Relationship of Recurrent Laryngeal Nerve with Inferior Horn of Thyroid Cartilage, Berry’s Ligament and Zuckerkandl’s Tubercle

Abstract

During neck surgery; Zuckerkandl’s tubercle, Berry’s ligament, the inferior horn of thyroid cartilages have become crucial anatomical landmarks in order to protect the integrity of the recurrent laryngeal nerve. Forty-two male postmortem human cadavers were used. The proximal part of the recurrent laryngeal nerve, before the inferior thyroid artery arises from its source has been observed in 87% inside the tracheoesophageal groove and in 13% running laterally to the trachea. The recurrent laryngeal nerve was encountered passing behind and through the branches of the inferior thyroid artery in 92% and 8% respectively. At all sides; the nerve was piercing the larynx 0.6 ± 0.1 mm below the inferior horn of thyroid cartilage, passing next to the inner-lower side of Berry’s ligament and running under the lower middle part of Zuckerkandl’s tubercle. These landmarks and their upper mentioned distances to the laryngeal nerve can be taken into consideration as important surgical guides.

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

Fig. 1
Fig. 2

Data Availability

Cadavers used in department of anatomy Akdeniz University.

References

  1. 1.

    Bergamaschi R, Becouarn G, Ronceray J, Arnaud JP (1998) Morbidity of thyroid surgery. Am J Surg 176(1):71–75. https://doi.org/10.1016/s0002-9610(98)00099-3

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Benouaich V, Porterie J, Bouali O, Moscovici J, Lopez R (2012) Anatomical basis of the risk of injury to the right laryngeal recurrent nerve during thoracic surgery. Surg Radiol Anat 34(6):509–512. https://doi.org/10.1007/s00276-012-0946-7

    Article  PubMed  Google Scholar 

  3. 3.

    Hisham AN, Aina EN (2000) Zuckerkandl's tubercle of the thyroid gland in association with pressure symptoms: a coincidence or consequence? Aust N Z J Surg 70(4):251–253. https://doi.org/10.1046/j.1440-1622.2000.01800.x

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Arıncı K, Elhan A (2016) Anatomi 1, 6th edn. Güneş Kitabevi, Ankara

    Google Scholar 

  5. 5.

    Ardito G, Revelli L, D'Alatri L, Lerro V, Guidi ML, Ardito F (2004) Revisited anatomy of the recurrent laryngeal nerves. Am J Surg 187(2):249–253. https://doi.org/10.1016/j.amjsurg.2003.11.001

    Article  PubMed  Google Scholar 

  6. 6.

    Lee MS, Lee UY, Lee JH, Han SH (2009) Relative direction and position of recurrent laryngeal nerve for anatomical configuration. Surg Radiol Anat 31(9):649–655. https://doi.org/10.1007/s00276-009-0494-y

    Article  PubMed  Google Scholar 

  7. 7.

    Richer SL, Randolph GW (2009) Management of the recurrent laryngeal nerve in thyroid surgery. Operative Tech Otolaryngol Head Neck Surg 20(1):29–34

    Article  Google Scholar 

  8. 8.

    Sunanda H, Tilakeratne S, Silva K (2010) Surgical anatomy of the recurrent laryngeal nerve; a cross-sectional descriptive study. Galle Med J 15(1):14–16

    Article  Google Scholar 

  9. 9.

    Campos BA, Henriques PR (2000) Relationship between the recurrent laryngeal nerve and the inferior thyroid artery: a study in corpses. Rev Hosp Clin Fac Med Sao Paulo 55(6):195–200

    CAS  Article  Google Scholar 

  10. 10.

    Poyraz M, Calguner E (2001) Bilateral investigation of the anatomical relationships of the external branch of the superior laryngeal nerve and superior thyroid artery, and also the recurrent laryngeal nerve and inferior thyroid artery. Okajimas Folia Anat Jpn 78(2–3):65–74. https://doi.org/10.2535/ofaj1936.78.2-3_65

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Kulekci M, Batioglu-Karaaltin A, Saatci O, Uzun I (2012) Relationship between the branches of the recurrent laryngeal nerve and the inferior thyroid artery. Ann Oto Rhinol Laryn 121(10):650–656. https://doi.org/10.1177/000348941212101005

    Article  Google Scholar 

  12. 12.

