The Incidence of Recurrent Laryngeal Nerve Damage Following an Anterior Cervical Spine Operation By: Brian Purcell, BSN, SRNA UPMC Hamot Medical Center School of Anesthesia/Gannon University
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By: Brian Purcell, BSN, SRNA UPMC Hamot Medical Center School of Anesthesia/Gannon University.
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Slide 1
By: Brian Purcell, BSN, SRNA UPMC Hamot Medical Center School
of Anesthesia/Gannon University
Slide 2
Slide 3
Branch of the Vagus Nerve, Crainial Nerve X. Left recurrent
laryngeal nerve passes at aortic arch. Provides sensory innervation
to infraglottis (Trachea below the vocal cords) Provides motor
innervation to all of the larynx except the cricothyroid
muscle
Slide 4
Innervates all of the 1 st set of Intrinsic Larynx Muscles.
These muscles alter the size and shape of the larynx.
Aryepiglottic- Pulls epiglottis down over larynx Thyroepiglottic-
Assists pulling epiglottis down Oblique arytenoid- Pulls arytenoids
together
Slide 5
Innervates all of the 2 nd set of intrinsic laryngeal muscles
except the cricothyroid (External Superior Laryngeal Nerve) These
muscles move the true vocal folds Thyroarytenoid- relaxes vocal
cords Lateral Cricoarytenoid- adducts vocal cords Posterior
Cricoarytenoid- abducts vocal cords Traverse Arytenoid- adducts
vocal cords Vocalis- weak abduction of vocal cords
Slide 6
Stimulation of Recurrent Laryngeal Nerve causes abduction,
opening of the vocal cords.
Slide 7
Damage to Recurrent Laryngeal Nerve causes vocal cord
adduction, closing.
Slide 8
Partial damage to Recurrent Laryngeal nerve on one side will
cause the cord on the same side to shut, resulting in a
deterioration of voice quality Unilateral damage usually does not
compromise airway function, but airway protection against
aspiration may be compromised.
Slide 9
Bilateral damage to Recurrent Laryngeal Nerve will cause both
vocal cords to shut. This results in stridor and respiratory
distress. If the recurrent laryngeal nerve is completely severed,
the vocal cords will partially close and will not move.
General Surgery Esophagostomy/Esophagectomy Esophageal
Diverticulectomy
Slide 16
Neurosurgery Anterior Cervical Fusion Involves anterior neck
dissection and retraction of the soft tissue that gives exposure to
the anterior vertebral column.
Slide 17
Retraction Injury For this surgery, Jaffe and Samuels report a
5% incidence. The exact cause recurrent laryngeal nerve injury is
not known, but it is hypothesized that compression of the recurrent
laryngeal nerve within the endolarynx leads to injury(Apfelbaum,
Kriskovich & Haller, 2000)
Slide 18
What can be done to decrease or prevent the incidence?
Manipulate ETT cuff after retractor placement Use the least amount
of air possible in the ETT cuff to maintain a seal Side of surgical
approach Replace Retractors Monitor Recurrent laryngeal nerve
during surgery
Slide 19
Apfelbaum, Kriskovich & Haller in 2000 studied the
relationship between deflating cuff after retractor placement and
re-inflating after 5 seconds. Allows ET tube to re-center within
the larynx The rate of temporary paralysis decreased from 6.4% to
1.69% using the described maneuver
Slide 20
Audu, et al. in 2006 did not find statistical significance in
their study as to the use of the above described method. Some
surgeons use the method some do not
Slide 21
Audu, et al describe this method as the just seal method. the
ETT was insufflated using the just seal method as follows: With the
ETT cuff deflated, positive pressure (2025 cm H2O) was generated in
the breathing circuit while listening for an air leak around the
ETT. The cuff was then insufflated with air until the leak was
obliterated.
Slide 22
Audu et al in 2006 did not find statistical significance in
decreasing incidence of vocal cord paralysis associated with
recurrent laryngeal nerve damage Jung and Schramm published in 2010
did find significance in in decreased incidence of paralysis with
lower ETT cuff pressures
Slide 23
Jung and Schramm (2010) report that in conjunction with
maintaining low ETT cuff pressures, the left side approach reduced
the incidence of vocal cord paralysis
Slide 24
Rackesh et al. (2010) conducted a study that found cuff
pressure in general may be the cause of vocal cord paralysis.
