Original Contribution

Contribution

Position of Terminal Branches of Inferior Thyroid Arteries in Relation to

Recurrent Laryngeal Nerve
* Rimi KR,1 Bose BK2

The thyroid gland is one of the largest endocrine gland. Medical treatment is not sufficient to
manage thyroid disorder especially in case of malignancy and when respiratory distress, dysphagia
are present due to thyroid disease. Major complication of thyroid surgery is recurrent laryngeal
nerve injury. Position of terminal branches of inferior thyroid arteries in relation to recurrent
laryngeal nerve varies. The artery may lie posterior or anterior to the nerve or the main trunk of the
nerve or its branches intermingle with the terminal branches of the inferior thyroid artery. The
variation in the relation of recurrent laryngeal nerve is important during the exposure and
mobilization of the gland in the various stages of partial and complete thyroidectomy. In
mobilization of the gland, the relationship of the recurrent laryngeal nerve and the inferior Thyroid
artery is important while placing the ligature in the inferior thyroid artery. To improve the results
of thyroidectomy a careful study of position of terminal branches of inferior thyroid arteries in
relation to recurrent laryngeal nerve is required. This is a descriptive analytic type of study. It was
done in the Department of Anatomy, Dhaka Medical College from July 2003 to December 2004.
Fifty seven (57) postmortem human thyroid gland and ten (10) thyroid gland surgery was from
BIRDEM hospital to see the relation of recurrent laryngeal nerve with inferior thyroid artery. Age
of the subjects ranged from 10 to 60 years. They were divided into three groups: group I (10 – 20
years), group II (21 – 40 years), group III (41 – 60 years). Relationship of terminal branches of
inferior thyroid arteries with recurrent laryngeal nerve in cadaver varies on both sides. On the right
side the recurrent laryngeal nerve was found to be passed most commonly in between the arteries
but on the left side it passes most commonly posterior to artery. But on both sides it passed
anterior, posterior or in between the branches of artery. In living body relationship showed similar
result. The main limitation of the study was small sample size in living body. However, to establish
normal standard for Bangladeshi people further studies with large samples from different zone,
especially in endemic zone of the country to correlate different types of anatomical variations with
age, sex and metabolic state of the individuals are suggested.

[Dinajpur Med Col J 2010 Jul; 3 (2):47-54]

Key words: Terminal Branches of Inferior thyroid artery, recurrent laryngeal nerve, post mortem,
living.

Introduction hyperthyroidism, autoimmune thyroiditis,

T hyroid gland receives more blood per

gram of tissue (5.5 ml/gm/min) than
any other organ.1 All blood is supplied
by a number of arteries and drained by an
Graves’ disease of which hypothyroidism due
to iodine deficiency is the commonest.2
Medical treatment is not sufficient to manage
thyroid disorder specially in case of
even greater number of veins. Recurrent malignancy and when respiratory distress,
laryngeal nerve is intimately related with dysphagia are present due to thyroid disease.3
thyroid gland especially with inferior thyroid
arteries. The diseases which usually affect the
thyroid gland are hypothyroidism,

1. *Dr. Kanata Roy Rimi, Associate Professor, Department of Anatomy, Dinajpur Medical College, Dinajpur.
2. Dr. B K Bose, Director, Center for Nuclear medicine and Ultrasound, Dinajpur.
*
For correspondence

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 Original Contribution
Contribution

