Table of ContentsView AllTable of ContentsLocation and How It WorksAnatomical VariationsAssociated ConditionsTreatment
Table of ContentsView All
View All
Table of Contents
Location and How It Works
Anatomical Variations
Associated Conditions
Treatment
The recurrent laryngeal nerve (RLN) anatomy is designed to supply function to most muscles of the larynx (voice box). It branches from thevagus nerve(cranial nerve 10) but follows an unusual pathway to reach the larynx. The paired nerves don’t follow the same symmetrical course.
The RLN supplies motor and sensory function to the voicebox. It plays an important role in your ability to speak, swallow, and protect the airway from aspiration (inhaling food and foreign matter into your lungs).It is vulnerable to injury, including damage from surgery in the neck.
There are 12cranial nervesin the human body. They occur in pairs on either side of the head and originate from the brain and brainstem rather than the spinal cord. Many of the nerves support function in the face and throat, as does the recurrent laryngeal nerve.
The RLN arises from the 10th cranial nerve (vagus nerve).The vagus emerges from the brain, exits the skull, then runs down your neck along the carotid arteries. It plays a role in controlling heart, lung, and digestive functions, but also contributes to RLN function.
The recurrent laryngeal nerve serves both motor and sensory functions. “Motor” has to do with movement and “sensory” deals with the senses, such as touch and temperature information.
Besides the RLN, speech-related structures arising from the vagus include the:
After the RLN branches off from the vagus nerve, it continues branching out. The two sides are different because:
Once it turns back upward, both recurrent laryngeal nerves travel through a groove where the trachea (windpipe) and esophagus meet, pass behind part of thethyroid gland, then enter the larynx underneath a throat muscle called the inferior constrictor.
The intrinsic muscles of the larynx that the RLN innervates are responsible for opening, closing, and changing the tension of your vocal cords. This includes the:
The RLN carries sensory information to the brain from mucous membranes that lie beneath the lower surface of the larynx’s vocal fold. It also sends sensory fibers, along with the motor and secretory fibers, to the esophagus and trachea.
Swallowing and SpeechYour ability to speak and swallow relies on the RLN and the muscles it serves.The RLN sends motor and secretory fibers to the segments of the esophagus and the trachea that are in the throat.
Swallowing and Speech
Your ability to speak and swallow relies on the RLN and the muscles it serves.The RLN sends motor and secretory fibers to the segments of the esophagus and the trachea that are in the throat.
A number of anatomical variations can occur with the recurrent laryngeal nerve, either on one or both sides of the voicebox and airway. In some people, for example, the RLN provides innervation to parts of the trachea and esophagus as well as the larynx.
A 2020 study, based on results from 55 cadavers (donated bodies), found changes to both the right and left RLN. Extra branching occurred in both.
Sometimes, the left RLN passes in front of the inferior thyroid artery. In two-thirds of the cases, it passed behind it. It’s the opposite frequency with the right RLN. This is important information when planning surgery, such as athyroid removal. Injury can occur due to overstretching and other causes.
A 2024 review of studies on the recurrent laryngeal nerve identified eight variations in the RLN, including the shape, pathway, distance of travel, or a thickening that occurs in older adults.
Keep in mind that the left RLN is longer and runs toward the heart, looping around the aortic arch before moving back up the body to reach the larynx. Less often, the aortic arch is on the right side of the chest instead of the left, so the left RLN has a direct course rather than a recurrent one.
Injury
Trauma to the throat or anywhere along its course can cause damage to the RLN. Injury can lead to:
Because the posterior cricoarytenoid muscle acts alone to open the vocal cords, severe damage or damage to both sides of the RLN may result in a complete loss of the ability to speak. It can also cause breathing problems during physical activity, which is calleddyspnea.
As the RLN heals from injury, you may experience uncoordinated movements of the vocal cord that will go away with further healing.
Six months is usually long enough to wait for a recurrent laryngeal nerve to heal on its own.If it doesn’t, you may need a referral to an ear, nose, and throat specialist.
Surgery
The most common surgeries to damage the RLN are thyroid and parathyroid surgery, because of how close the nerve is to the thyroid gland, which sits at the front of the throat. In fact, the RLN can pass in front of, behind, or between branches of the right inferior thyroid artery.
This problem is rare, though, with permanent damage occurring in less than 3% of thyroid surgeries. Even so, because the impairment or loss of speech has a significant impact on your life, vocal cord paralysis due to RLN damage is one of the leading causes of lawsuits against surgeons.
