Takagi Ryo, Mori Kosei, Tsuyuguchi Sayumi, Koike Takashi, Nguyen Dinh Nam, Kanai Kengo, Watanabe Yoshihiro, Okano Mitsuhiro, Noguchi Yoshihiro, Hayashi Yuichiro, Imanishi Yorihisa
Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, International University of Health and Welfare, Narita Hospital, Narita, Japan.
Department of Pathology, School of Medicine, International University of Health and Welfare, Narita Hospital, Narita, Japan.
BMC Endocr Disord. 2025 May 12;25(1):128. doi: 10.1186/s12902-025-01929-w.
Thyroid tumors presenting with recurrent laryngeal nerve (RLN) palsy are generally considered malignant; however, RLN palsy has been reported even in benign thyroid disease (BTD), mainly due to compression or stretching, although seemingly quite rare. Herein, we report an unusual case of nodular goiter that was extremely difficult to differentiate preoperatively from thyroid malignancy because of the concomitant ipsilateral RLN palsy caused by chronic inflammation.
A 59-year-old Japanese female presented with hoarseness and pharyngeal discomfort. Endoscopic examination revealed fixation of the right vocal cord, presumably due to right RLN palsy. Ultrasonography and computed tomography showed an ill-defined thyroid mass lesion in the right lobe, strongly suggestive of malignancy, although repeated aspiration cytology revealed no suspicion of malignancy. Intraoperatively, because the right RLN was found to be entirely embedded within the hard mass lesion and completely unresponsive to nerve integrity monitoring, the nerve was unavoidably excised along with the right lobe. Histopathology led to the final diagnosis of nodular goiter, wherein the resected RLN was severely degenerated and disrupted due to intense chronic inflammation accompanied by perineural fibrosis.
Our literature review suggests that RLN palsy associated with thyroid mass lesions should not be considered a definitive indicator of malignancy because it can also be observed in BTD, although it is significantly less frequent than in malignancy as corroborated by our meta-analysis. Even in BTD, if the primary cause of the coexisting RLN palsy is severe chronic inflammation, nerve preservation is potentially unfeasible.
出现喉返神经（RLN）麻痹的甲状腺肿瘤通常被认为是恶性的；然而，即使在良性甲状腺疾病（BTD）中也有RLN麻痹的报道，主要原因是压迫或牵拉，尽管似乎相当罕见。在此，我们报告一例结节性甲状腺肿的罕见病例，由于慢性炎症导致同侧RLN麻痹，术前极难与甲状腺恶性肿瘤区分开来。
一名59岁的日本女性出现声音嘶哑和咽部不适。内镜检查发现右侧声带固定，推测是由于右侧RLN麻痹所致。超声检查和计算机断层扫描显示右叶有一个边界不清的甲状腺肿块病变，强烈提示为恶性，尽管反复细针穿刺活检未发现恶性可疑。术中，由于发现右侧RLN完全包埋在坚硬的肿块病变内，且对神经完整性监测完全无反应，因此不可避免地将神经与右叶一并切除。组织病理学最终诊断为结节性甲状腺肿，其中切除的RLN因强烈的慢性炎症伴神经周围纤维化而严重变性和中断。
我们的文献综述表明，与甲状腺肿块病变相关的RLN麻痹不应被视为恶性肿瘤的决定性指标，因为在BTD中也可观察到，尽管正如我们的荟萃分析所证实的，其发生率明显低于恶性肿瘤。即使在BTD中，如果共存的RLN麻痹的主要原因是严重的慢性炎症，保留神经可能是不可行的。
