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The Role of Immediate Recurrent Laryngeal Nerve Reconstruction for Thyroid Cancer Surgery

The Role of Immediate Recurrent Laryngeal Nerve Reconstruction for Thyroid Cancer Surgery Hindawi Publishing Corporation Journal of Oncology Volume 2010, Article ID 846235, 7 pages doi:10.1155/2010/846235 Research Article The Role of Immediate Recurrent Laryngeal Nerve Reconstruction for Thyroid Cancer Surgery Tetsuji Sanuki, Eiji Yumoto, Ryosei Minoda, and Narihiro Kodama Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kumamoto University, 1-1-1 Honjo, Kumamoto 860-8556, Japan Correspondence should be addressed to Tetsuji Sanuki, otostl0319@fc.kuh.kumamoto-u.ac.jp Received 15 August 2009; Revised 16 March 2010; Accepted 4 May 2010 Academic Editor: Steven K. Libutti Copyright © 2010 Tetsuji Sanuki et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Unilateral vocal fold paralysis (UVFP) is one of the most serious problems in conducting surgery for thyroid cancer. Different treatments are available for the management of UVFP including intracordal injection, type I thyroplasty, arytenoid adduction, and laryngeal reinnervations. The effects of immediate recurrent laryngeal nerve (RLN) reconstruction during thyroid cancer surgery with or without UVFP before the surgery were evaluated with videostroboscopic, aerodynamic, and perceptual analyses. All subjects experienced postoperative improvements in voice quality. Particularly, aerodynamic analysis showed that the values for all patients entered normal ranges in both patients with and without UVFP before surgery. Immediate RLN reconstruction has the potential to restore a normal or near-normal voice by returning thyroarytenoid muscle tone and bulk seen with vocal fold denervation. Immediate RLN reconstruction is an efficient and effective approach to the management of RLN resection during surgery for thyroid cancer. 1. Introduction We report on cases involving the immediate recon- struction of the RLN during thyroid cancer surgery in Unilateral vocal fold paralysis (UVFP) is one of the most patients with or without UVFP preoperatively and voice serious problems in the management of thyroid cancer. The outcomes following the procedure with videostroboscopic, vocal folds may be paralyzed at the time of presentation, aerodynamic, and perceptual analyses. or the recurrent laryngeal nerve (RLN) may need to be sacrificed even when the RLN is functioning preoperatively. UVFP causes breathy voice, shortening of phonation, and 2. Materials and Methods aspiration. The negative impact of UVFP on a patient’s quality of life has been confirmed by several outcome During the period from 2000 to 2008, at Kumamoto measurements [1, 2]. University Hospital, Japan, we reconstructed the RLN in 12 Different treatments are available for the management of patients who had UVFP or whose unilateral RLN needed to UVFP including intracordal injection [3], type I thyroplasty be sacrificed due to thyroid cancer (Table 1). In 12 patients [4], arytenoid adduction [5], and laryngeal reinnervations with thyroid cancer involving unilateral RLN, we conducted [6–9]. Laryngeal reinnervation has several advantages over direct anastomosis, free nerve grafting, and ansa cervicalis other techniques. It has the potential of restoring a normal to RLN anastomosis in 1, 9, and 2 patients, respectively. or near normal voice. RLN reinnervation can prevent the There were 8 women and 4 men, and the ages at the time of progressive loss of thyroarytenoid muscle tone and bulk reconstruction ranged from 18 to 82 years (mean 61.8). Six [7, 9, 10] as seen with vocal fold denervation, which can limit of the 12 patients (50%) had UVFP preoperatively and were the long-term results of the conventional static laryngoplasty classified as group I. The remaining six patients did not have procedure. UVFP before surgery. However, their RLNs were sacrificed 2 Journal of Oncology or her habitual pitch and loudness. Images were recorded using a videoendoscopic (VNL-1171; Pentax, Tokyo, Japan) and stroboscopic unit (LS-3A; Nagashima, Tokyo, Japan) CC T onto a digital videocassette recorder (DVCPRO; Panasonic, Yokohama, Japan) to assess the mucosal wave and glottal closure. We rated the mucosal wave of vocal fold vibration RLN SC and glottal closure using a four-point grading scale (0 = worst, 3 = the best). For aerodynamic evaluation, each patient was asked to produce a sustained vowel /a/ at a comfortable pitch and CA loudness for as long as possible. The maximum phonation time (MPT) and mean airflow rate (MFR) were measured using a phonation analyzer (PS-77E, Nagashima, Tokyo, Japan). Figure 1: Free nerve graft. Supraclavicular nerves was used to fill the defect (allow). T: trachea, CA: common carotid artery. SC: Perceptual voice evaluations were conducted using the supraclavicular nerve, CC: cricoid cartilage. GRBAS (Overall Grade: G, Roughness: R, Breathiness: B, Asthenia: A, and Strain: S) rating scale [11]. Three of 5 parameters (G, R, and B) were analyzed because UVFP causes breathy dysphonia. S and A were not analyzed due to limited due to invasion by cancer, and these 6 patients were classified application in the measurement of UVFP. Each parameter as group II (Table 2). was rated by a speech language pathologist according to a 4- point scale (0 = normal; 1 = slight disturbance; 2 = moderate 2.1. Method of RLN Reconstructions. The immediate RLN disturbance, 3 = sever disturbance). reconstruction was done at the time of surgery for primary Perceptual analyses were performed following standard or recurrent thyroid cancer. The ends of the severed RLN procedures in cooperation with a trained speech therapist. were anastomosed directly when possible. When the defect Statistical analyses (SigmaStat 3.5 for windows, San Joe, was longer than 5 mm, a free nerve graft taken from the CA) were performed using the Wilcoxon signed-rank test transverse cervical nerve, supraclavicular nerve, or ansa and unpaired T test: P-values less than .05 were considered cervicalis was used to fill the defect (Figure 1). When the statistically significant. proximal stumps of the RLN could not be utilized for nerve repair, ansa cervicalis to RLN anastomosis was performed. The ipsilateral