Symptoms of RLN damage due to thyroid surgery depend on whether the damage is confined to one side or impacts both sides.
When one side is damaged, the voice may be normal right after surgery and then change over the next several days or even weeks to become hoarse or breathy. That’s because the paralyzed vocal fold starts out in a somewhat normal position but then atrophies over time. This can also cause:
With bilateral (both side) paralysis of the vocal fold, which is most common after a total thyroid removal, symptoms typically show up right away. The airway is often partially obstructed, and the patient may be in respiratory distress.
A condition called biphasic stridor is also possible. It results from turbulent airflow through the throat and results in a harsh, vibrating, and variably pitched voice.
In some cases of bilateral paralysis, breathing problems and/or exertion-related stridor may not be apparent until later.
Tumors
In some cases of cancer, the tumor(s) compresses the recurrent laryngeal nerve. Or, the cancer’s spread (metastasis) can affect either the left or right RLN.
Other Disease
Infection or inflammation can affect the RLN. Other diseases that may cause problems with the RLN include:
In these cases, symptoms are similar to that of RLN injury.
Recurrent laryngeal nerve reinnervation is a surgery that can help alleviate hoarseness after damage to one side of the RLN results in vocal cord paralysis.This outpatient procedure generally takes between two and three hours, to reconnect a working nerve to the RLN. Other options include:
Keep in mind that some people experience permanent damage. In a 2023 study of people who developed left RLN damage after minimally invasive surgery on the esophagus, only 25% ever fully recovered.Continued smoking, and the type of surgery used, were identified as factors.
Summary
The recurrent laryngeal nerve is critical to your ability to speak, swallow, and protect your airway from aspiration of fluid or foreign matter. There are two, with anatomical differences leading to a greater risk of injury on the left. RLN damage following surgery is a common cause of injury.
While there are treatment options for a damaged RLN, such as vocal therapy, it is not uncommon for the damage to be permanent. Surgeries including thyroplasty may be needed to relieve symptoms and fix a recurrent laryngeal nerve.
15 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.McGill University.The “Unintelligent Design” of the Recurrent Laryngeal Nerve.Thomas AM, Fahim DK, Gemechu JM.Anatomical Variations of the Recurrent Laryngeal Nerve and Implications for Injury Prevention during Surgical Procedures of the Neck.Diagnostics (Basel). 2020 Sep 4;10(9):670. doi:10.3390/diagnostics10090670Radiopaedia.Recurrent laryngeal nerve.Chao YK, Li Z, Jiang H, Wen YW, Chiu CH, Li B,et al.Multicentre randomized clinical trial on robot-assisted versus video-assisted thoracoscopic oesophagectomy (REVATE trial).Br J Surg. 2024 Jul 2;111(7):znae143. doi:10.1093/bjs/znae143Dos Santos Menezes Siqueira GV, Dos Santos Rodrigues MH, Santos CNN, Gonçalves PE, Garção DC.Anatomical variations of recurrent laryngeal nerve: a systematic review and meta-analyses.Surg Radiol Anat. 2024 Mar;46(3):353-362. doi:10.1007/s00276-023-03293-7Amer, Khalid.The Recurrent Laryngeal Nerves and the Thoracic Surgeon.Swonke ML, Shakibai N, Chaaban MR.Medical Malpractice Trends in Thyroidectomies among General Surgeons and Otolaryngologists.OTO Open. 2020 May 13;4(2):2473974X20921141. doi:10.1177/2473974X20921141Wojtczak B, Sutkowska-Stępień K, Głód M, Kaliszewski K, Sutkowski K, Barczyński M.Current Knowledge on the Use of Neuromonitoring in Thyroid Surgery.Biomedicines. 2024 Mar 18;12(3):675. doi: 10.3390/biomedicines12030675Celmina M, Paule S.Stridor in children.Breathe (Sheff). 2018;14(3):e111-e117. doi:10.1183/20734735.017018Chen TT, Yan HJ, He X, Fu SY, Zhang SX, Yang W,et al.A novel web-based dynamic nomogram for recurrent laryngeal nerve lymph node metastasis in esophageal squamous cell carcinoma.Front Surg. 2022 Aug 23;9:898705. doi:10.3389/fsurg.2022.898705Palanisamy V.Ortner’s Syndrome: a cause of unilateral vocal cord paralysis.Global Journal of Medical and Clinical Case Reports. 2017:069-071. doi:10.17352/2455-5282.000051Children’s Hospital of Philadelphia.Recurrent laryngeal nerve (RLN) reinnervation.Mount Sinai.Laryngeal nerve damage.University of California Irvine.Thyroplasty.Kuo CT, Chiu CH, Fang TJ, Chao YK.Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study.Ann Surg Oncol.2024 Mar;31(3):1546-1552. doi:10.1245/s10434-023-14560-7.
