  Google Scholar 

  2. Bures C, Bobak-Wieser R, Koppitsch C, Klatte T, Zielinski V, Freissmuth M et al (2014) Late-onset palsy of the recurrent laryngeal nerve after thyroid surgery. Br J Surg 101:1556–59. doi:10.1002/bjs.9648

    Article  CAS  PubMed  Google Scholar 

  3. Smith J, Douglas J, Smith B, Dougherty T, Ayshford C (2014) Assessment of recurrent laryngeal nerve function during thyroid surgery. Ann R Coll Surg Engl 96:130–35. doi:10.1308/003588414X13814021676594

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Hardman JC, Smith JA, Nankivell P, Sharma N, Watkinson JC (2015) Re-operative thyroid surgery: a 20-year prospective cohort study at a tertiary referral centre. Eur Arch Otorhinolaryngol 272:1503–08. doi:10.1007/s00405-014-3068-5

    Article  PubMed  Google Scholar 

  5. Roh J, Kim J, Park CI (2011) Central compartment reoperation for recurrent/persistent differentiated thyroid cancer: patterns of recurrence, morbidity, and prediction of postoperative hypocalcemia. Ann Surg Oncol 18:1312–18. doi:10.1245/s10434-010-1470-9

    Article  PubMed  Google Scholar 

  6. Karamanakos SN, Markou KB, Panagopoulos K, Karavias D, Vagianos CE, Scopa CD et al (2010) Complications and risk factors related to the extent of surgery in thyroidectomy. Results from 2,043 procedures. Hormones (Athens) 9:318–25

    Article  Google Scholar 

  7. Patow CA, Norton JA, Brennan MF (1986) Vocal cord paralysis and reoperative parathyroidectomy. A prospective study. Ann Surg 203(3):282–5

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  9. Zambudio AR, Rodríguez J, Riquelme J, Soria T, Canteras M, Parrilla P (2004) Prospective study of postoperative complications after total thyroidectomy for multinodular goiters by surgeons with experience in endocrine surgery. Ann Surg 240:18–25

    Article  PubMed  PubMed Central  Google Scholar 

  10. Rosato L, Carlevato MT, de Toma G, Avenia N (2005) Recurrent laryngeal nerve damage and phonetic modifications after total thyroidectomy: surgical malpractice only or predictable sequence? World J Surg 29:780–84. doi:10.1007/s00268-005-7653-z

    Article  PubMed  Google Scholar 

  11. Serpell JW, Lee JC, Chiu WK, Edwards G. Stressing the recurrent laryngeal nerve during thyroidectomy. ANZ J Surg. 2015 DOI: 10.1111/ans.13054.

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

    Article  PubMed  Google Scholar 

  13. Hayward NJ, Grodski S, Yeung M, Johnson WR, Serpell J (2013) Recurrent laryngeal nerve injury in thyroid surgery: a review. ANZ J Surg 83(1-2):15–21

    Article  PubMed  Google Scholar 

  14. Menorca RMG, Fussell TS, Elfar JC (2013) Nerve physiology: mechanisms of injury and recovery. Hand Clin 29:317–30. doi:10.1016/j.hcl.2013.04.002

    Article  PubMed  PubMed Central  Google Scholar 

  15. Lamadé W, Meyding-Lamadé U, Hund E, Senninger N, Herfarth C (1997) Transtracheales Monitoring des Nervus laryngeus recurrens. Der Prototyp eines neuen Tubus. Chirurg 68:193–95

    Article  PubMed  Google Scholar 

  16. Lamadé W, Brandner R, Brauer M, Hund E, Klar E, Herfarth C (1998) Continuous monitoring of the recurrent laryngeal nerve. Langenbecks Arch Chir Suppl Kongressbd 115:1055–7

    PubMed  Google Scholar 

  17. Lamadé W, Meyding-Lamadé U, Buchhold C, Brauer M, Brandner R, Uttenweiler V et al (2000) Erstes kontinuierliches Nerven-Monitoring in der Schilddrüsenchirurgie. Chirurg 71:551–57

    Article  PubMed  Google Scholar 

  18. Lamadé W, Ulmer C, Seimer A, Molnar V, Meyding-Lamadé U, Thon K et al (2007) A new system for continuous recurrent laryngeal nerve monitoring. Minim Invasive Ther Allied Technol 16:149–54. doi:10.1080/13645700701383241

    Article  PubMed  Google Scholar 

  19. Lamadé W, Ulmer C, Friedrich C, Rieber F, Schymik K, Gemkow HM et al (2011) Signalstabilität als Grundvoraussetzung für kontinuierliches intraoperatives Neuromonitoring. Chirurg 82:913–20. doi:10.1007/s00104-011-2080-1

    Article  PubMed  Google Scholar 

  20. Friedrich C, Ulmer C, Rieber F, Kern E, Kohler A, Schymik K, Thon KP, Lamadé W (2012) Safety analysis of vagal nerve stimulation for continuous nerve monitoring during thyroid surgery. Laryngoscope 122(9):1979–87

