Introduction

Vocal cord paresis or paralysis due to iatrogenic injury of the recurrent laryngeal nerve is one of the main problems in thyroid surgery. Although many procedures have been introduced to prevent the nerve injury, still the incidence of recurrent laryngeal nerve palsy varies between 1.5-14% [11. Zakaria HM, Al Awad NA, Al Kreedes AS, Al-Mulhim AM, Al-Sharway MA, et al. (2011) Recurrent Laryngeal Nerve Injury in Thyroid Surgery. Oman Med J 26: 34-38.].

This complication is generally unilateral and transient but occasionally it can be bilateral and permanent, and it may be either deliberate or accidental [11. Zakaria HM, Al Awad NA, Al Kreedes AS, Al-Mulhim AM, Al-Sharway MA, et al. (2011) Recurrent Laryngeal Nerve Injury in Thyroid Surgery. Oman Med J 26: 34-38.-33. Woodson GE (2007) Spontaneous laryngeal reinnervation after recurrent laryngeal or vagus nerve injury. Ann Otol Rhinol Laryngol 116: 57-65. ].

The time of recurrent laryngeal nerve function recovery ranges from several weeks to two years (mainly 6 months) [44. Jamski J, Jamska A, Graca M, Barczyński M, Włodyka J (2004) Recurrent laryngeal nerve injury following thyroid surgery. Przegl Lek 61: 13-16.].

In addition to the hoarseness that occurs with unilateral recurrent laryngeal nerve injury, bilateral injury leads to dyspnea and often life-threatening glottal obstruction [11. Zakaria HM, Al Awad NA, Al Kreedes AS, Al-Mulhim AM, Al-Sharway MA, et al. (2011) Recurrent Laryngeal Nerve Injury in Thyroid Surgery. Oman Med J 26: 34-38.,55. Jatzko GR, Lisborg PH, Müller MG, Wette VM (1994) Recurrent nerve palsy after thyroid operations–principal nerve identification and a literature review. Surgery 115: 139-144. ,66. Fewins J, Simpson CB, Miller FR (2003) Complications of thyroid and parathyroid surgery. Otolaryngol Clin North Am 36: 189-206. ].

The permanent lesion of damaged recurrent laryngeal nerve often manifests as an irreversible dysfunction of phonation and is the most common complication following thyroid surgery [11. Zakaria HM, Al Awad NA, Al Kreedes AS, Al-Mulhim AM, Al-Sharway MA, et al. (2011) Recurrent Laryngeal Nerve Injury in Thyroid Surgery. Oman Med J 26: 34-38.,77. Randolph GW, Kobler JB, Wilkins J (2004) recurrent laryngeal nerve identification and assessment during thyroid surgery: laryngeal palpation. World J Surg 28: 755-760. ], ranges from 0.5 to 5% in different thyroid surgery centers and increases in case of both recurrent goiter and complete thyroidectomy due to thyroid cancer [44. Jamski J, Jamska A, Graca M, Barczyński M, Włodyka J (2004) Recurrent laryngeal nerve injury following thyroid surgery. Przegl Lek 61: 13-16.].

The aim of this study was to assess the effect of meloxicam injection on the recovery of vocal cord paresis due to recurrent nerve injury after thyroid surgery, and neural inflammation as possible factor for delayed recovery.

Materials and Methods

With local ethical committee approval for peri neural injection of meloxicam, and informed consent, 47 years old female, 60 kg weight 163 cm height, presented two months after thyroid surgery complaining from aphonia, dyspnea, sleep disturbance due to breathing suffocation, patient on oxygen therapy through nasal cannula during night sleep.

The patient was submitted to total thyroidectomy and the intervention did not present any particular difficulties, was carried out by an experienced specialist surgeon.

Patient had no previous other medical illnesses, her overall post-surgical recovery was prompt and smooth and parathyroid hormone and serum calcium phosphate have always had normal values.

Histological examination of the excised piece was: cystic colloid goiter.

Unfortunately, the speech was presented immediately but strongly altered on the second day with hoarseness and low pitch phonation, laryngoscopy was performed which showed paresis of the vocal cords in semi abduction bilaterally (middle position).

After fifteen days following surgery: aphonia and severe dyspnea manifested, also choking with a spontaneous recovery, triage night.