15 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.McGill University.The “Unintelligent Design” of the Recurrent Laryngeal Nerve.Thomas AM, Fahim DK, Gemechu JM.Anatomical Variations of the Recurrent Laryngeal Nerve and Implications for Injury Prevention during Surgical Procedures of the Neck.Diagnostics (Basel). 2020 Sep 4;10(9):670. doi:10.3390/diagnostics10090670Radiopaedia.Recurrent laryngeal nerve.Chao YK, Li Z, Jiang H, Wen YW, Chiu CH, Li B,et al.Multicentre randomized clinical trial on robot-assisted versus video-assisted thoracoscopic oesophagectomy (REVATE trial).Br J Surg. 2024 Jul 2;111(7):znae143. doi:10.1093/bjs/znae143Dos Santos Menezes Siqueira GV, Dos Santos Rodrigues MH, Santos CNN, Gonçalves PE, Garção DC.Anatomical variations of recurrent laryngeal nerve: a systematic review and meta-analyses.Surg Radiol Anat. 2024 Mar;46(3):353-362. doi:10.1007/s00276-023-03293-7Amer, Khalid.The Recurrent Laryngeal Nerves and the Thoracic Surgeon.Swonke ML, Shakibai N, Chaaban MR.Medical Malpractice Trends in Thyroidectomies among General Surgeons and Otolaryngologists.OTO Open. 2020 May 13;4(2):2473974X20921141. doi:10.1177/2473974X20921141Wojtczak B, Sutkowska-Stępień K, Głód M, Kaliszewski K, Sutkowski K, Barczyński M.Current Knowledge on the Use of Neuromonitoring in Thyroid Surgery.Biomedicines. 2024 Mar 18;12(3):675. doi: 10.3390/biomedicines12030675Celmina M, Paule S.Stridor in children.Breathe (Sheff). 2018;14(3):e111-e117. doi:10.1183/20734735.017018Chen TT, Yan HJ, He X, Fu SY, Zhang SX, Yang W,et al.A novel web-based dynamic nomogram for recurrent laryngeal nerve lymph node metastasis in esophageal squamous cell carcinoma.Front Surg. 2022 Aug 23;9:898705. doi:10.3389/fsurg.2022.898705Palanisamy V.Ortner’s Syndrome: a cause of unilateral vocal cord paralysis.Global Journal of Medical and Clinical Case Reports. 2017:069-071. doi:10.17352/2455-5282.000051Children’s Hospital of Philadelphia.Recurrent laryngeal nerve (RLN) reinnervation.Mount Sinai.Laryngeal nerve damage.University of California Irvine.Thyroplasty.Kuo CT, Chiu CH, Fang TJ, Chao YK.Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study.Ann Surg Oncol.2024 Mar;31(3):1546-1552. doi:10.1245/s10434-023-14560-7.