ansa cervicalis was identified on the surface of 3. Results the internal jugular vein, and its branches to the sternohyoid The voices of the patients who underwent the immedi- muscles were dissected. The major branch or usually the ate RLN reconstruction began to improve after a certain branch common to these branches was transected, and the period postoperatively. Table 2 summarize the results of the proximal end was anastomosed to the distal stump of the videostroboscopic, aerodynamic, and perceptual examina- RLN. Most commonly, the ipsilateral ansa cervicalis was used tions. for reinnervation. In one case (Patient no. 7) suffering from The follow-up period in this study (Table 1)rangedfrom recurrent disease, due to loss of the ipsilateral ansa cervicalis 7 to 103 months (average of 34.6 months). We show the nerve in the excessive cicatricial tissue, the contralateral ansa data on the periods of vocal cord paralysis depending on the cervicalis was used. In Patient no. 2, thyroid cancer has referral form and or the patients’ history in group I. invaded the distal portion of the RLN at the Berry ligament. We resected the RLN at the entrance of the larynx. The inferior pharyngeal constrictor muscle was divided along the 3.1. Videostroboscopic Findings. No visible vocal fold move- lateral edge of the thyroid cartilage in order to find the distal ment was detected during the follow-up period. The post- stump of the RLN. The stumps were anastomosized with operative score of mucosal wave (2.5 ± 0.5) in group I was the supraclavicular nerve. The anastomosis was usually made significantly greater than the preoperative score (1.2 ± 1.0). with three, or sometimes four, stitches of 8–0 or 9–0 nylon The postoperative glottal closure (2.7 ± 0.5) in group I was thread using microsurgical instruments with an operation significantly greater than the preoperative score (1.5 ± 0.8). microscope or a surgical magnifying glass. Nine of the 12 patients had complete glottal closure during phonation. The small glottal gap remained in 2 patients 2.2. Voice Outcome Measurements. The patients received (Table 2). In one of the 12 patients (Patient no. 10), the vocal videostroboscopic, aerodynamic, and perceptual analyses folds could not be observed during phonation because of pre- and postoperatively. In group I, some patients were bilateral arytenoidal overhang on the glottis. Despite this, not analyzed preoperatively. The postoperative assessment the patient’s voice quality was quite good as demonstrated was done no less than 6 months after operation in all by other measurements. All patients recovered the mucosal patients. wave after the operation with the exception of one patient For videostroboscopic evaluation, each patient per- (Patient no. 9) who also suffered from a polypoid vocal formed a sustained phonation of the vowel /e/ or /i/ at his fold. Journal of Oncology 3 Table 1: List of twelve cases of immediate RLN reconstruction in the present series. UVFP before Methods of Follow-up, Patient No. Age Gender Side surgery reconstruction mo 139 F L 3mo FNG 27 264 F L 2mo FNG 36 382 F L 2mo FNG 12 4 69 F R — FNG 103 5 35 F L 13 mo FNG 68 672 M L 3mo FNG 18 774 F L — ARA 7 871 F R 3mo ARA 40 961 M R — FNG 38 10 86 F L — DA 36 11 18 M R — FNG 22 12 71 M R — FNG 9 UVFP: unilateral vocal fold paralysis, FNG: free nerve grafting, ARA: ansa cervicalis to RLN anastomosis, and DA: direct anastomosis. MPT MFR NS NS 17.1 17.2 5 100 7.1 107.5 0 0 Preoperative Postoperative Preoperative Postoperative Group I Group I Group II Group II ∗ ∗ P< .05 P< .05 NS: not significantly different NS: not significantly different Figure 2 3.2. Aerodynamic Findings. Normal speakers usually have differences between the postoperative data of both groups an MPT of more than 10 seconds and an MFR between (Figure 2). 100 ml/sec and 200 ml/sec. The postoperative recordings of MPT (16.2 sec ± 6.2) in group I were significantly greater 3.3. Perceptual Analysis. The comparative perceptual analy- than the preoperative levels (7.1 sec ± 2.55). The postoper- ses of each scale in group I and II are shown in Figure 3. ative MFR (110.3 ml/sec ± 38.4) in group I was significantly In group I, the mean score for G was 1.2 ± 0.8 preoper- reduced compared with the preoperative levels (271 ml/sec atively and 0.3 ± 0.8 postoperatively. The mean scores for B ± 325.1) (Figure 2). In group II, three of the 6 patients were 0.7 ± 0.8 preoperatively and 0.2 ± 0.4 postoperatively. did not receive a preoperative examination. Therefore, it The mean score for R was 1.0 ± 0.6 preoperatively and was was not possible to make a statistical comparison of preop- reduced to 0.2 ± 0.4 postoperatively. All three characteristic erative and postoperative data. However, the postoperative scores were significantly reduced postoperatively. results of MPT and MFR showed that patients’ voices were In group II, half of the cases did not receive preoperative returned to a normal condition. There were no significant examinations. Also, Patient no. 9 had a polypoid vocal cord Maximum phonation time (s) Mean airflow rate (mL/s) 4 Journal of Oncology Table 2: Preoperative and postoperative voice data. Mucosal wave Glottal closure MPT (sec) MFR (ml/sec) Grade Roughness Breathiness Patient No. Preop Postop Preop Postop Preop Postop Preop Postope Preope Postop Preop Postop Preop Postop Group I 1 1 3 1 3 8.9 26.5 184.0 86.0 1 0 0 0 1 0 2 1 2 2 2 6.2 19.9 109.0 70.0 2 0 1 0 1 0 3 3 3 2 3 9.6 13.5 116.0 104.0 0 0 0 0 0 0 5 1 2 2 2 8.7 16.2 176.0 168.0 1 0 1 0 1 0 6 0 2 0 3 2.7 10.6 932.0 146.0 2 1 2 1 2 1 8 1 3 2 3 6.5 10.4 114.0 88.0 1 0 0 0 1 0 Mean ± SD 1.2± 1.02.5± 0.51.5 ± 0.82.7 ± 0.57.1 ± 2.616.2 ± 6.2 271.8 ± 325 110.3 ± 38.41.2 ± 0.80.2 ± 0.40.7 ± 0.80.2 ± 0.41.0 ± 0.60.2 ± 0.4 Group II 4 3 2 3 3 22.2 25.4 61.0 62.0 0 0 0 0 0 0 7 NA 3 NA 3 NA 14.9 NA 64.0 NA 0 NA 0 NA 0 9 1 1 3 3 22.4 24.3 60.0 102.0 2 1 1 1 2 1 10 IV IV IV IV 11.3 11.5 41.0 78.0 0 0 0 0 0 0 11 NA 2 NA 3 NA 12.0 NA 168.0 NA 0 NA 0 NA 0 12 NA 3 NA 3 NA 17.7 NA 168.0 NA 0 NA 0 NA 0 Mean ± SD 2.0± 1.4 2.2 ± 08 3.0 ± 0.0 3.0 ± 0.0 18.6 ± 6.4 17.6 ± 6.0 54.0 ± 11.3 107 ± 49.4 0.7 ± 1.2 0.2 ± 0.4 0.3 ± 0.6 0.2 ± 0.4 0.7 ± 1.2 0.2 ± 0.4 NA: not assessed, IV: invisible glottis during phonation, MPT: maximum phonation time, and MFR: mean airflow rate. Journal of Oncology 5 Grade Roughness 3 3 2.5 2.5 2 NS 2 1.5 1.5 NS 1 1 0.5 0.5 0 0 Preoperative Postoperative Preoperative Postoperative Group I Group I Group II Group II (a) (b) Breathiness 2.5 1.5 NS 0.5 Preoperative Postoperative Group I Group II P< .05 NS: not significantly different (c) Figure 3 which caused an elevated score of the perceptual analysis the potential of restoring a normal or near-normal voice by before the surgery. However, the postoperative perceptual returning thyroarytenoid muscle tone and bulk [6, 7, 9, 12, scores were within normal ranges. 