The foundation of thyroid surgery is to identify and save the nerves to the voicebox. There is a right and left nerve to the voicebox that travels under the thyroid gland on each side of the neck.  They are in predictable locations and have predictable courses in the neck to the voice box. We have to safely identify these nerves 100% of the time before we proceed with any thyroid operation. Only highly skilled and experienced thyroid surgeons will be able to safely perform this operation. It is very important for you to find an expert thyroid surgeon to make sure your nerve to the voicebox is preserved to ensure a normal speaking voice after surgery. 

Top 3 Things to Know About the Nerve to the Voicebox

1) What is the nerve to the voice box?

The nerve to the voicebox is called the recurrent laryngeal nerve. It is a branch of the vagus nerve, which is a major nerve that comes from the brain. There are two recurrent laryngeal nerves, a right nerve and a left nerve. They travel in the neck, on each side of the windpipe, underneath the thyroid gland and insert into the voicebox. There are branches of the recurrent laryngeal nerve that are responsible for sensation and movement. The most important function of this nerve is to provide movement of the vocal cords so that you can speak with a normal voice.

2) What is the normal course of the nerve to the voicebox?

Although the left and right recurrent laryngeal nerves have the same function, they are not symmetrical in their course in the neck.  The left nerve travels down the neck with the vagus nerve (major nerve from the brain) and loops around a major artery in the chest called the aortic arch.  After it loops around the aortic arch, it travels upwards and under the left thyroid gland along the windpipe to insert into the voice box on the left side. 

The right recurrent laryngeal nerve also travels down the neck with the vagus nerve, but it loops around a different major artery coming off of the heart called the subclavian artery.  After it loops around the right subclavian artery, it travels upwards and under the right thyroid gland along the windpipe to insert into the right side of the voice box. 

They are called recurrent nerves because after they travel DOWN the neck to loop around their respective arteries, they then course in the opposite direction and travel UP to insert into the voicebox.

3) Are there any variations to the nerve to the voicebox?

There is a predictable location of this nerve on both the left and right side of the neck, and during a thyroid operation, we are able to locate it very quickly.  Once identified, the recurrent laryngeal nerve also has a predictable course that can be followed in order to dissect the nerve safely to the voice box.

However, variations do occur. On ONLY the right side of the neck, the laryngeal nerve can vary in its location and course <1% of the time.  This variation on the right side of the neck is called a NONrecurrent laryngeal nerve. Only a highly experienced surgeon will be able to know the different tracts that the right laryngeal nerve can take and be able to locate it and save it.  As we said above, the right recurrent laryngeal nerve normally can be seen coursing UP the neck in a VERTICAL direction to insert into the voice box on the right side. However, a NONrecurrent laryngeal nerve will come straight off the vagus nerve and travel ACROSS the neck in a HORIZONTAL fashion to insert into the right side of the voicebox. It never loops around that large vessel coming off of the heart, and therefore does NOT RECUR going up in the neck.

During a thyroid operation, if the nerve cannot be identified in a normal location, only an expert thyroid surgeon will know that it must be a NONrecurrent laryngeal nerve and will know exactly where to look next.  The nerve will then be identified travelling across the neck in a horizontal fashion. It can then be dissected and saved to perform a successful thyroid operation, while preserving the voice.

If you need thyroid surgery, please do your research to find an expert thyroid surgeon. Only highly experienced surgeons will perform successful thyroid operations with the lowest complication rates. Become our patient here.

Figure A: Recurrent laryngeal nerve

Figure B: Nonrecurrent laryngeal nerve

Additional Resources

• Become our patient by filling out the form at this link. 
• Learn more  The Clayman Thyroid Center here. 
• Learn more about our sister surgeons at the Scarless Thyroid Surgery Center, Norman Parathyroid Center, and Carling Adrenal Center
• Learn more about the Hospital for Endocrine Surgery.