    Armstrong WG, Hinton JW (1951) Multiple divisions of the recurrent laryngeal nerve. An anatomic study. AMA Arch Surg 62(4):532–539. https://doi.org/10.1001/archsurg.1951.01250030540011

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Weeks C, Hinton JW (1942) Extralaryngeal division of the recurrent laryngeal nerve: its significance in vocal cord paralysis. Ann Surg 116(2):251–258. https://doi.org/10.1097/00000658-194208000-00009

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Yalcin B, Ozan H (2008) Anatomic configurations of the recurrent laryngeal nerve and inferior thyroid artery. Surg Today 38(5):478. https://doi.org/10.1007/s00595-006-3640-8

    Article  PubMed  Google Scholar 

  15. 15.

    Botelho JB, Vieira D, Monteiro de Carvalho D, Batista MB (2012) Anatomic and surgical study of the recurrent laryngeal nerve and its involvement with the ligament of Berry. Rev Col Bras Cir 39(5):364–367. https://doi.org/10.1590/s0100-69912012000500004

    Article  PubMed  Google Scholar 

  16. 16.

    John A, Etienne D, Klaassen Z, Shoja MM, Tubbs RS, Loukas M (2012) Variations in the locations of the recurrent laryngeal nerve in relation to the ligament of Berry. Am Surg 78(9):947–951

    PubMed  Google Scholar 

  17. 17.

    Kaisha W, Wobenjo A, Saidi H (2011) Topography of the recurrent laryngeal nerve in relation to the thyroid artery, Zuckerkandl tubercle, and Berry ligament in Kenyans. Clin Anat 24(7):853–857. https://doi.org/10.1002/ca.21192

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Sheahan P, Murphy MS (2011) Thyroid tubercle of Zuckerkandl: importance in thyroid surgery. Laryngoscope 121(11):2335–2337. https://doi.org/10.1002/lary.22188

    Article  PubMed  Google Scholar 

  19. 19.

    Mehmood Z, Khan U, Bokhari I, Hussain A, Subhan A, Nazeer M (2015) Zuckerkandl tubercle: an important landmark in thyroid surgery. J Coll Physicians Surg Pak 25(7):495–497

    PubMed  Google Scholar 

  20. 20.

    Musajo FG, Mangiante G, Ischia A, Marchiori L, Benati G, Mainente M, Tenci A, Costa V, Asnicar A, Nicoli N (1989) Zuckerkandl tubercle of the thyroid gland (anatomo-surgical study: preliminary considerations). Chir Ital 41(2–3):129–136

    CAS  PubMed  Google Scholar 

  21. 21.

    Yalcin B, Poyrazoglu Y, Ozan H (2007) Relationship between Zuckerkandl's tubercle and the inferior laryngeal nerve including the laryngeal branches. Surg Today 37(10):919–920. https://doi.org/10.1007/s00595-007-3538-0

    Article  Google Scholar 

  22. 22.

    Irawati N, Vaish R, Chaukar D, Deshmukh A, D'Cruz A (2016) The tubercle of Zuckerkandl: an important landmark revisited. Indian J Surg Oncol 7(3):312–315. https://doi.org/10.1007/s13193-015-0482-0

    Article  PubMed  Google Scholar 

  23. 23.

    Gauger PG, Delbridge LW, Thompson NW, Crummer P, Reeve TS (2001) Incidence and importance of the tubercle of Zuckerkandl in thyroid surgery. Eur J Surg 167(4):249–254. https://doi.org/10.1080/110241501300091363

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Pelizzo MR, Toniato A, Gemo G (1998) Zuckerkandl's tuberculum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark). J Am Coll Surg 187(3):333–336. https://doi.org/10.1016/s1072-7515(98)00160-4

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Butskiy O, Chang BA, Luu K, McKenzie RM, Anderson DW (2018) A systematic approach to the recurrent laryngeal nerve dissection at the cricothyroid junction. J Otolaryngol Head Neck Surg 47(1):57. https://doi.org/10.1186/s40463-018-0306-7

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Cakir BO, Ercan I, Sam B, Turgut S (2006) Reliable surgical landmarks for the identification of the recurrent laryngeal nerve. Otolaryngol Head Neck Surg 135(2):299–302. https://doi.org/10.1016/j.otohns.2006.03.026

    Article  PubMed  Google Scholar 

  27. 27.

    Fatogoma Issa K, Sidiki D, Naouma C, Kassim D, N'Faly K, Djibril S, Neuilly T, Abdoul Wahab H, Boubacary G, Siaka S, Kadidiatou S, Samba Karim T, Mohamed Amadou K (2019) Superior approach of recurrent laryngeal nerve: review of the literature. J Thyroid Res 2019:5671816. https://doi.org/10.1155/2019/5671816

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Snyder SK, Lairmore TC, Hendricks JC, Roberts JW (2008) Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy. J Am Coll Surgeons 206(1):123–130. https://doi.org/10.1016/j.jamcollsurg.2007.07.017

    Article  Google Scholar 

  29. 29.