13] in contrast with the conventional laryngoplasty proce- dure [7]. Reconstruction of the RLN in the management of UVFP during the thyroid cancer surgery is rarely reported 4. Discussion [9, 14–18]. Some disadvantages of this technique are the A major morbidity associated with thyroid surgery is injury requirement of a delayed time to voice improvement, the to the RLN, resulting in poor voice quality and the potential requirement of intact donor and recipient nerves, and the for recurrent aspiration. possible delay or failure of reinnervation in elderly patients. Reconstitution of vocal fold thickness and median In this study, we assessed the outcome of immediate position can be accomplished by vocal fold augmentation RLN reconstruction during thyroid cancer surgery with or without UVFP before the surgery. In particular, the aero- [3], vocal fold medialization with type I thyroplasty [4], arytenoid adduction [5], or RLN reinnervation [6–8]. These dynamic analysis showed that all measured values entered techniques can be used alone or in combination to achieve normal ranges in both groups I and II. It should be noted that as patients in group II had a normal voice preoperatively, improved vocal and swallowing functions. RLN reinnerva- tion has several advantages over other techniques. It has phonatory function was not analyzed in some cases. As such, Overall grade Breathiness Roughness 6 Journal of Oncology aerodynamic analyses were employed to measure changes in stump of the RLN. The thyroid cartilage is retracted, and phonatory function postoperatively. These results coincided cricothyroid joint is opened. Behind the thyroid cartilage the with the glottal closure and mucosal wave assessed with RLN forms several branches. The abductor and adductor videostroboscopy (Table 2). These results were achieved with branches of the RLN are identified, and the adductor no bias as to the method of RLN reconstruction such as direct branch is dissected superior to ensure sufficient length for anastomosis, nerve grafting, and ansa cervicalis and RLN anastomosis. When adductor branches cannot be found and anastomosis. Nerve anastomosis under microscopic control opposite RLN can be preserved, arytenoid adduction may be was important for precise neuronal repairs. performed to keep phonatory function. Several techniques of peripheral nerve repair exist, including microsuturing, gluing [19, 20] and grafting [21]. 5. Conclusion Cyanoacrylate synthetic glue has therefore been proposed because its application for nerve repair is relatively easy, it In thiscaseserieswereportedfavorable patientoutcomesas maintains the anastomosis even while under tension, and measured by aerodynamic and perceptional analyses as well it avoids all risk of viral transmission [22, 23]. In spite of as videostroboscopic findings after immediate RLN recon- this, this adhesive has received criticism due to its toxicity, struction for severed RLN during thyroid cancer surgery. excessively slow resorption, as well as the possibility of the Also, we reported that our patients experienced a normal or induction of an inflammatory reaction in the perineural improved voice postoperatively, regardless of the length of tissues [24, 25]. In the present study, the standard micro- time they had suffered from UVFP. Despite these favorable suturing technique was employed for RLN reconstruction. results, the small sample size utilized in this study limits the RLN reconstruction requires surgical precision; however, conclusions that may be drawn. Further research could help most surgeons involved in the treatment of thyroid cancer to confirm the results and expand the application of this and RLN should possess the requisite proficiency to conduct procedure. the procedure. The immediate RLN reconstruction for severed RLN In group I, all patients who had UVFP with vocal fold during the thyroid cancer surgery is highly effective in atrophy before the surgery experienced restored phonatory preventing the loss of phonatory function. function after the immediate RLN reconstruction during thyroid cancer surgery. According to other studies, clini- cal improvements have been noted 2–4 months after the References reinnervation [10, 15, 16, 26], which corresponds with our findings of 3-4 months (not shown). Green et al. [1] N. D. Hogikyan, W. P. Wodchis, J. E. Terrell, C. R. Bradford, and R. M. Esclamado, “Voice-Related Quality of Life (V- [7] demonstrated in a canine model that at 5-6 months, RQOL) following type I thyroplasty for unilateral vocal fold evoked electromyography (EMG) indicated some degree of paralysis,” Journal of Voice, vol. 14, no. 3, pp. 378–386, 2000. reinnervation. These EMG findings in animal experiments [2] B. C. Spector, J. L. Netterville, C. Billante, J. Clary, L. Reinisch, were also reported in clinical patients who underwent and T. L. Smith, “Quality-of-life assessment in patients with serial EMG studies after laryngeal reinnervation for UVFP unilateral vocal cord paralysis,” Otolaryngology, vol. 125, no. 3, [13, 26]. Miyauchi et al. [18] reported phonatory function pp. 176–182, 2001. improvement after reconstruction of RLN in 88 patients with [3] C. N. Ford and D. M. Bless, “A preliminary study of injectable nerve resection and also in 51 (58%) patients who had UVFP collagen in human vocal fold augmentation,” Otolaryngology, preoperatively. Reconstruction of RLN may provide partial vol. 94, no. 1, pp. 104–112, 1986. or full recovery from vocal fold atrophy and the returning [4] N. Isshiki, H. Okamura, and T. Ishikawa, “Thyroplasty type I thyroarytenoid muscle tone during phonation. (lateral compression) for dysphonia due to vocal cord paralysis Feasibility of the GRBAS scale for assessment of sub- or atrophy,” Acta Oto-Laryngologica, vol. 80, no. 5-6, pp. 465– jective voice outcome with laryngoplasty has been reported 473, 1975. [11, 27, 28]. This study also indicated a G change from 1.2 [5] N. Isshiki, M. Tanabe, and M. Sawada, “Arytenoid adduction for unilateral vocal cord paralysis,” Archives of Otolaryngology, to 0.2, an R change from 0.7 to 0.2, and a B change from 1.0 vol. 104, no. 10, pp. 555–558, 1978. to 0.2 in group I patients with reinnervation RLN. In group [6] R. L. Crumley, “Update: ansa cervicalis to recurrent laryngeal II, mean values of G, R, and B reached the same values as nerve anastomosis for unilateral laryngeal paralysis,” Laryngo- Group I postoperatively. All G, R, and B scores were under scope, vol. 101, no. 4, pp. 384–388, 1991. 