Vagus Nerve's Topography in the Carotid Sheath: preliminary results
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The knowledge of the vagus nerve's location within the carotid sheath is essencial in many surgical contexts, such as thyroidectomy. Intraoperative neuromonitoring may prevent iatrogenic nerve injury. There are only few studies about vagus nerve and its topography in the carotid sheath. This study aims to analyze the variation of the vagus nerve topography and its relation with the common carotid artery and the internal jugular vein, at the infrahyoid region. We dissected 10 carotid sheaths from 5 cadavers and the position of the vagus nerve and its relationship with the common carotid artery and the internal jugular vein were determined. Based on the carotid sheath cross‐section, the location of the vagus nerve was classified in four quadrants: between the common carotid artery and the internal jugular vein, but anterior to the carotid artery's cross section (A), between the common carotid artery and the internal jugular vein, but posterior to the carotid artery's cross‐section (B), posterior and medial to the carotid artery's cross section (C) and posterior and lateral to the internal jugular vein's cross‐section (D). We found 6 vagus nerve in position (A), 1 in position (B), 0 in position (C) and 3 in position (D). The knowledge of variations and their prevalence regarding the position of the vagus nerve as described in this preliminary study may contribute to avoid iatrogenic lesions in cervical surgeries.Keywords:
Internal jugular vein
Jugular vein
Objective 1) Provide normative electrophysiological vagal and recurrent laryngeal nerve reference range values for intraoperative nerve monitoring in humans. 2) Highlight potential documentation implications of intraoperative nerve monitoring. Method Consecutive monitored adult patients undergoing thyroid, parathyroid, and related neck surgery were included in this IRB approved study performed over an 8 month period. All patients had a preoperative and postoperative laryngeal examination to assess vocal cord function. Patients with an abnormal preoperative laryngeal examination were excluded. Results In 64 patients the mean amplitude of the RLN (704mV, SD ± 512.7mV) was greater than the vagus nerve (524.5mV, SD± 388.0mV). The mean latency of the left and right RLN were 3.36ms (SD ± 0.92) and 3.45ms (SD ± 0.62) respectively. The mean latency of the left vagus was 7.48ms (SD ± 1.32), and the right vagus was 6.65ms (SD ± 1.28). The mean threshold intensity of stimulation of the right (0.41 mV, SD 0.20 mV) and left vagus (0.40 mV, SD 0.23 mV) were similar. The mean threshold of stimulation was higher in the right RLN (0.51 mV, SD 0.44). Amplitudes tended to be higher in females. Conclusion Normative vagal and RLN data is presented. The mean amplitude of the RLN was greater than the vagus nerve. The mean latency of the left vagus is longer than the right side. The threshold of stimulation is well below the standard stimulation current of 1 to 2 milliamps.
Vagus Nerve Stimulation
Superior laryngeal nerve
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Total thyroidectomy was performed in a 53-year-old male, with Graves-Basedow's disease. At surgery, the vagus nerve was found to be located medially to the carotid artery associated with a non-recurrent laryngeal nerve arising directly from the cervical vagus: this association has never been described in the literature. These results indicate that a medial location of the vagus nerve may be considered as a "pilot light" of the non-recurrent laryngeal nerve.
Superior laryngeal nerve
Recurrent nerve
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In the present study we determine the feasibility of intraoperative neuromonitoring following the administration of a nondepolarizing neuromuscular blocking agent during thyroid operations, as well as the influence of rocuronium on the achievement of optimal vagal stimulation during intraoperative neuromonitoring in thyroid surgery. We further investigate whether accelerometry is a reliable approach to obtaining an ipsilateral vagus signal prior to recurrent laryngeal nerve dissection. Included in the study were 61 thyroidectomized patients whose demographic data, indications, type of surgery, vagus, and recurrent nerve values before and after resection were obtained. We created five groups of patients based on the twitch values recorded during ipsilateral vagus stimulation prior to the recurrent laryngeal nerve dissection: (1) <10%, (2) 11–25%, (3) 26–50%, (4) 51–75% and (5) >75%. The average electromyography amplitudes of the vagus nerve prior to the determination of the recurrent laryngeal nerve for each group were 552 μV, 463 μV, 543 μV, 513 μV and 551 μV, respectively. No difference between the groups was observed in this regard (p > 0.05). It can be expected that as soon as the effects of neuromuscular blockers on the peripheral muscles begin to abate, it will be possible to obtain the ipsilateral vagus signal prior to recurrent laryngeal nerve dissection at the desired levels. It can be concluded from this study that accelerometry using the pollicis muscle is an unreliable tool for the interpretation of the proper electromyography signals of the vagus nerve prior to the determination of the recurrent laryngeal nerve.
