Gurleyik Journal of Medical Case Reports 2011, 5:266 http://www.jmedicalcasereports.com/content/5/1/266 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Three variations of the laryngeal nerve in the same patient: a case report Emin Gurleyik Abstract Introduction: A non-recurrent course is a rare anatomic variation of the inferior laryngeal nerve (ILN). Bilateral extra-laryngeal bifurcation of the ILN seldom occurs before its laryngeal entry. Anastomosis between the ILN and cervical sympathetic chain is another rare anatomic feature. The prevalence of extra-laryngeal branching of the non-recurrent nerve is unknown. We present an example of triple anatomic variations of ILNs in the same patient, and also two anatomic variations in the same nerve. Case presentation: A 56-year-old Caucasian man with a large toxic multi-nodular goiter was surgically treated with total thyroidectomy. Both his right and left ILNs were identified, fully exposed and preserved along their cervical courses. We discovered many variations during bilateral exploration of the two ILNs. His right ILN was non- recurrent. This non-recurrent ILN showed a terminal division before laryngeal entry. The left nerve had a usual course as a recurrent laryngeal nerve (RLN) at his tracheaesophageal groove. We also discovered bifurcation of his RLN beginning at a neurovascular (RLN and inferior thyroid artery) crossing point. Anterior and posterior branches of both nerves entered his larynx separately. The sympathetic inferior laryngeal anastomotic branch (SILAB) between the posterior branch of his left ILN and the cervical sympathetic chain was established in the distal part of the nerve before laryngeal entry. Conclusion: A non-recurrent nerve and extra-laryngeal branching of the ILN are two different variations. The coincidence of a right non-recurrent ILN and bilateral bifurcation of both nerves is a very interesting feature. SILAB is a rare additional finding as a third anatomic variation in the same patient. Extra-laryngeal terminal division of a non-recurrent ILN is an extremely unusual anatomic finding. Two anatomic variations have occurred in the same nerve, like “the variation of the variation”. Introduction The inferior laryngeal nerve (ILN) is the most important structure in thyroid operations. Anatomic variations of a recurrent laryngeal nerve (RLN) may threaten the safety of thyroid surgery and so a complete knowledge of RLN anatomy, including all of its variations, must be manda- tory for thyroid surgeons. Extra-laryngeal branching of the RLN as a terminal division is a common anatomic variation macroscopically discovered at surgical explora- tion. Terminal division of both right and left nerves sel- dom occurs bilaterally. Larger branches of the nerve bifurcation may affect laryngeal function. Non-recurrent ILN is a rare and important anatomic variation, threaten- ing the safety of thyroid surgery [1-7]. The association of a non-recurrent nerve and extra-laryngeal branching is Correspondence: egurleyik@yahoo.com Department of Surgery, Duzce University, Medical Faculty, Duzce, Turkey an extremely rare occurrence. An anastomosis between an ILN and the cervical sympathetic chain is another rare anatomic variation, known as sympathetic inferior laryn- geal anastomotic branch (SILAB) [6,8]. In this case report, three variations of ILN, with two var- iations in one ILN, are presented in the same patient with a large goiter surgically treated with total thyroidectomy. Case Report A 56-year-old Caucasian male patient with a goiter, situ- ated in an endemic goiter region, had a 40-year history of thyroid gland enlargement. He presented to the depart- ment of surgery with a large goiter and symptoms of hyperthyroidism. A physical examination, blood chemistry for thyroid- stimulating hormone and free thyroxin, ultrasound ima- ging and thyroid nuclear scanning established the © 2011 Gurleyik; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.