The overall incidence of accidental unilateral see the relation of recurrent laryngeal nerve
recurrent laryngeal nerve injury was 4.8 with inferior thyroid artery.
percent.4 One of the major complication of
thyroidectomy is recurrent laryngeal nerve Only fresh body were chosen for collection of
injury.5 The relationship of the recurrent study materials who died within the preceding
laryngeal nerve to the inferior thyroid arteries 12 to 24 hours. From each cadaver the thyroid
varies. The artery may lie posterior or anterior and related neighbouring structures were
to the nerve or the main trunk of the nerve or collected using the following procedure. The
its branches intermingle with the terminal personnel of the Department of Forensic
branches of the inferior thyroid artery.6 Medicine, Dhaka Medical College were
requested to give incisions carefully not to
The recurrent laryngeal nerve may lie in front, damage the isthmus or any other part of the
behind or between the branches of the artery.7 thyroid gland particularly vessels and nerves
There are 28 possible variations described. during postmortem examination. In the neck
For practical purposes, three major types are region, the skin along with the platysma was
important. Among the 102 cadavers, the nerve retracted laterally and the thyroid gland and
passed behind the artery in a majority of related structures (e.g. the carotid arteries, the
cases.8 On the right the nerve most frequently internal jugular veins) were identified. The
lies between arterial branches (48%), on the sternocleidomastoid muscle was cut in its
left, it was usually behind the artery (64%).9 middle and was better exposed. In the chest,
the skin, superficial fascia, and deep fascia
The incidence of permanent recurrent were retracted laterally in one flap. Then the
laryngeal nerve paralysis was 2.4%.10 pectoralis major muscle was cut at its origin
Paralysis of vocal cord is a common and was retracted laterally.
complication of thyroidectomy. Iatrogenic Structures extending from the base of the
injury to the recurrent laryngeal nerve or to its skull up to the mediastinum which included
branches better avoided by searching, the thyroid and parathyroid glands, tongue,
identifying and exposing the nerve itself and parts of the pharynx, oesophagus, larynx,
by following its course with care. Deep trachea, thymus, fibrous pericardium, great
knowledge of the thyroid region and the vessels of the neck, arch of aorta and its
awareness of the extremely varying course of branches, hyoid bone, part of right and left
the recurrent laryngeal nerve and the inferior bronchus were separated enmass from the
thyroid artery and their relations should be body (Enayetullah, 1996).
taken into account by surgeons.11
The collecting viscera was washed gently
Methods with tap water, blood and the blood clot were
The study was carried out on human thyroid removed as far as possible. Selected viscera
glands of sixty seven (67) Bangladeshi people were duly tagged with a piece of waxed cloth
out of this, fifty seven (57) glands were which bear an identifying number along with
collected from unclaimed dead bodies the age & sex of the victim. Then the viscera
autopsied in the morgue of the Department of was fixed and preserved in 10% formalin
Forensic Medicine, Dhaka Medical College solution.
after requisite legal formalities. Remaining
ten (10) thyroid gland surgery was observed The samples were divided into three different
in ENT Department of BIRDEM Hospital to age groups (Table I). Male and female
subjects are shown in table II.