ENT specialist confirm by Laryngoscopy the vocal cord were fixed in paramedian position and recommend for monthly follow-up and the need of speech therapy twice weekly. Also the need for apnea controlled and use for Oxygen therapy at night.

Patient presented to us after 40 days of aphonia and dyspnea seeking for help, we consider injections of 7.5 mg of meloxicam peri recurrent laryngeal nerve bilaterally anterior to sternocleidomastoid muscles at the level of 1.5 cm depth, using 27G needle (19mm) (Figure 1).

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   Figure 1:

   Injection of meloxicam peri recurrent laryngeal nerve.
   
   
   

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   Figure 1: Injection of meloxicam peri recurrent laryngeal nerve.

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Results

Immediately after the injections, the patient was able to tell her first name and a progressive improvement in the basic function of vocal cord was notice later, in which the patient can speak with clear hearable sound, and with improvement of dyspnea symptom. Total improvement in sound was noticed after 6 hours of the injection, with disappearance of her dyspnea symptoms.

We follow up the patient twice weekly keeping up same improvement in sound and breathing. Laryngoscopy normal vocal cord position and function.

Discussion

Mechanisms of injury to the nerve include complete or partial transection, traction, or handling of the nerve, contusion, crush, burn, clamping, misplaced ligature, and compromised blood supply [11. Zakaria HM, Al Awad NA, Al Kreedes AS, Al-Mulhim AM, Al-Sharway MA, et al. (2011) Recurrent Laryngeal Nerve Injury in Thyroid Surgery. Oman Med J 26: 34-38.,88. Steurer M, Passler C, Denk DM, Schneider B, Niederle B, et al. (2002) Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope 112: 124-133. ,99. Rice DH, Cone-Wesson B (1991) Intraoperative recurrent laryngeal nerve monitoring. Otolaryngol Head Neck Surg 105: 372-375.]. In unilateral recurrent laryngeal nerve injury the voice becomes husky because the vocal cords do not approximate with one another. Dysphonia starting on the 2nd – 5th post-operative days is commonly due to edema, whereas traction injury of the nerve and damage of axons may result in dysphonia lasting up to 6 months. Dysphonia continuing after 6 months is commonly permanent caused by cutting, ligating or cauterization of the nerve [11. Zakaria HM, Al Awad NA, Al Kreedes AS, Al-Mulhim AM, Al-Sharway MA, et al. (2011) Recurrent Laryngeal Nerve Injury in Thyroid Surgery. Oman Med J 26: 34-38.,1010. Eisele DW (1996) Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve. Laryngoscope 106: 443-449.].

Bilateral recurrent laryngeal nerve injury is much more serious, because both vocal cords may assume a median or paramedian position and cause airway obstruction and tracheostomy may be required [11. Zakaria HM, Al Awad NA, Al Kreedes AS, Al-Mulhim AM, Al-Sharway MA, et al. (2011) Recurrent Laryngeal Nerve Injury in Thyroid Surgery. Oman Med J 26: 34-38.,1111. Dimov RS, Doikov IJ, Mitov FS, Deenichin GP, Yovchev IJ (2001) Intraoperative identification of recurrent laryngeal nerves in thyroid surgery by electrical stimulation. Folia Med (Plovdiv) 43: 10-13. ,1212. Marcus B, Edwards B, Yoo S, Byrne A, Gupta A, Kandrevas J, et al. (2003) recurrent laryngeal nerve monitoring in thyroid and parathyroid surgery: the University of Michigan experience. Laryngoscope 113: 356- 361.].

Bilateral vocal cord paralysis is a serious illness requiring emergency intervention to resolve the potentially life-threatening respiratory distress. Several surgical procedures were proposed to help improve the airway and to eliminate the tracheostoma in those patients with permanent paralysis [1313. Dispenza F, Dispenza C, Marchese D, Kulamarva G, Saraniti C (2012) Treatment of bilateral vocal cord paralysis following permanent recurrent laryngeal nerve injury. Am J Otolaryngol 33: 285-288. ].

Inflammation of neural origin as suggested by some studies as Mystic transient recurrent nerve palsy after thyroid surgery suggested due to surgical manipulation [1414. Altorjay A, Rüll M, Paál B, Csáti G, Szilágyi A (2013) "Mystic" transient recurrent nerve palsy after thyroid surgery. Head Neck 35: 934-941.].