0.5 scales after the surgery. Perceptual analysis showed that [7] D.C.Green,G.S.Berke,and M. C. Graves,“Afunctional our patients’ voices were returned to normal or near normal evaluation of ansa cervicalis nerve transfer for unilateral vocal after the surgery. cord paralysis: future directions for laryngeal reinnervation,” In this study, thyroid cancer was only limited to invasion Otolaryngology, vol. 104, no. 4, pp. 453–466, 1991. of the unilateral RLN. There are some advanced invasions, [8] R. C. Paniello, “Laryngeal reinnervation,” Otolaryngologic such as to the trachea, larynx, or esophagus. In such Clinics of North America, vol. 37, no. 1, pp. 161–181, 2004. advanced cases it may not be possible to reserve distal stumps [9] E. Yumoto, T. Sanuki, and Y. Kumai, “Immediate recurrent of RLN at the entrance of the larynx. If there is no distal laryngeal nerve reconstruction and vocal outcome,” Laryngo- portion of the RLN left below the Berry’s ligament, the scope, vol. 116, no. 9, pp. 1657–1661, 2006. inferior pharyngeal constrictor muscle should be divided [10] W. T. Lee, C. Milstein, D. Hicks, L. M. Akst, and R. M. along the lateral edge of the thyroid cartilage to find a distal Esclamado, “Results of ansa to recurrent laryngeal nerve Journal of Oncology 7 reinnervation,” Otolaryngology, vol. 136, no. 3, pp. 450–454, compatibility and antimicrobial activity of two cyanoacrylate 2007. glues for surgical use,” Biomaterials, vol. 22, no. 1, pp. 59–66, [11] M. Hirano, “Clinical examination of voice,” The Journal of the 2001. Acoustical Society of America, vol. 80, no. 4, pp. 81–84, 1981. [26] N. Maronian, P. Waugh, L. Robinson, and A. Hillel, “Elec- [12] D. K. Chhetri, B. R. Gerratt, J. Kreiman, and G. S. Berke, tromyographic findings in recurrent laryngeal nerve reinner- “Combined arytenoid adduction and laryngeal reinnervation vation,” Annals of Otology, Rhinology and Laryngology, vol. 112, in the treatment of vocal fold paralysis,” Laryngoscope, vol. 109, no. 4, pp. 314–323, 2003. no. 12, pp. 1928–1936, 1999. [27] P. Dulguerov, V. Schweizer, I. Caumel, and F. Esteve, “Medial- [13] H. Zheng, Z. Li, S. Zhou, Y. Cuan, and W. Wen, “Update: ization laryngoplasty,” Otolaryngology, vol. 120, no. 2, pp. 275– laryngeal reinnervation for unilateral vocal cord paralysis with 278, 1999. theansacervicalis,” Laryngoscope, vol. 106, no. 12, pp. 1522– [28] C. W. Cummings, L. L. Purcell, and P. W. Flint, “Hydrox- 1527, 1996. ylapatite laryngeal implants for medialization. Preliminary [14] A. Miyauchi, K. Matsusaka, M. Kihara, F. Matsuzuka, K. report,” Annals of Otology, Rhinology and Laryngology, vol. 102, Hirai, T. Yokozawa, K. Kobayashi, A. Kobayashi, and K. Kuma, no. 11, pp. 843–851, 1993. “The role of ansa-to-recurrent-laryngeal nerve anastomosis in operations for thyroid cancer,” European Journal of Surgery, vol. 164, no. 12, pp. 927–933, 1998. [15] F.-Y. Chiang, L.-F. Wang, Y.-F. Huang, K.-W. Lee, and W.- R. Kuo, “Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve,” Surgery, vol. 137, no. 3, pp. 342–347, 2005. [16] A. Miyauchi, T. Yokozawa, K. Kobayashi, K. Hirai, F. Mat- suzuka, and K. Kuma, “Opposite ansa cervicalis to recurrent laryngeal nerve anastomosis to restore phonation in patients with advanced thyroid cancer,” European Journal of Surgery, vol. 167, no. 7, pp. 540–541, 2001. [17] A. Miyauchi, Y. Ito, A. Miya, T. Higashiyama, C. Tomoda, Y. Takamura, K. Kobayashi, and F. Matsuzuka, “Lateral mobilization of the recurrent laryngeal nerve to facilitate tracheal surgery in patients with thyroid cancer invading the trachea near Berry’s ligament,” World Journal of Surgery, vol. 31, no. 11, pp. 2081–2084, 2007. [18] A. Miyauchi, H. Inoue, C. Tomoda, M. Fukushima, M. Kihara, T. Higashiyama, Y. Takamura, Y. Ito, K. Kobayashi, and A. Miya, “Improvement in phonation after reconstruction of the recurrent laryngeal nerve in patients with thyroid cancer invading the nerve,” Surgery, vol. 146, no. 6, pp. 1056–1062, [19] A. Piner ˜ os-Fernandez, ´ P. F. Rodeheaver, and G. T. Rodeheaver, “Octyl 2-cyanoacrylate for repair of peripheral nerve,” Annals of Plastic Surgery, vol. 55, no. 2, pp. 188–195, 2005. [20] T. Landegren, M. Risling, A. Brage, and J. K.E. Persson, “Long- term results of peripheral nerve repair: a comparison of nerve anastomosis with ethyl-cyanoacrylate and epineural sutures,” Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, vol. 40, no. 2, pp. 65–72, 2006. [21] C. Auba, ´ B. Hontanilla, J. Arcocha, and O. Gorr´ıa, “Peripheral nerve regeneration through allografts compared with auto- grafts in FK506-treated monkeys,” Journal of Neurosurgery, vol. 105, no. 4, pp. 602–609, 2006. [22] B.-H. Choi, B.-Y. Kim, J.-Y. Huh, S.-H. Lee, S.-J. Zhu, J.- H. Jung, and B.-P. Cho, “Microneural anastomosis using cyanoacrylate adhesives,” International Journal of Oral and Maxillofacial Surgery, vol. 33, no. 8, pp. 777–780, 2004. [23] Y. C. Tseng, S. H. Hyon, Y. Ikada, Y. Shimizu, K. Tamura, and S. Hitomi, “In vivo evaluation of 2-cyanoacrylates as surgical adhesives,” Journal of Applied Biomaterials,vol. 1, no.2,pp. 111–119, 1990. [24] K. Wieken, K. Angioi-Duprez, A. Lim, L. Marchal, and M. Merle, “Nerve anastomosis with glue: comparative histologic study of fibrin and cyanoacrylate glue,” Journal of Reconstruc- tive Microsurgery, vol. 19, no. 1, pp. 17–20, 2003. [25] L. Montanaro, C. R. Arciola, E. Cenni, G. Ciapetti, F. Savioli, F. Filippini, and L. A. 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The Role of Immediate Recurrent Laryngeal Nerve Reconstruction for Thyroid Cancer Surgery

