Ann Thorac Surg 2000;70:1722-1723
© 2000 The Society of Thoracic Surgeons
Case report
Esophageal carcinoma with nonrecurrent inferior laryngeal nerve
Tomoyuki Shimada, MDa,
Hideo Terashima, MDa,
Takuya Shimizu, MDa,
Ryuya Abe, MDa,
Katsu Hirayama, MDa
a Department of Surgery, Hiraka General Hospital, Akita, Japan
Address reprint requests to Dr Shimada, Department of Surgery, Hiraka General Hospital, 1-30, Ekimaecho, Yokote, Akita, 013-8610, Japan
e-mail: tomoyuki{at}rnac.ne.jp
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Abstract
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Occurrence of a nonrecurrent inferior laryngeal nerve is quite rare. We present the case of a 70-year-old man with carcinoma of the esophagus. An abnormal right subclavian artery was detected preoperatively. This anomaly suggested that the right inferior laryngeal nerve branched directly from the vagal trunk. A carcinoma of the esophagus was resected, and lymph nodes were dissected. The right inferior laryngeal nerve was fully preserved, and the esophagus was primarily repaired.
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Introduction
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Although a lymphadenectomy along the inferior laryngeal nerve is efficient for treating carcinoma of the esophagus, injury to the inferior laryngeal nerve is not an unusual complication, especially if the carcinoma occurs on the upper thoracic or cervical esophagus. The right inferior laryngeal nerve usually takes a recurrent course under the right subclavian artery, but in rare cases, it takes an almost direct course to the larynx depending on the anomaly of the aortic arch. Preoperative recognition of this nerve anomaly allows surgeons to avoid injuring the nerve. We present an operated case of esophageal carcinoma with a nonrecurrent inferior laryngeal nerve.
A 70-year-old man presented at our institution in 1999 with the diagnosis of esophageal carcinoma. The tumor was 2.2 x 1.9 cm in size and located in the upper third of the thoracic esophagus. Histologic examination from a biopsy specimen revealed moderately differentiated squamous cell carcinoma. A barium swallow test showed not only the tumor but also a rounded notch mark above it (Fig 1). Computed tomography revealed the anomaly of the right subclavian artery which arose as the fourth branch of the aortic arch. This artery arose from the posterior wall of the aortic arch and ran rightward between the esophagus and the vertebral column (Fig 2). This anomaly suggested that the right inferior laryngeal nerve, having no vessel around which to recur, took a direct course to the larynx.
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Fig 1. A barium swallow test shows not only the tumor (white arrow) but also posterior compression of the esophagus (black arrow).
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After a complete medical examination, surgery for carcinoma of the esophagus was performed. First, a laparotomy was performed and a stomach tube was made for use in reconstruction. Second, the procedure shifted to the cervical field. The right recurrent laryngeal nerve was not found at its usual place, but the vagal nerve branched directly to the larynx as was previously expected. It was identified and preserved in safety. Swollen metastatic lymph nodes were observed at the cervical paraesophageal area and continuing to the thoracic paratracheal area. A lymphadenectomy was performed and was continued down to the intrathoracic lymph nodes. Finally, the esophageal tumor was approached through the right fifth intercostal thoracotomy. The tumor lesion was inspected and palpated in the upper third of the esophagus. An esophagectomy was performed from the lower area to the upper area with regional lymph nodes dissection.
The right subclavian artery ran rightward between the esophagus and the vertebral column. We had to be meticulous so as not to injury the aberrant artery. The right vagal nerve was identified but had no recurrent branch along the artery. We did not need to be careful to prevent a recurrent nerve injury during lymph node dissection because the right inferior laryngeal nerve had already been identified and preserved in the cervical field. The swollen metastatic lymph nodes, which had already been manipulated through a cervical approach, were completely dissected with additional lymphadenectomy through a thoracic approach. The esophago-gastrostomy was performed with staples through the posterior mediastinal route. Histologic examination revealed moderately differentiated squamous cell carcinoma with nodal metastasis. The postoperative course was uneventful. The patient left our institute after adjuvant radiotherapy.