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Superior laryngeal nerve
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Ultrasonography, computed tomography, and magnetic resonance imaging were performed to differentiate preoperatively between schwannomas of the vagus nerve and schwannomas of the cervical sympathetic chain by observing the position of schwannomas in regard to the surrounding blood vessels. Ultrasonography also permitted direct visualization of the vagus nerve, so its position relative to the schwannoma could be examined. In schwannomas of the vagus nerve the schwannoma grew between the common carotid artery and the internal jugular vein or between the internal carotid artery and the internal jugular vein, resulting in an increase in the distance between the artery and vein (separation). In schwannomas of the cervical sympathetic chain, no separation was observed between the internal jugular vein and the common carotid artery or internal carotid artery. Ultrasonography with a 7.5-MHz transducer showed the derivation of the tumor from the vagus nerve in schwannomas of the vagus nerve but showed the vagus nerve on the tumor surface in schwannomas of the cervical sympathetic chain.
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Superior laryngeal nerve
Superior thyroid artery
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Objective:To locate the recurrent laryngeal nerve fascicles in vagus and investigate the effect of latero terminal neurorrhaphy to repair recurrent laryngeal nerve.Method:The method of dissection and acetylcholinesterase histochemical staining of neural fibers were used to locate the recurrent laryngeal nerve fascicles in vagus. Then 60 SD rats were divided into three groups. In experimental group right recurrent laryngeal nerve were incised and anastomosed to recurrent laryngeal nerve fascicles in vagus by means of latero terminal neurorrhaphy. In control group right recurrent laryngeal were incised and sutured immediately by means of end to end nerve anastomosis. In normal group rats were not treated by any elements. One to three months later, 10 rats from each group were examined for vocal cord movement and nerve regeneration by using fibrolaryngscope and nerve electrormyography.Result:The recurrent laryngeal nerve fascicles is in the medial front segment of the vagus and it's diameter is about one fourth as large as the vagus. One months after operation, This effect of latero terminal neurorrhaphy had significant difference compared with the control group (P 0.05 ) .Three months after operation, This effect of latero terminal neurorrhaphy had not significant difference compared with the control group (P 0.05 ).Conclusion:The location of the recurrent laryngeal nerve fascicles in vagus provids important anatomical guideline for surgery. The latero teminal neurorrhaphy has a similiar treatment effect compared with end to end nerve anastomosis. This microsurgical technique provides a new method for repairing recurrent laryngeal nerve.
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Objective To investigate the value of CT in the diagnosis of schwannomas of the cervical sympathetic nerve(SSN) corrleated with surgical findings.Method Sixteen consecutive patients with schwannomas of the cervical sympathetic nerve,proven by surgery and pathology,were referred to computed tomography axial scanning.The CT findings for the location of masses,size,margin,contrast enhancement,and the rules of displacement of the common carotid artery,internal carotid artery and internal jugular vein were evaluated.Also the locations,characteristics of the lesions and rules of displacement of the common carotid artery,internal carotid artery and internal jugular vein were described with surgical correlation.Results 10 SSNs were located at the level of the common carotid bifurcation with the common carotid artery abutting against and displacing the lateral periphery of the tumor,and 16 SSNs with the internal carotid artery abutting against and displacing the lateral periphery of the tumor.In 14 SSNs with enhanced CT,the internal jugular vein also abutted against and displaced the lateral periphery of the tumor.All the anatomical positional relationships among the common carotid artery,internal carotid artery and internal jugular vein with the cervical sympathetic nerve were proved by operation.Conclusion CT axial scan can accurately reflect the anatomical positional relationships among the common carotid artery,internal carotid artery and internal jugular vein with the cervical sympathetic nerve.