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Copyright © 2010 Tetsuji Sanuki et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Publishing Corporation Journal of Oncology Volume 2010, Article ID 846235, 7 pages doi:10.1155/2010/846235 Research Article The Role of Immediate Recurrent Laryngeal Nerve Reconstruction for Thyroid Cancer Surgery Tetsuji Sanuki, Eiji Yumoto, Ryosei Minoda, and Narihiro Kodama Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kumamoto University, 1-1-1 Honjo, Kumamoto 860-8556, Japan Correspondence should be addressed to Tetsuji Sanuki, otostl0319@fc.kuh.kumamoto-u.ac.jp Received 15 August 2009; Revised 16 March 2010; Accepted 4 May 2010 Academic Editor: Steven K. Libutti Copyright © 2010 Tetsuji Sanuki et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Unilateral vocal fold paralysis (UVFP) is one of the most serious problems in conducting surgery for thyroid cancer. Different treatments are available for the management of UVFP including intracordal injection, type I thyroplasty, arytenoid adduction, and laryngeal reinnervations. The effects of immediate recurrent laryngeal nerve (RLN) reconstruction during thyroid cancer surgery with or without UVFP before the surgery were evaluated with videostroboscopic, aerodynamic, and perceptual analyses. All subjects experienced postoperative improvements in voice quality. Particularly, aerodynamic analysis showed that the values for all patients entered normal ranges in both patients with and without UVFP before surgery. Immediate RLN reconstruction has the potential to restore a normal or near-normal voice by returning thyroarytenoid muscle tone and bulk seen with vocal fold denervation. Immediate RLN reconstruction is an efficient and effective approach to the management of RLN resection during surgery for thyroid cancer. 1. Introduction We report on cases involving the immediate recon- struction of the RLN during thyroid cancer surgery in Unilateral vocal fold paralysis (UVFP) is one of the most patients with or without UVFP preoperatively and voice serious problems in the management of thyroid cancer. The outcomes following the procedure with videostroboscopic, vocal folds may be paralyzed at the time of presentation, aerodynamic, and perceptual analyses. or the recurrent laryngeal nerve (RLN) may need to be sacrificed even when the RLN is functioning preoperatively. UVFP causes breathy voice, shortening of phonation, and 2. Materials and Methods aspiration. The negative impact of UVFP on a patient’s quality of life has been confirmed by several outcome During the period from 2000 to 2008, at Kumamoto measurements [1, 2]. University Hospital, Japan, we reconstructed the RLN in 12 Different treatments are available for the management of patients who had UVFP or whose unilateral RLN needed to UVFP including intracordal injection [3], type I thyroplasty be sacrificed due to thyroid cancer (Table 1). In 12 patients [4], arytenoid adduction [5], and laryngeal reinnervations with thyroid cancer involving unilateral RLN, we conducted [6–9]. Laryngeal reinnervation has several advantages over direct anastomosis, free nerve grafting, and ansa cervicalis other techniques. It has the potential of restoring a normal to RLN anastomosis in 1, 9, and 2 patients, respectively. or near normal voice. RLN reinnervation can prevent the There were 8 women and 4 men, and the ages at the time of progressive loss of thyroarytenoid muscle tone and bulk reconstruction ranged from 18 to 82 years (mean 61.8). Six [7, 9, 10] as seen with vocal fold denervation, which can limit of the 12 patients (50%) had UVFP preoperatively and were the long-term results of the conventional static laryngoplasty classified as group I. The remaining six patients did not have procedure. UVFP before surgery. However, their RLNs were sacrificed 2 Journal of Oncology or her habitual pitch and loudness. Images were recorded using a videoendoscopic (VNL-1171; Pentax, Tokyo, Japan) and stroboscopic unit (LS-3A; Nagashima, Tokyo, Japan) CC T onto a digital videocassette recorder (DVCPRO; Panasonic, Yokohama, Japan) to assess the mucosal wave and glottal closure. We rated the mucosal wave of vocal fold vibration RLN SC and glottal closure using a four-point grading scale (0 = worst, 3 = the best). For aerodynamic evaluation, each patient was asked to produce a sustained vowel /a/ at a comfortable pitch and CA loudness for as long as possible. The maximum phonation time (MPT) and mean airflow rate (MFR) were measured using a phonation analyzer (PS-77E, Nagashima, Tokyo, Japan). Figure 1: Free nerve graft. Supraclavicular nerves was used to fill the defect (allow). T: trachea, CA: common carotid artery. SC: Perceptual voice evaluations were conducted using the supraclavicular nerve, CC: cricoid cartilage. GRBAS (Overall Grade: G, Roughness: R, Breathiness: B, Asthenia: A, and Strain: S) rating scale [11]. Three of 5 parameters (G, R, and B) were analyzed because UVFP causes breathy dysphonia. S and A were not analyzed due to limited due to invasion by cancer, and these 6 patients were classified application in the measurement of UVFP. Each parameter as group II (Table 2). was rated by a speech language pathologist according to a 4- point scale (0 = normal; 1 = slight disturbance; 2 = moderate 2.1. Method of RLN Reconstructions. The immediate RLN disturbance, 3 = sever disturbance). reconstruction was done at the time of surgery for primary Perceptual analyses were performed following standard or recurrent thyroid cancer. The ends of the severed RLN procedures in cooperation with a trained speech therapist. were anastomosed directly when possible. When the defect Statistical analyses (SigmaStat 3.5 for windows, San Joe, was longer than 5 mm, a free nerve graft taken from the CA) were performed using the Wilcoxon signed-rank test transverse cervical nerve, supraclavicular nerve, or ansa and unpaired T test: P-values less than .05 were considered cervicalis was used to fill the defect (Figure 1). When the statistically significant. proximal stumps of the RLN could not be utilized for nerve repair, ansa cervicalis to RLN anastomosis was performed. The ipsilateral ansa