Many excellent studies about vocal cord paresis were concerns regarded the improvement of phonation of vocal cord by methods related to vocal cords contour and position.

Such studies, injection laryngoplasty with hyaluronic acid gel which is a relatively safe procedure that allows for short-term improvements in objective and subjective outcome measures of vocal function in patients with glottic insufficiency, provided the surgeon remains alert to the possibility of postprocedural injection site inflammation [1515. Upton DC, Johnson M, Zelazny SK, Dailey SH (2013) Prospective evaluation of office-based injection laryngoplasty with hyaluronic acid gel. Ann Otol Rhinol Laryngol 122: 541-546.].

Others, such calcium hydroxylapatite (CaHA) injection laryngoplasty in unilateral vocal fold paralysis (UVFP) patients, with repeated injection, 6 and 9 injection laryngoplasties [1616. Chang J, Courey MS, Al-Jurf SA, Schneider SL, Yung KC (2014) Injection laryngoplasty outcomes in irradiated and non-irradiated unilateral vocal fold paralysis. Laryngoscope 124: 1895-1899.].

Endoscopic coblation assisted arytenoidectomy is a new surgical method for the treatment of patients with bilateral vocal cord paralysis, which is efficient, minimally invasive and safe [1717. Zhang QF, Zhang JJ, Zhang Y, She CP, Ma L (2013) Endoscopic coblation assisted arytenoidectomy in the treatment of bilateral vocal cord paralysis. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 48: 589-591.].

Laryngeal reinnervation by anza cervicalis is an effective treatment for laryngeal paralysis related to operations on the thyroid gland and laryngeal function can be improve to almost normal of the spoken voice parameters and the basic functions of the larynx [1818. Palamarchuk VA (2013) Larynx reinnervation by the main branch of ansa cervicalis use in the thyroid surgery in cases of unilateral vocal fold paralysis. Klin Khir 75-79.].

Although the Excellency of these studies, all were in long time bases, and supportive for the atrophied vocal cord. but none concerns about resolving the acute injury of the NERVE in the transient period of injury less than 6month, which could be the main problem and save the vocal cord from atrophy and permanent paresis. In contrast, our approach was aim for removing of acute injury of recurrent laryngeal nerve, with simple, minimally invasive and time saving with immediate results. Also the possible diagnostic way between partial or complete injury, and the possibility to differentiate if that neural inflammation of recurrent laryngeal nerve could be the risk factor for delayed recovery of the vocal cord paresis.

Based in our experience with Meloxicam in treatment of neural inflammation as reviewed in article: long-lasting beneficial effect of periradicular injection of meloxicam for treating chronic low back pain and sciatica [1919. Borghi B, Aurini L, White PF, Mordenti A, Lolli F, et al. (2013) Long-lasting beneficial effects of periradicular injection of meloxicam for treating chronic low back pain and sciatica. Minerva Anestesiol 79: 370-378.], which show significant improvement in patients cases and as marked anti-inflammatory drug, suggested in a review article on meloxicam Mobic [2020. Ogino K, Saito K, Osugi T, Satoh H (2002) Meloxicam (Mobic): a review of its pharmacological and clinical profile. Nihon Yakurigaku Zasshi 120: 391-397.], we consider meloxicam therapy trial.

The resolution of aphonia and dyspnea symptoms, and the significant and immediate improvement and return of vocal cord function suggests the potential benefit of this minimally-invasive therapy using meloxicam with possible treatment and end of the suffering of many patients with same complain, instead of leaving it for more possible chance for vocal cord function to be lost permanently and get atrophied, and farther the need of more complex approach to support the contour of larynx.

It also suggests the potential inflammatory origin of the recurrent laryngeal nerve injury.

Hoping that this trial would be consider as methods of therapy and open the door for more clinical trials and study regards this approach.

Conclusion

Perineural injection of 7.5 mg meloxicam appears to be potentially promising therapeutic option for patients with vocal cord paresis due to transient recurrent laryngeal nerve injury. Further clinical studies are necessary to confirm the efficacy of this approach for treatment for both acute and chronic bases. Neural inflammation of recurrent laryngeal nerve could be possible cause of vocal cord paresis and delayed its recovery.

Acknowledgements

The authors reported no conflict of interest and no funding was. Received for this work.

Patient permission is obtained and reports of clinical and laryngoscopy examination were done by specialist doctors, documented and saved.