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Comment
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Recurrence of esophageal carcinoma frequently occurs in the cervical and superior mediastinal lymph nodes and contributes to a poor prognosis. Extended (three-field) lymphadenectomy including cervical and superior mediastinal lymph nodes prevents this type of recurrence and improves the survival rate [1, 2]. Although the most important lymph node dissection for carcinoma of the esophagus is along the bilateral inferior laryngeal nerves, the dissection procedure sometimes causes inferior laryngeal nerve paralysis and deteriorates the quality of life after surgery. The inferior laryngeal nerve is usually called a recurrent nerve because it takes a recurrent course along the subclavian artery on the right side or the aortic arch on the left side, but in rare cases it takes an aberrant nonrecurrent pathway to the larynx, depending on the anomaly of the aortic arch. This is called the nonrecurrent inferior laryngeal nerve, and it was first reported by Stedman in 1823 [3]. In the present case, the branches of the aortic arch arose in the following order: (1) the right common carotid artery, (2) the left common carotid artery, (3) the left subclavian artery, and (4) the right subclavian artery. This is a type G arrangement, according to the Adachi-Williams-Nakagawa’s classification system for the branching patterns of the aortic arch [4]. This type of vascular anomaly always causes nonrecurrent laryngeal nerve on the right side.
Henry and colleagues [5] reported 31 cases of right nonrecurrent laryngeal nerve and 2 cases of left nonrecurrent laryngeal nerve with situs inversus and a right-sided arch from 6,307 excisions for thyroid and parathyroid lesions. The incidence of right nonrecurrent laryngeal nerve was 0.63% [5]. Others report almost the same incidence: less than 1% for Avisse and coworkers [6], and 0.58% for Reeve and associates [7]. Although its incidence is rare, nonrecurrent laryngeal nerve represents a major surgical risk for laryngeal nerve paralysis. This nervous anomaly may be suggested only if the corresponding vascular anomaly was diagnosed. However, a barium swallow test and computed tomography are absolutely necessary for the treatment of esophageal carcinoma, and these examinations can easily detect this vascular anomaly. We diagnosed this anomaly before the patient’s operation, so the nonrecurrent inferior laryngeal nerve was preserved without injury. Preoperative recognition of this nerve anomaly allows surgeons to avoid injuring the nerve during surgery for carcinoma of the esophagus. Nonrecurrent inferior laryngeal nerve is a rare anomaly, but it is very important to think about the possibility of arch and laryngeal nerve anomalies before embarking on any operation on the upper esophagus.
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References
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Nishihira T., Hirayama K., Mori S. A prospective randomized trial of extended cervical and superior mediastinal lymphadenectomy for carcinoma of the thoracic esophagus. Am J Surg 1998;175:47-51.[Medline]
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Fujita H., Kakegawa T., Yamana H., et al. Mortality and morbidity rates, postoperative course, quality of life, and prognosis after extended radical lymphadenectomy for esophageal cancer. Comparison of three-field lymphadenectomy with two-field lymphadenectomy. Ann Surg 1995;222:654-662.[Medline]
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Stedman G.W. A singular distribution of some of the nerves and arteries of the neck and the top of the thorax. Edin Med Surg J 1823;19:564-565.
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Matsuno Y., Komiyama M., Shimada Y. An anomalous case of the right subclavian artery as the last branch of the aortic arch. Chiba M J 1996;72:315-317.
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Henry J.F., Audiffret J., Denizot A., Plan M. The nonrecurrent inferior laryngeal nerve. Surgery 1988;104:977-984.[Medline]
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Avisse C., Marcus C., Delattre J.F., et al. Right nonrecurrent inferior laryngeal nerve and arteria lusoria. Surg Radiol Anat 1998;20:227-232.[Medline]
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Reeve T.S., Coupland G.A.E., Johnson D.C., Buddee F.W. The recurrent and external laryngeal nerves in thyroidectomy. Med J Aust 1969;1:380-382.[Medline]
Accepted for publication January 21, 2000.
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Abstract
Introduction