cervicalis was identified on the surface of 3. Results the internal jugular vein, and its branches to the sternohyoid The voices of the patients who underwent the immedi- muscles were dissected. The major branch or usually the ate RLN reconstruction began to improve after a certain branch common to these branches was transected, and the period postoperatively. Table 2 summarize the results of the proximal end was anastomosed to the distal stump of the videostroboscopic, aerodynamic, and perceptual examina- RLN. Most commonly, the ipsilateral ansa cervicalis was used tions. for reinnervation. In one case (Patient no. 7) suffering from The follow-up period in this study (Table 1)rangedfrom recurrent disease, due to loss of the ipsilateral ansa cervicalis 7 to 103 months (average of 34.6 months). We show the nerve in the excessive cicatricial tissue, the contralateral ansa data on the periods of vocal cord paralysis depending on the cervicalis was used. In Patient no. 2, thyroid cancer has referral form and or the patients’ history in group I. invaded the distal portion of the RLN at the Berry ligament. We resected the RLN at the entrance of the larynx. The inferior pharyngeal constrictor muscle was divided along the 3.1. Videostroboscopic Findings. No visible vocal fold move- lateral edge of the thyroid cartilage in order to find the distal ment was detected during the follow-up period. The post- stump of the RLN. The stumps were anastomosized with operative score of mucosal wave (2.5 ± 0.5) in group I was the supraclavicular nerve. The anastomosis was usually made significantly greater than the preoperative score (1.2 ± 1.0). with three, or sometimes four, stitches of 8–0 or 9–0 nylon The postoperative glottal closure (2.7 ± 0.5) in group I was thread using microsurgical instruments with an operation significantly greater than the preoperative score (1.5 ± 0.8). microscope or a surgical magnifying glass. Nine of the 12 patients had complete glottal closure during phonation. The small glottal gap remained in 2 patients 2.2. Voice Outcome Measurements. The patients received (Table 2). In one of the 12 patients (Patient no. 10), the vocal videostroboscopic, aerodynamic, and perceptual analyses folds could not be observed during phonation because of pre- and postoperatively. In group I, some patients were bilateral arytenoidal overhang on the glottis. Despite this, not analyzed preoperatively. The postoperative assessment the patient’s voice quality was quite good as demonstrated was done no less than 6 months after operation in all by other measurements. All patients recovered the mucosal patients. wave after the operation with the exception of one patient For videostroboscopic evaluation, each patient per- (Patient no. 9) who also suffered from a polypoid vocal formed a sustained phonation of the vowel /e/ or /i/ at his fold. Journal of Oncology 3 Table 1: List of twelve cases of immediate RLN reconstruction in the present series. UVFP before Methods of Follow-up, Patient No. Age Gender Side surgery reconstruction mo 139 F L 3mo FNG 27 264 F L 2mo FNG 36 382 F L 2mo FNG 12 4 69 F R — FNG 103 5 35 F L 13 mo FNG 68 672 M L 3mo FNG 18 774 F L — ARA 7 871 F R 3mo ARA 40 961 M R — FNG 38 10 86 F L — DA 36 11 18 M R — FNG 22 12 71 M R — FNG 9 UVFP: unilateral vocal fold paralysis, FNG: free nerve grafting, ARA: ansa cervicalis to RLN anastomosis, and DA: direct anastomosis. MPT MFR NS NS 17.1 17.2 5 100 7.1 107.5 0 0 Preoperative Postoperative Preoperative Postoperative Group I Group I Group II Group II ∗ ∗ P< .05 P< .05 NS: not significantly different NS: not significantly different Figure 2 3.2. Aerodynamic Findings. Normal speakers usually have differences between the postoperative data of both groups an MPT of more than 10 seconds and an MFR between (Figure 2). 100 ml/sec and 200 ml/sec. The postoperative recordings of MPT (16.2 sec ± 6.2) in group I were significantly greater 3.3. Perceptual Analysis. The comparative perceptual analy- than the preoperative levels (7.1 sec ± 2.55). The postoper- ses of each scale in group I and II are shown in Figure 3. ative MFR (110.3 ml/sec ± 38.4) in group I was significantly In group I, the mean score for G was 1.2 ± 0.8 preoper- reduced compared with the preoperative levels (271 ml/sec atively and 0.3 ± 0.8 postoperatively. The mean scores for B ± 325.1) (Figure 2). In group II, three of the 6 patients were 0.7 ± 0.8 preoperatively and 0.2 ± 0.4 postoperatively. did not receive a preoperative examination. Therefore, it The mean score for R was 1.0 ± 0.6 preoperatively and was was not possible to make a statistical comparison of preop- reduced to 0.2 ± 0.4 postoperatively. All three characteristic erative and postoperative data. However, the postoperative scores were significantly reduced postoperatively. results of MPT and MFR showed that patients’ voices were In group II, half of the cases did not receive preoperative returned to a normal condition. There were no significant examinations. Also, Patient no. 9 had a polypoid vocal cord Maximum phonation time (s) Mean airflow rate (mL/s) 4 Journal of Oncology Table 2: Preoperative and postoperative voice data. Mucosal wave Glottal closure MPT (sec) MFR (ml/sec) Grade Roughness Breathiness Patient No. Preop Postop Preop Postop Preop Postop Preop Postope Preope Postop Preop Postop Preop Postop Group I 1 1 3 1 3 8.9 26.5 184.0 86.0 1 0 0 0 1 0 2 1 2 2 2 6.2 19.9 109.0 70.0 2 0 1 0 1 0 3 3 3 2 3 9.6 13.5 116.0 104.0 0 0 0 0 0 0 5 1 2 2 2 8.7 16.2 176.0 168.0 1 0 1 0 1 0 6 0 2 0 3 2.7 10.6 932.0 146.0 2 1 2 1 2 1 8 1 3 2 3 6.5 10.4 114.0 88.0 1 0 0 0 1 0 Mean ± SD 1.2± 1.02.5± 0.51.5 ± 0.82.7 ± 0.57.1 ± 2.616.2 ± 6.2 271.8 ± 325 110.3 ± 38.41.2 ± 0.80.2 ± 0.40.7 ± 0.80.2 ± 0.41.0 ± 0.60.2 ± 0.4 Group II 4 3 2 3 3 22.2 25.4 61.0 62.0 0 0 0 0 0 0 7 NA 3 NA 3 NA 14.9 NA 64.0 NA 0 NA 0 NA 0 9 1 1 3 3 22.4 24.3 60.0 102.0 2 1 1 1 2 1 10 IV IV IV IV 11.3 11.5 41.0 78.0 0 0 0 0 0 0 11 NA 2 NA 3 NA 12.0 NA 168.0 NA 0 NA 0 NA 0 12 NA 3 NA 3 NA 17.7 NA 168.0 NA 0 NA 0 NA 0 Mean ± SD 2.0± 1.4 2.2 ± 08 3.0 ± 0.0 3.0 ± 0.0 18.6 ± 6.4 17.6 ± 6.0 54.0 ± 11.3 107 ± 49.4 0.7 ± 1.2 0.2 ± 0.4 0.3 ± 0.6 0.2 ± 0.4 0.7 ± 1.2 0.2 ± 0.4 NA: not assessed, IV: invisible glottis during phonation, MPT: maximum phonation time, and MFR: mean airflow rate. Journal of Oncology 5 Grade Roughness 3 3 2.5 2.5 2 NS 2 1.5 1.5 NS 1 1 0.5 0.5 0 0 Preoperative Postoperative Preoperative Postoperative Group I Group I Group II Group II (a) (b) Breathiness 2.5 1.5 NS 0.5 Preoperative Postoperative Group I Group II P< .05 NS: not significantly different (c) Figure 3 which caused an elevated score of the perceptual analysis the potential of restoring a normal or near-normal voice by before the surgery. However, the postoperative perceptual returning thyroarytenoid muscle tone and bulk [6, 7, 9, 12, scores were within normal ranges. 