Non-recurrent laryngeal nerve injury associated with an aberrant right subclavian artery: a case report

Injury to the recurrent laryngeal nerve (RLN) is a recognised complication of surgery in the neck. The presence of a non-recurrent laryngeal nerve (NRLN) significantly increases the risks of a nerve injury. Given that NRLNs are strongly associated with vascular abnormalities that can be visualised on preoperative imaging, we describe a case to raise awareness of this association with the aim of reducing the risk of iatrogenic nerve injury.

A 61-year-old gentleman was referred by his family doctor with a history of radiating left arm pain and paraesthesia consistent with C6 +/- C7 radiculopathy. The patient failed conservative management, and elected to undergo an anterior cervical discectomy and fusion procedure. Preoperative magnetic resonance imaging (MRI) showed an incidental finding of an aberrant right subclavian artery (ARSA) following a retro-oesophageal path. Surgery was performed with a right sided cervical approach without intraoperative complications; however, the patient had marked dysphonia post-operatively. Assessment by otorhinolaryngology (ORL) concluded that this was most likely secondary to a right NRLN palsy. The patient underwent a vocal fold injection laryngoplasty for temporary vocal fold augmentation, and the voice subsequently recovered and remained asymptomatic at 1-year post-procedure.

This case demonstrated that identification of vascular anomalies associated with NRLNs on preoperative imaging should prompt a left sided cervical approach to avoid a nerve injury during surgery.