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Special Feature
Nov 2011

Image of the Month—Diagnosis

Arch Surg. 2011;146(11):1328. doi:10.1001/archsurg.2011.274-b
Answer: Right-Sided Inferior Nonrecurrent Laryngeal Nerve

A right-sided inferior nonrecurrent laryngeal nerve is an uncommon anomaly found in 0.3% to 1.6% of the population.1 The anomaly results from abnormal embryonic development of the aortic arches. When the right fourth arch is absent, the innominate artery is absent. The right subclavian artery runs an aberrant course, originating from the aortic arch, distal to the left subclavian artery, and traversing midline behind the esophagus and is termed an arteria lusoria. The absent innominate artery with aberrant right subclavian artery is the most common anomaly of the aortic arch, occurring in 0.4% to 1.8% of the population.2,3 During embryonic lengthening of the neck, the nerve branch is not attached at the level of the thorax and migrates upward, arising directly from the vagus nerve in the cervical region.1,2,46

The best way to identify a nonrecurrent laryngeal nerve is systematic location and dissection of the nerve intraoperatively.2 Early visualization of the nerve as it perpendicularly divides from the vagus nerve will eliminate a lengthy dissection within the tracheoesophageal groove.3 Once a patient has been diagnosed as having this abnormality, further evaluation is useful to identify potential causes of dysphagia, secondary to tracheal and/or esophageal compression and possible aneurysm.2,3 A barium swallow test may demonstrate a notch on the posterior wall of the esophagus.2 Arteriography and contrast-enhanced computed tomography, magnetic resonance angiogram, and/or duplex ultrasonography may be used to identify the absence of the right subclavian artery.4

This patient underwent successful thyroidectomy, with great care to preserve the nonrecurrent laryngeal nerve. She had no voice changes after surgery.

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Article Information

Correspondence: Amanda L. Amin, MD, Department of Surgery, 9200 W Wisconsin Ave, Milwaukee, WI 53204 (aamin@mcw.edu).

Accepted for Publication: March 1, 2011.

Author Contributions:Study concept and design: Amin and Wang. Acquisition of data: Amin. Analysis and interpretation of data: Amin. Drafting of the manuscript: Amin. Critical revision of the manuscript for important intellectual content: Amin and Wang. Administrative, technical, and material support: Wang. Study supervision: Wang.

Financial Disclosure: None reported.

Additional Information: This study was declared exempt from the Medical College of Wisconsin/Froedtert Hospital Institutional Review Board approval.

Box Reference
Submissions

The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

References
1.
Toniato A, Mazzarotto R, Piotto A, Bernante P, Pagetta C, Pelizzo MR. Identification of the nonrecurrent laryngeal nerve during thyroid surgery: 20-year experience.  World J Surg. 2004;28(7):659-661PubMedArticle
2.
Avisse C, Marcus C, Delattre JF,  et al.  Right nonrecurrent inferior laryngeal nerve and arteria lusoria: the diagnostic and therapeutic implications of an anatomic anomaly: review of 17 cases.  Surg Radiol Anat. 1998;20(3):227-232PubMed
3.
Pettiford J, Erasmus J, Grubbs EG, Perrier ND. Dysphagia lucoria: consideration for the endocrine surgeon.  Surgery. 2010;147(6):890-892PubMedArticle
4.
Deveze A, Sebag F, Hubbard J, Jaunay M, Maweja S, Henry JF. Identification of patients with a non-recurrent inferior laryngeal nerve by duplex ultrasound of the brachiocephalic artery.  Surg Radiol Anat. 2003;25(3-4):263-269Article
5.
Henry JF, Audiffret J, Denizot A, Plan M. The nonrecurrent inferior laryngeal nerve: review of 33 cases, including two on the left side.  Surgery. 1988;104(6):977-984PubMed
6.
Mra Z, Wax MK. Nonrecurrent laryngeal nerves: anatomic considerations during thyroid and parathyroid surgery.  Am J Otolaryngol. 1999;20(2):91-95PubMedArticle
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