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Original Investigation |

Comparison of Conventional, Revascularized, and Bioengineered Methods of Recurrent Laryngeal Nerve Reconstruction

Jordan P. Sand, MD1; Andrea M. Park, MD1; Neel Bhatt, MD1; Shaun C. Desai, MD1; Laura Marquardt, PhD2; Shelly Sakiyama-Elbert, PhD2; Randal C. Paniello, MD, PhD1
[+] Author Affiliations
1Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
2Department of Biomedical Engineering, Washington University, St Louis, Missouri
JAMA Otolaryngol Head Neck Surg. 2016;142(6):526-532. doi:10.1001/jamaoto.2016.0151.
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Importance  Damage to the recurrent laryngeal nerve (RLN) is highly detrimental to voice, swallow, and cough. The optimal method for reconstitution of a nerve gap after injury is unknown.

Objective  To evaluate multiple methods of RLN reconstruction.

Design, Setting, and Participants  This study used an established canine model of RLN injury to examine purpose-bred, conditioned, female, 20-kg mongrel hounds at Washington University. A total of 32 dogs were examined, with 63 experiments performed.

Interventions  Surgical transection or excision of the RLN with reconstruction by multiple methods.

Main Outcomes and Measures  Six months after injury repair, laryngeal adductor pressures (LAPs), spontaneous and stimulable movement, and graft axon counts by histologic analysis were assessed.

Results  Simple RLN transection with direct neurorrhaphy provided a mean (SD) recovery of 55.5% (12.5%) of baseline LAPs (P = .18 for comparison of LAP recovery among cases from the conventional nerve graft [39.4% (22.2%)]; P = .63 for comparison of LAP recovery among cases from the reverse autograft [60.8% (27.5%)]). Revascularized grafts provided a recovery of 54.5% (46.4%) while short and long acellular grafts provided recoveries of 60.4% (NA) and 39.5% (17.0%). Two of 11 polyglycolic acid reconstructions provided a measurable LAP with a mean (SD) recovery of 37.1% (8.9%) of baseline. Reconstruction with a neural conduit in any condition provided no measurable LAP recovery.

Conclusions and Relevance  Conventional nerve grafting resulted in no significant difference in recovery of LAP function compared with simple neurorrhaphy or reverse autograft. Conventional and revascularized nerve grafts provided similar recovery. The use of bioengineered acellular nerve grafts or nerve conduits for reconstruction resulted in poor recovery of function.

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Figure 1.
Polyglycolic Acid Tube In Vivo

A total of 0.5 cm of each of 2 recurrent laryngeal nerve stumps is sutured into a 2-cm segment of a polyglycolic acid tube after 1 cm of the nerve segment has been removed. A 1-cm gap exists between the 2 nerves inside the polyglycolic acid tube.

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Figure 2.
Saphenous Neurovascular Bundle In Vivo

A dissected canine hind limb with saphenous nerve (white arrowhead) and its associated vasculature (black arrowhead).

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Figure 3.
Revascularized Nerve Graft In Vivo

Dissected recurrent laryngeal nerve after removal of 5 cm of nerve and placement of a vascularized saphenous nerve graft showing 2 nerve anastomoses (green arrowheads), arterial anastomosis (white arrowhead), and vein anastomosis (blue arrowhead).

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Figure 4.
Axon Histologic Analysis

Postinjury recurrent laryngeal nerve showing staining of the axons for counting (osmium tetroxide and hematoxylin-eosin, original magnification ×40). Scale bar indicates 1 mm.

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