Non-Recurrent Laryngeal Nerve in Thyroid Surgery: Contemporary Strategies for Prediction, Identification, and Preservation
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The non-recurrent laryngeal nerve (NRLN) is a rare but high-risk anatomical variant that is strongly associated with an aberrant right subclavian artery (arteria lusoria) and a significantly increased risk of nerve injury during thyroid surgery. A recent systematic review and meta-analysis reported a pooled NRLN injury risk of about 7% and a risk ratio of approximately 3.8 compared with a normal recurrent laryngeal nerve. Preoperative detection of arteria lusoria by computed tomography or ultrasonography with assessment of the “Y-sign,” combined with intraoperative nerve mapping using the distal-negative/proximal-positive vagal stimulation algorithm, enables early and reliable NRLN identification. Continuous intraoperative nerve monitoring provides real-time protection against traction-related injury, particularly in anatomically constrained settings. This review synthesizes current evidence and describes a transoral robotic thyroidectomy-specific approach incorporating carotid sheath exposure, long-probe A–B stimulation, and ink marking of the NRLN branching point, aiming to make NRLN injury a largely preventable complication in modern thyroid surgery.
Abstract
The non-recurrent laryngeal nerve (NRLN) is a rare but high-risk anatomical variant that is strongly associated with an aberrant right subclavian artery (arteria lusoria) and a significantly increased risk of nerve injury during thyroid surgery. A recent systematic review and meta-analysis reported a pooled NRLN injury risk of about 7% and a risk ratio of approximately 3.8 compared with a normal recurrent laryngeal nerve. Preoperative detection of arteria lusoria by computed tomography or ultrasonography with assessment of the “Y-sign,” combined with intraoperative nerve mapping using the distal-negative/proximal-positive vagal stimulation algorithm, enables early and reliable NRLN identification. Continuous intraoperative nerve monitoring provides real-time protection against traction-related injury, particularly in anatomically constrained settings. This review synthesizes current evidence and describes a transoral robotic thyroidectomy-specific approach incorporating carotid sheath exposure, long-probe A–B stimulation, and ink marking of the NRLN branching point, aiming to make NRLN injury a largely preventable complication in modern thyroid surgery.