13] in contrast with the conventional laryngoplasty proce- dure [7]. Reconstruction of the RLN in the management of UVFP during the thyroid cancer surgery is rarely reported 4. Discussion [9, 14–18]. Some disadvantages of this technique are the A major morbidity associated with thyroid surgery is injury requirement of a delayed time to voice improvement, the to the RLN, resulting in poor voice quality and the potential requirement of intact donor and recipient nerves, and the for recurrent aspiration. possible delay or failure of reinnervation in elderly patients. Reconstitution of vocal fold thickness and median In this study, we assessed the outcome of immediate position can be accomplished by vocal fold augmentation RLN reconstruction during thyroid cancer surgery with or without UVFP before the surgery. In particular, the aero- [3], vocal fold medialization with type I thyroplasty [4], arytenoid adduction [5], or RLN reinnervation [6–8]. These dynamic analysis showed that all measured values entered techniques can be used alone or in combination to achieve normal ranges in both groups I and II. It should be noted that as patients in group II had a normal voice preoperatively, improved vocal and swallowing functions. RLN reinnerva- tion has several advantages over other techniques. It has phonatory function was not analyzed in some cases. As such, Overall grade Breathiness Roughness 6 Journal of Oncology aerodynamic analyses were employed to measure changes in stump of the RLN. The thyroid cartilage is retracted, and phonatory function postoperatively. These results coincided cricothyroid joint is opened. Behind the thyroid cartilage the with the glottal closure and mucosal wave assessed with RLN forms several branches. The abductor and adductor videostroboscopy (Table 2). These results were achieved with branches of the RLN are identified, and the adductor no bias as to the method of RLN reconstruction such as direct branch is dissected superior to ensure sufficient length for anastomosis, nerve grafting, and ansa cervicalis and RLN anastomosis. When adductor branches cannot be found and anastomosis. Nerve anastomosis under microscopic control opposite RLN can be preserved, arytenoid adduction may be was important for precise neuronal repairs. performed to keep phonatory function. Several techniques of peripheral nerve repair exist, including microsuturing, gluing [19, 20] and grafting [21]. 5. Conclusion Cyanoacrylate synthetic glue has therefore been proposed because its application for nerve repair is relatively easy, it In thiscaseserieswereportedfavorable patientoutcomesas maintains the anastomosis even while under tension, and measured by aerodynamic and perceptional analyses as well it avoids all risk of viral transmission [22, 23]. In spite of as videostroboscopic findings after immediate RLN recon- this, this adhesive has received criticism due to its toxicity, struction for severed RLN during thyroid cancer surgery. excessively slow resorption, as well as the possibility of the Also, we reported that our patients experienced a normal or induction of an inflammatory reaction in the perineural improved voice postoperatively, regardless of the length of tissues [24, 25]. In the present study, the standard micro- time they had suffered from UVFP. Despite these favorable suturing technique was employed for RLN reconstruction. results, the small sample size utilized in this study limits the RLN reconstruction requires surgical precision; however, conclusions that may be drawn. Further research could help most surgeons involved in the treatment of thyroid cancer to confirm the results and expand the application of this and RLN should possess the requisite proficiency to conduct procedure. the procedure. The immediate RLN reconstruction for severed RLN In group I, all patients who had UVFP with vocal fold during the thyroid cancer surgery is highly effective in atrophy before the surgery experienced restored phonatory preventing the loss of phonatory function. function after the immediate RLN reconstruction during thyroid cancer surgery. According to other studies, clini- cal improvements have been noted 2–4 months after the References reinnervation [10, 15, 16, 26], which corresponds with our findings of 3-4 months (not shown). Green et al. [1] N. D. Hogikyan, W. P. Wodchis, J. E. Terrell, C. R. Bradford, and R. M. Esclamado, “Voice-Related Quality of Life (V- [7] demonstrated in a canine model that at 5-6 months, RQOL) following type I thyroplasty for unilateral vocal fold evoked electromyography (EMG) indicated some degree of paralysis,” Journal of Voice, vol. 14, no. 3, pp. 378–386, 2000. reinnervation. These EMG findings in animal experiments [2] B. C. Spector, J. L. Netterville, C. Billante, J. Clary, L. Reinisch, were also reported in clinical patients who underwent and T. L. Smith, “Quality-of-life assessment in patients with serial EMG studies after laryngeal reinnervation for UVFP unilateral vocal cord paralysis,” Otolaryngology, vol. 125, no. 3, [13, 26]. Miyauchi et al. [18] reported phonatory function pp. 176–182, 2001. improvement after reconstruction of RLN in 88 patients with [3] C. N. Ford and D. M. Bless, “A preliminary study of injectable nerve resection and also in 51 (58%) patients who had UVFP collagen in human vocal fold augmentation,” Otolaryngology, preoperatively. Reconstruction of RLN may provide partial vol. 94, no. 1, pp. 104–112, 1986. or full recovery from vocal fold atrophy and the returning [4] N. Isshiki, H. Okamura, and T. Ishikawa, “Thyroplasty type I thyroarytenoid muscle tone during phonation. (lateral compression) for dysphonia due to vocal cord paralysis Feasibility of the GRBAS scale for assessment of sub- or atrophy,” Acta Oto-Laryngologica, vol. 80, no. 5-6, pp. 465– jective voice outcome with laryngoplasty has been reported 473, 1975. [11, 27, 28]. This study also indicated a G change from 1.2 [5] N. Isshiki, M. Tanabe, and M. Sawada, “Arytenoid adduction for unilateral vocal cord paralysis,” Archives of Otolaryngology, to 0.2, an R change from 0.7 to 0.2, and a B change from 1.0 vol. 104, no. 10, pp. 555–558, 1978. to 0.2 in group I patients with reinnervation RLN. In group [6] R. L. Crumley, “Update: ansa cervicalis to recurrent laryngeal II, mean values of G, R, and B reached the same values as nerve anastomosis for unilateral laryngeal paralysis,” Laryngo- Group I postoperatively. All G, R, and B scores were under scope, vol. 101, no. 4, pp. 384–388, 1991. 