Management of Recurrent Laryngeal Nerve Injury During Radiofrequency Ablation of Thyroid Nodules.

Introduction

Although radiofrequency ablation (RFA) is a safe and effective treatment for benign thyroid nodules,, the proximity of the recurrent laryngeal nerve (RLN) to the posterior part of the thyroid gland in the tracheoesophageal groove puts it at risk of thermal injury during the procedure. Most RLN injuries result in immediate voice change. No standardized protocol has been described to treat this; however, the injection of cold dextrose 5% in water (D5W) around the RLN has been shown to improve symptoms of nerve damage during RFA in recent retrospective studies., In this video, we present this technique.

Case Description

A 44-year-old woman with euthyroid presented with a 3.4-cm right-sided thyroid nodule causing compressive symptoms and cosmetic issues. She elected to proceed with RFA to relieve symptoms.

Technique

Informed consent was obtained, and standard aseptic technique was followed. The vagus nerve was identified superior and lateral to the carotid. Using a trans-isthmic approach, an 18-gauge RFA probe with a 0.7-cm active tip was inserted into the nodule, and ablation was started using an initial power of 30 watts.

The patient was asked to verbalize every 1 to 2 minutes by asking a standard question, and voice was evaluated each time. Her voice changed and became hoarse as the inferior part of the nodule was being ablated. The procedure was stopped immediately.

A 25-gauge needle was used to inject D5W at a temperature of 0 to 4 °C into the transesophageal groove under ultrasound guidance. This was performed by injecting small, intermittent boluses until a total of 10 mL of D5W was introduced, infusion was stopped, and the needle was removed once the patient’s voice returned back to baseline.

The patient’s voice returned to baseline after the cold D5W. The ablation was completed after recovery of voice. Her voice was evaluated both 3 days and 2 weeks after RFA and remained normal.

Conclusions

The immediate injection of cold D5W mitigates thermal injury to the RLN during RFA of thyroid nodules. It is recommended that cold D5W at temperature of 0 to 4 °C be readily available prior to performing RFA(4), allowing for immediate intervention should changes in voice occur.

Disclosure

The authors have no multiplicity of interest to disclose.