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Contribution

Table I: Different groups of thyroid gland Results

according to age of cadaver Table III and figure 3 shows the Position of
terminal branches of inferior thyroid arteries
Age (in Number of thyroid gland in relation to recurrent laryngeal nerve in
Group %
year) n=57 cadaveric male and female. In this study one
I 10 - 20 13 22.80 non-recurrent laryngeal nerve was found on
the right side but in that case on the left side
II 21 - 40 32 56.15 recurrent laryngeal nerve was present (figure
2). So, total number of recurrent laryngeal
III 41 - 60 12 21.05
nerve was 53 on the right side. Among the
male cadaver in 19.4% cases, the recurrent
Table II: Groups according to sex laryngeal nerve passes anterior to the arteries,
35.5% to posterior and 45.2% cases, it passes
Sex Cadaver Living Total between the arteries on the right side. Among
Male 34 3 37
Female 23 7 30 the female cadaver in 27.3% cases, the
recurrent laryngeal nerve passes anterior to
arteries and in another 27.3% cases it passes
It was observed whether recurrent laryngeal posterior and 45.4% cases, it passes between
nerve placed in front or behind or in between the arteries.
of terminal branches of inferior thyroid
arteries. Position of terminal branches of On left side, among the male cadaver, 6.3%
inferior thyroid arteries in relation to recurrent cases, the recurrent laryngeal nerve passes
laryngeal nerve in cadaver and in living body anterior to the arteries in 56.3% posterior and
during thyroid surgery was observed.. When 37.5% cases, it passes between the arteries.
total thyroidectomy done by ENT specialist, Among the female cadaver, 15.8% cases, the
relationship was observed in both sides, but in recurrent laryngeal nerve passes anterior to
case of lobectomy, relationship was observed the arteries and another 57.9% passes
in respective side of surgery. posterior and 26.3% cases, it passes between
the arteries.
In operation theater ten cases of thyroid
surgery was observed. Among them, 3 Analysis revealed that no statistically
persons were male and female were 7 in significant variation of relation was found
number. Total thyroidectomy has been between recurrent laryngeal nerve and inferior
observed in 6 persons (Male 1 and female 5) thyroid arteries among the male and female
and lobectomy has been observed in 4 persons cadaver (p>0.05).
(male 2 and female 2). Surgery was done by
ENT specialist. In total thyroidectomy cases, Table III shows the position of terminal
relationship on both sides of recurrent branches of inferior thyroid arteries in relation
laryngeal nerve and terminal (glandular) to recurrent laryngeal nerve in the living male
branches of inferior thyroid artery has been and female body. In case of male, three
observed, but in case of lobectomy, the lobectomies was seen, so relationship of nerve
relationship has been observed in the and artery had observed in three cases on one
respective side of surgery. side. No total thyroidectomy had seen in case
of male. Two thyroidectomy and five
lobectomy in female was observed. So
relationship of nerve and artery had observed

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Contribution

on both side in case of two female living and in 33.3% cases, it passes between the
body. In five cases relationship of nerve and inferior thyroid arteries.
artery had observed on one side in case of
female. On the right side, among the male On the left side, no recurrent laryngeal nerve
body, in 50.0% cases, the recurrent laryngeal passes anterior to inferior thyroid artery in
nerve passes anterior to inferior thyroid both male and female living body. Only in
artery, in one case (50.0%), it passes between one (100%) cases, the recurrent laryngeal
the inferior thyroid arteries. Among the nerve passes in between the inferior thyroid
female body, in 16.7% cases, the recurrent artery in case of male. Among the female
laryngeal nerve passes anterior to inferior cases, in 60.0% cases it passes posterior to
thyroid artery and in 50.0% passes posterior inferior thyroid artery and in 40.0% passes
between the inferior thyroid artery.

Table III: Position of terminal branches of inferior thyroid arteries in relation to recurrent laryngeal
nerve in cadaveric male and female

Relationship of recurrent of laryngeal nerve with terminal (glandular) branches of inferior thyroid arteries

Right side (n=53) Left side (n=51)

Sex

Anterior Posterior In between Anterior Posterior In between

No. % No. % No. % No. % No. % No. %

Male 6 19.4 11 35.5 14 45.2 2 6.3 18 56.3 12 37.5

Female 6 27.3 6 27.3 10 45.4 3 15.8 11 57.9 5 26.3

Total 12 22.6 17 32.1 24 45.3 5 9.8 29 56.9 17 33.3

p value p>0.05 p>0.05

*p value obtained from chi square analysis

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Contribution

Figure 1. Possible relationship of the inferior thyroid artery to the laryngeal nerve
A. Recurrent laryngeal nerve (n) passing anterior to the arteries (a).
B. Recurrent laryngeal nerve (n) passing posterior to the arteries (a).
C. Recurrent laryngeal nerve (n) passing in between the arteries (a).
D. Non-recurrent laryngeal nerve(n) passing directly to the larynx
(From: Tzinas [Link], 1980)

Figure 2. The thyroid gland and its related structures. Upper arrow indicates glandular branch of inferior thyroid artery
of left side, which divides into two branches. Lower arrow indicates recurrent laryngeal nerve of left side. Nerve passes
behind the artery.