    Article  PubMed  Google Scholar 

  21. Dionigi G, Donatini G, Boni L, Rausei S, Rovera F, Tanda ML et al (2013) Continuous monitoring of the recurrent laryngeal nerve in thyroid surgery: a critical appraisal. Int J Surg 11(Suppl 1):S44–6. doi:10.1016/S1743-9191(13)60014-X

    Article  PubMed  Google Scholar 

  22. Schneider R, Randolph GW, Sekulla C, Phelan E, Thanh PN, Bucher M et al (2013) Continuous intraoperative vagus nerve stimulation for identification of imminent recurrent laryngeal nerve injury. Head Neck 35:1591–98. doi:10.1002/hed.23187

    Article  PubMed  Google Scholar 

  23. Schneider R, Sekulla C, Machens A, Lorenz K, Nguyen Thanh P, Dralle H (2015) Postoperative vocal fold palsy in patients undergoing thyroid surgery with continuous or intermittent nerve monitoring. Br J Surg 102:1380–87. doi:10.1002/bjs.9889

    Article  CAS  PubMed  Google Scholar 

  24. Randolph GW, Kamani D (2014) Intraoperative neural monitoring in thyroid cancer surgery. Langenbecks Arch Surg 399:199–207. doi:10.1007/s00423-013-1141-y

    Article  PubMed  Google Scholar 

  25. Wu C, Dionigi G, Sun H, Liu X, Kim HY, Hsiao P et al (2014) Intraoperative neuromonitoring for the early detection and prevention of RLN traction injury in thyroid surgery: a porcine model. Surgery 155:329–39. doi:10.1016/j.surg.2013.08.015

    Article  PubMed  Google Scholar 

  26. Puram SV, Chow H, Wu C, Heaton JT, Kamani D, Gorti G, et al. Vocal cord paralysis predicted by neural monitoring electrophysiologic changes with recurrent laryngeal nerve compressive neuropraxic injury in a canine model. Head Neck. 2015 DOI: 10.1002/hed.24225.

Download references

Authors’ contributions

Wolfram Lamadé Prof. Dr. med.

Maren Béchu M.Sc.

Ester Lauzana Dr. med.

Peter Köhler Dr. rer. Nat.

Sabine Klein Dr. agr. Ing.

Tuncay Tuncer

Noor Isra Heryantee Rashid M.D.

Erich Kahle

Bertram Erdmann

Uta Meyding-Lamadé Prof. Dr. med.

Study concept and design

Wolfram Lamadé Prof. Dr. med.

Maren Béchu M.Sc.

Ester Lauzana Dr. med.

Peter Köhler Dr. rer. Nat.

Noor Isra Heryantee Rashid M.D.

Uta Meyding-Lamadé Prof. Dr. med.

Acquisition of data

Maren Béchu M.Sc.

Ester Lauzana Dr. med.

Peter Köhler Dr. rer. Nat.

Tuncay Tuncer

Sabine Klein Dr. agr. Ing.

Erich Kahle

Analysis and interpretation of data

Maren Béchu M.Sc.

Wolfram Lamadé Prof. Dr. med.

Tuncay Tuncer

Sabine Klein Dr. agr. Ing.

Bertram Erdmann

Drafting of manuscripts

Wolfram Lamadé Prof. Dr. med.

Maren Béchu M.Sc.

Sabine Klein Dr. agr. Ing.

Critical revision of manuscript

Wolfram Lamadé Prof. Dr. med.

Maren Béchu M.Sc.

Uta Meyding-Lamadé Prof. Dr. med.

Author information

Authors and Affiliations

  1. Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany

    Wolfram Lamadé, Maren Béchu, Ester Lauzana, Tuncay Tuncer & Noor Isra Heryantee Rashid

  2. Friedrich-Loeffler-Institut, Bundesforschungsinstitut für Tiergesundheit, Neustadt, Germany

    Peter Köhler, Sabine Klein & Erich Kahle

  3. Klinik für Neurologie, Krankenhaus Nordwest, Frankfurt am Main, Germany

    Maren Béchu & Uta Meyding-Lamadé

  4. Airbus Defence and Space, Immenstaad, Germany

    Bertram Erdmann

Authors
  1. Wolfram Lamadé
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Maren Béchu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ester Lauzana
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Peter Köhler
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sabine Klein
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Tuncay Tuncer
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Noor Isra Heryantee Rashid
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Erich Kahle
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Bertram Erdmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Uta Meyding-Lamadé
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Wolfram Lamadé.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Sources of financial support

HELIOS Kliniken GmbH grant-ID: 005837

Additional information

Wolfram Lamadé and Maren Béchu as joint First Authors

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lamadé, W., Béchu, M., Lauzana, E. et al. The weepy nerve—different sensitivity of left and right recurrent laryngeal nerves under tensile stress in a porcine model. Langenbecks Arch Surg 401, 983–990 (2016). https://doi.org/10.1007/s00423-016-1439-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00423-016-1439-7

Keywords

Search

Navigation