    Yalçın B, Ozan H (2006) Detailed investigation of the relationship between the inferior laryngeal nerve including laryngeal branches and ligament of Berry. J Am Coll Surgeons 202(2):291–296. https://doi.org/10.1016/j.jamcollsurg.2005.09.025

    Article  Google Scholar 

  30. 30.

    Miyauchi A, Ito Y, Miya A, Higashiyama T, Tomoda C, Takamura Y, Kobayashi K, Matsuzuka F (2007) Lateral mobilization of the recurrent laryngeal nerve to facilitate tracheal surgery in patients with thyroid cancer invading the trachea near Berry's ligament. World J Surg 31(11):2081–2084. https://doi.org/10.1007/s00268-007-9180-6

    Article  PubMed  Google Scholar 

  31. 31.

    Pradeep PV, Jayashree B, Harshita SS (2012) A closer look at laryngeal nerves during thyroid surgery: a descriptive study of 584 nerves. Anat Res Int 2012:490390. https://doi.org/10.1155/2012/490390

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Henry BM, Sanna B, Graves MJ, Sanna S, Vikse J, Tomaszewska IM, Tubbs RS, Tomaszewski KA (2017) The reliability of the tracheoesophageal groove and the ligament of Berry as landmarks for identifying the recurrent laryngeal nerve: a cadaveric study and meta-analysis. Biomed Res Int 2017:4357591. https://doi.org/10.1155/2017/4357591

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Mirilas P, Skandalakis JE (2003) Zuckerkandl's tubercle: Hannibal ad Portas. J Am Coll Surg 196(5):796–801. https://doi.org/10.1016/S1072-7515(02)01831-8

    Article  PubMed  Google Scholar 

  34. 34.

    O'Neill JP, Fenton JE (2008) The recurrent laryngeal nerve in thyroid surgery. Surgeon 6(6):373–377. https://doi.org/10.1016/s1479-666x(08)80011-x

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Gurleyik E, Dogan S, Cetin F (2017) Coexistence of right nonrecurrent nerve and bifurcated recurrent laryngeal nerve pointed by Zuckerkandl's tubercle. Cureus 9(3):e1078. https://doi.org/10.7759/cureus.1078

    Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Sanudo JR, Maranillo E, Leon X, Mirapeix RM, Orus C, Quer M (1999) An anatomical study of anastomoses between the laryngeal nerves. Laryngoscope 109(6):983–987. https://doi.org/10.1097/00005537-199906000-00026

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Costanzo M, Caruso LA, Veroux M, Messina DC, Marziani A, Cannizzaro MA (2005) The lobe of Zuckerkandl: an important sign of recurrent laryngeal nerve. Ann Ital Chir 76(4):337–340 (discussion 340–331)

    PubMed  Google Scholar 

  38. 38.

    Gravante G, Delogu D, Rizzello A, Filingeri V (2007) The Zuckerkandl tubercle. Am J Surg 193(4):484–485. https://doi.org/10.1016/j.amjsurg.2006.06.040

    Article  PubMed  Google Scholar 

  39. 39.

    Gurleyik E, Gurleyik G (2012) Incidence and surgical importance of Zuckerkandl's tubercle of the thyroid and its relations with recurrent laryngeal nerve. ISRN Surg 2012:450589. https://doi.org/10.5402/2012/450589

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Funding

This research received no specific grant from any funding agency in the public, commercial, or nonprofit sectors.

Author information

Affiliations

Authors

Contributions

Özlem Zümre Kaştan and Serra Öztürk were made dissection and making measurements, analysis of data, literature review and revising it critically for important intellectual content Muzaffer Sindel and Engin Çalgüner made drafting the work and substantial contributions to the conception of the work and interpretation of data for the work. Bülent Veli Ağırdır made dissection.

Corresponding author

Correspondence to Serra Ozturk.

Ethics declarations

Conflict of interest

The authors have no conflicts of interest to declare.

Ethical Approval

The study was approved by the Clinical Research Ethics Committee of Akdeniz University, Faculty of Medicine (Date: 03.09.2014 & No: 347).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kastan, O.Z., Ozturk, S., Calguner, E. et al. Relationship of Recurrent Laryngeal Nerve with Inferior Horn of Thyroid Cartilage, Berry’s Ligament and Zuckerkandl’s Tubercle. Indian J Otolaryngol Head Neck Surg (2020). https://doi.org/10.1007/s12070-020-02018-1

Download citation

Keywords

  • Recurrent laryngeal nerve
  • Inferior laryngeal nerve
  • Thyroid cartilage
  • Berry’s ligament
  • Zuckerkandl’s tubercle