Recovery of Post Thyroidectomy Aphonia with Peri Recurrent Laryngeal Nerve Injection of Meloxicam

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% [1]-[1],[1],[4].

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.

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).

Figure 1: Injection of meloxicam peri recurrent laryngeal nerve.

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.

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 [1],[9]. 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 [1],[12].

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 [14].

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 [[16].

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 [17].

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 [[20], 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.

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.

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.