Image of the Month—Quiz Case

A 56-year-old woman was referred for evaluation of a multinodular goiter. Fine-needle aspiration of a dominant 4.6-cm nodule was consistent with a Hürthle cell neoplasm. She noted occasional vocal raspiness but denied any other symptoms of compression secondary to her goiter, such as dysphagia or respiratory distress. Preoperative laryngoscopy demonstrated bilateral normal vocal cord motion. The patient was brought to the operating room for planned total thyroidectomy. At the time of surgery, the patient had the findings seen in Figure 1. Findings of a postoperative computed tomography scan are shown in Figure 2.

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Figure 1. Intraoperative image demonstrating the right nonrecurrent laryngeal nerve exiting the carotid sheath and traveling medially to insert into the larynx. V indicates vagus; N, nonrecurrent laryngeal nerve.

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Figure 2. Computed tomography demonstrating the arteria lusoria or aberrant right subclavian artery coming directly off the aortic arch and coursing posteriorly behind the esophagus. T indicates trachea; E, esophagus; and S, subclavian artery.

A.  Right-sided thoracic duct

B.  Right-sided inferior nonrecurrent laryngeal nerve

C.  Prominent ansa cervicalis

D.  Low-lying hypoglossal nerve

Answer