Internal jugular vein
External carotid artery
Jugular vein
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A schwannoma arising from the vagus nerve is relatively uncommon in the neck. In 3 years, 2 patients with a vagus nerve schwannoma were at the Kyoto First Red Cross Hospital. The two patients were 50 and 59-year-old-males. A CT scan showed the tumor between the common carotid artery and the internal jugular vein, and between the internal carotid artery and the internal jugular vein, respectively resulting in an increase in the distance between the artery and the vein (separation). Both patients underwent complete removal of the tumor using an external approach following a CT preoperative diagnosis of a neurilemmoma of the vagus nerve.A discussion was then made on clinical problems related to the diagnosis including FNA (fine needle aspiration cytology).
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Jugular vein
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To determine the location of thyroid-related nerves by nerve monitoring and demonstrate the usefulness of Nerve Integrity Monitor in thyroid surgery.Descriptive study.Department of General Surgery, University of Health Sciences, Istanbul Training and Research Hospital, Turkey, from February 2017 to January 2020.Patients, who underwent thyroid surgery, were evaluated for age, gender, preoperative diagnosis, type of surgery, histopathological result, postoperative hoarseness, and postoperative vocal cord examinations. The vagus nerve, recurrent laryngeal nerve (RLN), and superior laryngeal nerve (SLN) were mapped by nerve monitoring.A total of 328 patients were included in this study. On both sides, the vagus nerve was most often located in the posterior of the internal carotid artery and internal jugular vein and less frequently anterior to this vein. A total of 303 right RLNs and 305 left RLNs were verified. The SLN was visualised or motor activity was verified by nerve monitoring on the right side in 181 patients and on the left side in 179 patients. The SLN's location was classified most frequently as type I and least frequently as type IIb on the right and left sides.The reported variations, the experience of the surgeon, and these anatomical markers cannot be adequate in preventing nerve injuries. Furthermore, the variations can be identified more clearly peroperatively with the use of nerve monitoring.Laryngeal nerves, Nerve mapping, Nerve monitoring, Nervus vagus, Thyroid surgery, Zuckerkandl tubercles.
Internal jugular vein
Vocal Cord Paralysis
Superior thyroid artery
Superior laryngeal nerve
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Variations in position and relationship between the internal jugular vein (IJV) and the common carotid artery (CCA) may lead to inadvertent artery puncture which could be disastrous during central venous access. We demonstrated the anatomic relationship of the IJV with CCA in order to find the optimal site and avoid damage of CCA.Two hundred and twenty surgical patients were enrolled. We analyzed the distance and relationship between the IJV and CCA at three cross sections (upper border of the thyroid cartilage, cricoid cartilage and second tracheal ring) by ultrasonography and then measured the diameters of the IJV and CCA and the distances from the IJV and CCA to the skin.Twenty patients were excluded on the basis of exclusion criteria. From up to down at bilateral neck, the IJV became gradually more superficial while the CCA became deeper. The diameter of the IJV became gradually larger while that of the CCA gradually smaller. The IJV from lateral to the CCA gradually moved to the front of the CCA, so the percent overlap of the IJV and CCA was gradually increased. Compared with the left side at the same transverse scan level, the distance between the CCA and IJV was wider at the right side and the right IJV was wider. The IJV location in 11 patients was medial to the CCA at one or more transverse scan levels. The angle between the IJV and CCA was significantly small in elderly patients. The CCA had already furcated at the level of the upper border of the thyroid cartilage in seven patients at the right side and in 12 patients at the left side.There are variations in the position and relationship between the IJV and CCA. It is relatively more difficult to puncture at the left side of the neck, at a lower position or in elderly patients. On the contrary, it is relatively easier to puncture at the right side, at the level of the cricoid cartilage or in younger patients.
Internal jugular vein
Cricoid cartilage
Thyroid cartilage
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