Introduction
The recurrent laryngeal nerve (RLN) supplies motor control to the intrinsic laryngeal muscles, and provides the sensory and autonomic fibers to the larynx, trachea, esophagus, and pharynx. RLN injury can cause dysphagia or dysphonia. In this report, we present a case of successful rehabilitation of dysphagia after left RLN injury.
Case Report
A 67-year-old male was admitted to our hospital for the treatment of malignant thymoma located at the left anterior mediastinum. Tumor resection was done, and left RLN could not be saved during the operation. After the operation, nutrition was supplied by nasogastric tube. Three weeks after the surgery, the patient was referred to the department of rehabilitation medicine before the initiation of oral feeding. On videofluoroscopic swallowing study (VFSS), penetration-aspiration scale (PAS) 8 aspiration on liquid and PAS 3 penetration on thickened liquid were found. Grade 3 residues in vallecular and pyriform sinuses were observed. Nasogastric tube feeding was kept, and dysphagia treatment was done to strengthen the intrinsic laryngeal muscles. Shaker, Masako, and Mendelsohn maneuvers were included in dysphagia treatment program. On the second VFSS after two-week dysphagia treatment, PAS 7 aspiration on liquid was found, but penetration on thickened liquid disappeared. Vallecular and pyriform sinus residues decreased from grade 3 to grade 2. Left-side dominant pharyngeal residues were observed at anteroposterior projection. When the patient turned the head to left side and did chin tuck posture, left-side dominant pharyngeal residues decreased on VFSS. Oral feeding started with level 2 dysphagia-type diet. Left head turning, chin tuck posture, and supraglottic swallowing education was done for compensatory strategies. The third VFSS was done 6 weeks after the first VFSS. Penetration and aspiration were not found on liquid, thickened liquid, soft-blended, and regular diet. Grade 1 vallecular residue and grade 0 pyriform residue were observed. At anteroposterior projection, mild bilateral symmetric pharyngeal residues were found. The patient started regular diet without thickener.
Conclusion
Management of RLN injury includes surgery, intra-vocal fold injection, and conservative treatment expecting natural recovery. It is known that spontaneous recovery of RLN injury may take 6-12 months. There were some reports about dysphagia after RLN injury, but most of them focused on injury mechanisms, dysphagia status, or natural progression. Through VFSS, this case shows effective and early improvement of dysphagia after unilateral RLN injury by early dysphagia treatment and compensatory strategies. Early active rehabilitation of dysphagia after RLN injury before considering invasive management might be implemented. |