0.5 scales after the surgery. Perceptual analysis showed that [7] D.C.Green,G.S.Berke,and M. C. Graves,“Afunctional our patients’ voices were returned to normal or near normal evaluation of ansa cervicalis nerve transfer for unilateral vocal after the surgery. cord paralysis: future directions for laryngeal reinnervation,” In this study, thyroid cancer was only limited to invasion Otolaryngology, vol. 104, no. 4, pp. 453–466, 1991. of the unilateral RLN. There are some advanced invasions, [8] R. C. Paniello, “Laryngeal reinnervation,” Otolaryngologic such as to the trachea, larynx, or esophagus. In such Clinics of North America, vol. 37, no. 1, pp. 161–181, 2004. advanced cases it may not be possible to reserve distal stumps [9] E. Yumoto, T. Sanuki, and Y. Kumai, “Immediate recurrent of RLN at the entrance of the larynx. If there is no distal laryngeal nerve reconstruction and vocal outcome,” Laryngo- portion of the RLN left below the Berry’s ligament, the scope, vol. 116, no. 9, pp. 1657–1661, 2006. inferior pharyngeal constrictor muscle should be divided [10] W. T. Lee, C. Milstein, D. Hicks, L. M. Akst, and R. M. along the lateral edge of the thyroid cartilage to find a distal Esclamado, “Results of ansa to recurrent laryngeal nerve Journal of Oncology 7 reinnervation,” Otolaryngology, vol. 136, no. 3, pp. 450–454, compatibility and antimicrobial activity of two cyanoacrylate 2007. glues for surgical use,” Biomaterials, vol. 22, no. 1, pp. 59–66, [11] M. Hirano, “Clinical examination of voice,” The Journal of the 2001. Acoustical Society of America, vol. 80, no. 4, pp. 81–84, 1981. [26] N. Maronian, P. Waugh, L. Robinson, and A. Hillel, “Elec- [12] D. K. Chhetri, B. R. Gerratt, J. Kreiman, and G. S. Berke, tromyographic findings in recurrent laryngeal nerve reinner- “Combined arytenoid adduction and laryngeal reinnervation vation,” Annals of Otology, Rhinology and Laryngology, vol. 112, in the treatment of vocal fold paralysis,” Laryngoscope, vol. 109, no. 4, pp. 314–323, 2003. no. 12, pp. 1928–1936, 1999. [27] P. Dulguerov, V. Schweizer, I. Caumel, and F. Esteve, “Medial- [13] H. Zheng, Z. Li, S. Zhou, Y. Cuan, and W. Wen, “Update: ization laryngoplasty,” Otolaryngology, vol. 120, no. 2, pp. 275– laryngeal reinnervation for unilateral vocal cord paralysis with 278, 1999. theansacervicalis,” Laryngoscope, vol. 106, no. 12, pp. 1522– [28] C. W. Cummings, L. L. Purcell, and P. W. Flint, “Hydrox- 1527, 1996. ylapatite laryngeal implants for medialization. Preliminary [14] A. Miyauchi, K. Matsusaka, M. Kihara, F. Matsuzuka, K. report,” Annals of Otology, Rhinology and Laryngology, vol. 102, Hirai, T. Yokozawa, K. Kobayashi, A. Kobayashi, and K. Kuma, no. 11, pp. 843–851, 1993. “The role of ansa-to-recurrent-laryngeal nerve anastomosis in operations for thyroid cancer,” European Journal of Surgery, vol. 164, no. 12, pp. 927–933, 1998. [15] F.-Y. Chiang, L.-F. Wang, Y.-F. Huang, K.-W. Lee, and W.- R. Kuo, “Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve,” Surgery, vol. 137, no. 3, pp. 342–347, 2005. [16] A. Miyauchi, T. Yokozawa, K. Kobayashi, K. Hirai, F. Mat- suzuka, and K. Kuma, “Opposite ansa cervicalis to recurrent laryngeal nerve anastomosis to restore phonation in patients with advanced thyroid cancer,” European Journal of Surgery, vol. 167, no. 7, pp. 540–541, 2001. [17] A. Miyauchi, Y. Ito, A. Miya, T. Higashiyama, C. Tomoda, Y. Takamura, K. Kobayashi, and F. Matsuzuka, “Lateral mobilization of the recurrent laryngeal nerve to facilitate tracheal surgery in patients with thyroid cancer invading the trachea near Berry’s ligament,” World Journal of Surgery, vol. 31, no. 11, pp. 2081–2084, 2007. [18] A. Miyauchi, H. Inoue, C. Tomoda, M. Fukushima, M. Kihara, T. Higashiyama, Y. Takamura, Y. Ito, K. Kobayashi, and A. Miya, “Improvement in phonation after reconstruction of the recurrent laryngeal nerve in patients with thyroid cancer invading the nerve,” Surgery, vol. 146, no. 6, pp. 1056–1062, [19] A. Piner ˜ os-Fernandez, ´ P. F. Rodeheaver, and G. T. Rodeheaver, “Octyl 2-cyanoacrylate for repair of peripheral nerve,” Annals of Plastic Surgery, vol. 55, no. 2, pp. 188–195, 2005. [20] T. Landegren, M. Risling, A. Brage, and J. K.E. Persson, “Long- term results of peripheral nerve repair: a comparison of nerve anastomosis with ethyl-cyanoacrylate and epineural sutures,” Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, vol. 40, no. 2, pp. 65–72, 2006. [21] C. Auba, ´ B. Hontanilla, J. Arcocha, and O. Gorr´ıa, “Peripheral nerve regeneration through allografts compared with auto- grafts in FK506-treated monkeys,” Journal of Neurosurgery, vol. 105, no. 4, pp. 602–609, 2006. [22] B.-H. Choi, B.-Y. Kim, J.-Y. Huh, S.-H. Lee, S.-J. Zhu, J.- H. Jung, and B.-P. Cho, “Microneural anastomosis using cyanoacrylate adhesives,” International Journal of Oral and Maxillofacial Surgery, vol. 33, no. 8, pp. 777–780, 2004. [23] Y. C. Tseng, S. H. Hyon, Y. Ikada, Y. Shimizu, K. Tamura, and S. Hitomi, “In vivo evaluation of 2-cyanoacrylates as surgical adhesives,” Journal of Applied Biomaterials,vol. 1, no.2,pp. 111–119, 1990. [24] K. Wieken, K. Angioi-Duprez, A. Lim, L. Marchal, and M. Merle, “Nerve anastomosis with glue: comparative histologic study of fibrin and cyanoacrylate glue,” Journal of Reconstruc- tive Microsurgery, vol. 19, no. 1, pp. 17–20, 2003. [25] L. Montanaro, C. R. Arciola, E. Cenni, G. Ciapetti, F. Savioli, F. Filippini, and L. A. 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