Conclusions were to create a just seal and possibly institute
intermittent release of the retractors which would keep the cuff
pressures at an acceptable level
Slide 25
Tisdall, M., Henn, C., & Dorward, N. (2010) study on 19
patients using vagal/recurrent laryngeal nerve stimulation to
monitor the integrity of the recurrent laryngeal nerve. With small
sample size, researchers concluded that intraoperative monitoring
may potentially reduce the incidence of recurrent laryngeal nerve
palsy.
Slide 26
Slide 27
Stimulation monitoring similar to that used in Thyroid surgery,
where such monitoring is manditory Monitoring identifies the
recurrent laryngeal nerve, and can identify areas of concern which
can be avoided to reduce recurrent laryngeal nerve injury Tisdall,
M., Henn, C., & Dorward, N. (2010)
Slide 28
Recurrent Laryngeal Nerve is Branch of Cranial Nerve X (Vagus
Nerve) Left recurrent laryngeal nerve passes at the aortic arch
Provides sensory innervation to infraglottis (Trachea below the
vocal cords) Provides motor innervation to all of the larynx except
the cricothyroid muscle
Slide 29
Stimulation of Recurrent Laryngeal Nerve causes abduction,
opening of the vocal cords. Damage to Recurrent Laryngeal Nerve
causes vocal cord adduction, closing. Unilateral damage causes
vocal cord on same side as the damage to close. This can result in
hoarseness and the inability to protect against aspiration.
Slide 30
Bilateral damage will cause both cords to close and will result
in respiratory distress Damage to recurrent laryngeal nerve during
anterior cervical surgery is thought to be caused by compression of
the caused by retractor placement. Recurrent laryngeal nerve damage
is the most common ENT complication associated with anterior
cervical procedures.
Slide 31
Methods of preventing recurrent laryngeal nerve injury:
Manipulate the endotracheal tube cuff after retractor placement.
Create a just seal with ETT cuff Possibly perform surgery from left
side. Stimulation monitoring of recurrent laryngeal nerve
Slide 32
Still no concrete standard of care in preventing recurrent
laryngeal nerve damage. More study and research needs to be
completed to create a concrete standard of care.
Slide 33
Apfelbaum, R., Kriskovich, M., & Haller, J. (2000). On the
incidence, cause, and prevention of recurrent laryngeal nerve
palsies during anterior cervical spine surgery. Spine, 25(22),
2906-2912. Audu, P., Artz, G., Scheid, S., Harrop, J., Albert, T.,
Vaccaro, A., &... Rosen, M. (2006). Recurrent laryngeal nerve
palsy after anterior cervical spine surgery: the impact of
endotracheal tube cuff deflation, reinflation, and pressure
adjustment. Anesthesiology, 105(5), 898-901.
Slide 34
Jaffe, R., & Samuels, S. (2009). Anesthesiologist's manual
of surgical procedures. (4th ed.). Philadelphia: Lippincott,
Williams & Wilkins, a Wolters Kluwer business. Jung, A., &
Schramm, J. (2010). How to Reduce Recurrent Laryngeal Nerve Palsy
in Anterior Cervical Spine Surgery: A Prospective Observational
Study. Neurosurgery (67)1, 10-15
Slide 35
Rakesh, G., Girija,R., Parmod, B., Hemansh, P., Manish, M.
(2010). Clinical Investigation Effects of Retractor Application on
Cuff Pressure and Vocal Cord Function in Patients Undergoing
Anterior Cervical Discectomy and Fusion. Indian Journal of
Anaesthesia (54)4, 292-295. DOI: 10.4103/0019- 5049.68370 Tisdall,
M., Henn, C., & Dorward, N. (2010). Intra-operative Recurrent
Laryngeal Nerve Stimulation During Anterior Cervical Discectomy: A
Simple and Effective Technique. British Journal of Neurosurgery
(24)1, 77-79. DOI: 10.3109/02688690903398459