[The role of radical surgical approach in the treatment of benign multinodular goitre depending on anatomical variations of the recurrent laryngeal nerve].
From time to time there is a surprise at the end of surgery - even after subtotal resection - when a vocal cord is observed on indirect laryngoscopy to be non-functional. Surgeons are highly individualistic and develop their own special ways of locating and protecting the nerve. The present study has tried to clarify whether relying on palpation alone during surgery is safe enough in each case.


METHODS
Between 01.01.2001 and 31.12.2008, 1228 recurrent laryngeal nerve (RLN) were exposed in 702 patients on thyroid surgery. The RLN was found and traced until the laryngeal entry point in all patients. Substernal spreading was noted in 38.6% (271/702), while tracheal compression or dislocation was present in 19.5% (137/702). Recurrent thyroid disease counted for 8.4% (59/702) of all cases. Total thyroid lobectomy was carried out in 82.2% (1009/1228), near-total thyroidectomy in 15.5% (191/1228), and subtotal resection only in 2.3% (28/1228).


RESULTS
Palpation was helpful in 80.7% (991/1228), proved false positive in 8.7% (107/1228), while in 10.6% (130/1228) it did not provide any help in the localization. The palpability of the RLN showed marked discrepancy between the two sides. False positivity was noted with palpation in 3.4% (21/625) and 14.3% (86/603) on the right and left side, respectively. On the other hand, palpation helped localization in 4.8% (29/603) on the left side, while the same figure was 16.2% (101/603) on the right side. Definitive RLN palsy was experienced in 0.8% of all cases (10/1228), whilst transient paresis was encountered in 1.4% (17/1228). Occult malignancy was noticed in 5.6% (39/702).


CONCLUSIONS
No indication has been left for subtotal resection. Even if benign multinodular goitre is present, since the clinical and pathophysiological evidences suggest that multinodular goitre affects the entire gland, any surgery that leaves potentially abnormal thyroid tissue in situ carries a risk of recurrent disease. RLN palpatory method is a useful part of thyroid surgery but it is suitable for rough orientation only.
Fejér Megyei Szent György Kórház Sebészeti Osztály Székesfehérvár Seregélyesi út 3. 8000, Hungary. altorjay@mail.fmkorhaz.hu
Aron
A
Altorjay
Mihály
M
Mucs
Balázs
B
Hamvas
Gábor
G
Füredi
Balázs
B
Botos
Róbert
R
Jaskó
Zsuzsanna
Z
Bencsik
Miklós
M
Rüll
Anna
A
Szilágyi
Géza
G
Csáti
D000328:Adult; D000368:Aged; D005260:Female; D006044:Goiter, Nodular / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010173:Palpation; D061226:Recurrent Laryngeal Nerve Injuries; D012189:Retrospective Studies; D013959:Thyroid Diseases / Q000601:surgery; D013965:Thyroidectomy / Q000009:adverse effects* / Q000379:methods*; D014826:Vocal Cord Paralysis / Q000209:etiology* / Q000517:prevention & control*