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70

60 57.9
56.3

50
45.245.4

40 37.5
35.5

30 27.3 27.3 26.3

19.4
20 15.8

10 6.3

0
Anterior Posterior In between Anterior Posterior In between

Right Side Left Side

Male Female

Figure 3. Position of terminal branches of inferior thyroid arteries in relation to recurrent

laryngeal nerve in cadaveric male and female

Table IV: Position of terminal branches of inferior thyroid arteries in relation to recurrent laryngeal
nerve in living body (n=10)

Position of terminal branches of inferior thyroid arteries in relation to recurrent laryngeal nerve in living
body

Right side Left side

Sex
Anterior Posterior In between Anterior Posterior In between

No. % No. % No. % No. % No. % No. %

Male 1 50.0 0 0.0 1 50.0 0 0.0 0 0.0 1 100.0

Female 1 16.7 3 50.0 2 33.3 0 0.0 3 60.0 2 40.0

Total 2 25.0 3 37.5 3 37.5 0 0.0 3 50.0 3 50.0

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Discussion On the right side among male patients in

The position of terminal branches of inferior 50.0% cases the recurrent laryngeal nerve
thyroid arteries in relation to recurrent passed anterior to the inferior thyroid arteries
laryngeal nerve varies. The artery may be and 50.0% cases it passed in between the
posterior or anterior to the nerve or the main artery, no artery was found to pass posterior
trunk of the nerve or its branches may be to the artery. Among female patient in 16.7%
intermingled with the terminal branches of the cases the recurrent laryngeal nerve passed
inferior thyroid artery.12 On the right side anterior to inferior thyroid artery and in
there are almost equal chances of finding the 50.0% cases passed posterior and in 33.3%
nerve anterior, posterior or intermingled with cases it passed between the inferior thyroid
the branches of the artery.13 Aberrant nerve is arteries on the right side. In 100% cases the
more common on the right. On the left side nerve passed in between the arteries in case of
the nerve is most likely to the posterior to the male. In case of female the nerve passed
artery and least likely to be anterior.14 The posteriorly in 60% cases and in 40% cases
present study shows that on right side among passed in between the arteries on the left side.
male cadaver in 19.4% cases recurrent The variation in the position, branching and
laryngeal nerve passed anterior to the arteries, relations of the recurrent laryngeal nerve is
in 35.5% posterior and in 45.2% cases, it important during the exposure and
passed between the arteries. In female cadaver mobilization of the gland in the various stages
in 45.4% cases the nerve passed between the of partial and complete thyroidectomy. In
arteries, 27.3% cases recurrent laryngeal mobilization of the gland, the relationship of
nerve passed anterior to arteries, another the nerve and the artery is important while
27.3% cases it passed posterior to arteries. In placing the ligature in the inferior thyroid
this study it was also seen that on the left side, artery, as far as laterally to safeguard the
among male cadaver, recurrent laryngeal nerve in all cases but in case of non recurrent
nerve mostly passed in 56.3% cases posterior laryngeal nerve there is still risk of damaging
to arteries, in 6.3% cases it passed anterior to the nerve when securing bleeding points on or
the arteries and in 37.5% cases it passed near at a later stage of the operation.15. In
between the arteries. Among the female order to minimize the risk of damage to the
cadaver in 15.8% cases the recurrent nerve and others have advocated the
laryngeal nerve passed anterior to the arteries identification of the laryngeal nerve in all
and another 57.9% cases passed posterior to cases of thyroidectomy.16
the arteries and in 26.3% cases it passed
between the arteries. It was revealed that no
statistically significant variation of relation
was found between recurrent laryngeal nerve
and inferior thyroid artery among the male
and female cadaver (p>0.05). In this study the
position of terminal branches of inferior
thyroid arteries in relation to recurrent
laryngeal nerve was studied during thyroid
surgery among 10 patients to see whether
there was any difference between cadaver and
living body. The observations were more or
less similar between cadaver and living body.

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Contribution

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