Anatomy
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Head and Neck
A 50 year old female patient presents to ED complaining of voice hoarseness. She underwent a thyroidectomy 2 weeks ago. What is the most likely cause of her symptoms:
Answer:
Damage to the recurrent laryngeal nerves may result in hoarseness, respiratory obstruction, inability to speak and loss of sensation below the vocal cord. Causes of damage include:- thyroid/parathyroid surgery
- mediastinal lymphadenopathy
- cricothyroidotomy
- aneurysm of the aortic arch
- lung cancer in the apex of the right lung
- malignancy infiltrating into the 'aortopulmonary window'
Recurrent Laryngeal Nerve
Anatomy / Head and Neck / Neck
Last Updated: 11th April 2019
Right Recurrent Laryngeal Nerve
The right recurrent laryngeal nerve originates in the root of the neck, as a branch of the right vagus nerve as it reaches the lower edge of the first part of the subclavian artery. It passes around the subclavian artery and travels upwards and medially in a groove between the trachea and the oesophagus as it heads to the larynx.
Right Recurrent Laryngeal Nerve. (Image by Henry Vandyke Carter [Public domain])
Left Recurrent Laryngeal Nerve
The left recurrent laryngeal nerve originates more inferiorly, from the left vagus nerve as it crosses the arch of the aorta in the superior mediastinum. It passes below and behind the arch of the aorta and then ascends beside the trachea to the larynx.
Left Recurrent Laryngeal Nerve. (Image by Jkwchui (Based on drawing by Truth-seeker2004) [CC BY-SA 3.0 , via Wikimedia Commons)
Clinical Implications
Damage to the recurrent laryngeal nerves may result in hoarseness, respiratory obstruction, inability to speak and loss of sensation below the vocal cord.
Causes of damage include:
- thyroid/parathyroid surgery
- mediastinal lymphadenopathy
- cricothyroidotomy
- aneurysm of the aortic arch
- lung cancer in the apex of the right lung
- malignancy infiltrating into the 'aortopulmonary window'
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