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
McGill University.The “Unintelligent Design” of the Recurrent Laryngeal Nerve.Thomas AM, Fahim DK, Gemechu JM.Anatomical Variations of the Recurrent Laryngeal Nerve and Implications for Injury Prevention during Surgical Procedures of the Neck.Diagnostics (Basel). 2020 Sep 4;10(9):670. doi:10.3390/diagnostics10090670Radiopaedia.Recurrent laryngeal nerve.Chao YK, Li Z, Jiang H, Wen YW, Chiu CH, Li B,et al.Multicentre randomized clinical trial on robot-assisted versus video-assisted thoracoscopic oesophagectomy (REVATE trial).Br J Surg. 2024 Jul 2;111(7):znae143. doi:10.1093/bjs/znae143Dos Santos Menezes Siqueira GV, Dos Santos Rodrigues MH, Santos CNN, Gonçalves PE, Garção DC.Anatomical variations of recurrent laryngeal nerve: a systematic review and meta-analyses.Surg Radiol Anat. 2024 Mar;46(3):353-362. doi:10.1007/s00276-023-03293-7Amer, Khalid.The Recurrent Laryngeal Nerves and the Thoracic Surgeon.Swonke ML, Shakibai N, Chaaban MR.Medical Malpractice Trends in Thyroidectomies among General Surgeons and Otolaryngologists.OTO Open. 2020 May 13;4(2):2473974X20921141. doi:10.1177/2473974X20921141Wojtczak B, Sutkowska-Stępień K, Głód M, Kaliszewski K, Sutkowski K, Barczyński M.Current Knowledge on the Use of Neuromonitoring in Thyroid Surgery.Biomedicines. 2024 Mar 18;12(3):675. doi: 10.3390/biomedicines12030675Celmina M, Paule S.Stridor in children.Breathe (Sheff). 2018;14(3):e111-e117. doi:10.1183/20734735.017018Chen TT, Yan HJ, He X, Fu SY, Zhang SX, Yang W,et al.A novel web-based dynamic nomogram for recurrent laryngeal nerve lymph node metastasis in esophageal squamous cell carcinoma.Front Surg. 2022 Aug 23;9:898705. doi:10.3389/fsurg.2022.898705Palanisamy V.Ortner’s Syndrome: a cause of unilateral vocal cord paralysis.Global Journal of Medical and Clinical Case Reports. 2017:069-071. doi:10.17352/2455-5282.000051Children’s Hospital of Philadelphia.Recurrent laryngeal nerve (RLN) reinnervation.Mount Sinai.Laryngeal nerve damage.University of California Irvine.Thyroplasty.Kuo CT, Chiu CH, Fang TJ, Chao YK.Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study.Ann Surg Oncol.2024 Mar;31(3):1546-1552. doi:10.1245/s10434-023-14560-7.
McGill University.The “Unintelligent Design” of the Recurrent Laryngeal Nerve.
Thomas AM, Fahim DK, Gemechu JM.Anatomical Variations of the Recurrent Laryngeal Nerve and Implications for Injury Prevention during Surgical Procedures of the Neck.Diagnostics (Basel). 2020 Sep 4;10(9):670. doi:10.3390/diagnostics10090670
Radiopaedia.Recurrent laryngeal nerve.
Chao YK, Li Z, Jiang H, Wen YW, Chiu CH, Li B,et al.Multicentre randomized clinical trial on robot-assisted versus video-assisted thoracoscopic oesophagectomy (REVATE trial).Br J Surg. 2024 Jul 2;111(7):znae143. doi:10.1093/bjs/znae143
Dos Santos Menezes Siqueira GV, Dos Santos Rodrigues MH, Santos CNN, Gonçalves PE, Garção DC.Anatomical variations of recurrent laryngeal nerve: a systematic review and meta-analyses.Surg Radiol Anat. 2024 Mar;46(3):353-362. doi:10.1007/s00276-023-03293-7
Amer, Khalid.The Recurrent Laryngeal Nerves and the Thoracic Surgeon.
Swonke ML, Shakibai N, Chaaban MR.Medical Malpractice Trends in Thyroidectomies among General Surgeons and Otolaryngologists.OTO Open. 2020 May 13;4(2):2473974X20921141. doi:10.1177/2473974X20921141
Wojtczak B, Sutkowska-Stępień K, Głód M, Kaliszewski K, Sutkowski K, Barczyński M.Current Knowledge on the Use of Neuromonitoring in Thyroid Surgery.Biomedicines. 2024 Mar 18;12(3):675. doi: 10.3390/biomedicines12030675
Celmina M, Paule S.Stridor in children.Breathe (Sheff). 2018;14(3):e111-e117. doi:10.1183/20734735.017018
Chen TT, Yan HJ, He X, Fu SY, Zhang SX, Yang W,et al.A novel web-based dynamic nomogram for recurrent laryngeal nerve lymph node metastasis in esophageal squamous cell carcinoma.Front Surg. 2022 Aug 23;9:898705. doi:10.3389/fsurg.2022.898705
Palanisamy V.Ortner’s Syndrome: a cause of unilateral vocal cord paralysis.Global Journal of Medical and Clinical Case Reports. 2017:069-071. doi:10.17352/2455-5282.000051
Children’s Hospital of Philadelphia.Recurrent laryngeal nerve (RLN) reinnervation.
Mount Sinai.Laryngeal nerve damage.
University of California Irvine.Thyroplasty.
Kuo CT, Chiu CH, Fang TJ, Chao YK.Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study.Ann Surg Oncol.2024 Mar;31(3):1546-1552. doi:10.1245/s10434-023-14560-7.
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