Zuckerkandl’s tubercle and its relation with recurrent laryngeal nerve during thyroid surgery in a tertiary care hospital in Nepal: A cross-sectional study

Background: Thyroid surgery occurs frequently in our part of the world, with Recurrent Laryngeal Nerve (RLN) injury being a serious intraoperative complication that affects airway and voice quality. Zuckerkandl’s Tubercle (ZT), present in over 70% of patients, is a reliable landmark for locating the RLN to follow careful dissection and identification. The purpose of this study is to assess Zuckerkandl’s Tubercle (ZT) and its relation with Recurrent Laryngeal Nerve during Thyroid Surgeries. Methods: A cross-sectional study was conducted prospectively at the Department of Otorhinolaryngology, Head and neck surgery, Kathmandu Medical College and Teaching hospital, Sinamangal from December 2019 to November 2020. Forty-four RLNs were evaluated in 34 patients undergoing thyroid surgery. Per-operative documentation on the prevalence of ZT and its relation with RLN was recorded, its size and distance from the RLN measured. Results: Zuckerkandl’s tubercle was present in 73.7% in the right side and in 76% in the left side. On the right side, 92.9% were unilobed in nature and 7.1% were bilobed, while on the left side, 100% were unilobed in nature. The size of the ZT was graded according to Pelizzo's grading system for ZT into grade 0-3. On the right side, 26.31% was grade 0, 31.57% were grade 1, 36.8% were grade 2 and 5.2% was grade 3. On the left side, 24% were grade 0, 20.0% were grade 1, 44.0% were grade 2 and 12.0% were grade 3. On the right side, RLN was present medial to the ZT in all cases (100%), while on the left side, RLN was present medial to ZT in 84.2% and lateral to ZT in 15.8% cases. Conclusion: Identification and preservation of RLN is of utmost importance during thyroid surgeries. Zuckerkandl’s tubercle has a consistent relationship with RLN and can be used as an important landmark for identifying RLN during thyroid surgery.