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

Zuckerkandl’s tubercle and its relation with recurrent laryngeal nerve during thyroid surgery in a tertiary care hospital in Nepal: A cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Zuckerkandl’s tubercle and its relation with recurrent laryngeal nerve during thyroid surgery in a tertiary care hospital in Nepal: A cross-sectional study Rachana Baidhya, Deepak Regmi, Suzit Bhusal, Apeksha Bista, Reshika Shrestha This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4595496/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract 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. Inferior thyroid artery Recurrent laryngeal nerve Thyroid surgeries Zuckerkandl’s tubercle Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Thyroid surgery is very common in our part of the world. One of the most serious complications of thyroid surgery is injury to Recurrent Laryngeal Nerve (RLN). RLN is very important for the airway and voice quality. Injury to RLN during thyroid surgery can cause hoarseness and stridor. The gold standard for its identification is through careful dissection across the various anatomical landmarks before proceeding with the removal of the thyroid gland. As a complication of thyroid surgery, permanent RLN palsy occurs in 0.3-3% of cases, with transient palsies in 5–8% [ 1 ]. However, when the nerve is identified and dissected, the reported RLN injury rate during thyroidectomy is 0.2-1% [ 2 ]. Therefore, it would be ideal to have some anatomical landmarks to help identify the RLN easily [ 3 , 4 ]. When identified, Zuckerkandl’sTubercle (ZT) is a consistent landmark which can locate the RLN [ 5 , 6 ]. Inspite of its surgical significance, the ZT is often ignored in the literature and underutilized as a surgical landmark. Because the ZT is present in more than 70% of patients, it may readily be used by surgeons to locate the RLN [ 2 ]. Hence the purpose of this study was to offer a complete evidence-based assessment of the prevalence and anatomical features of ZT, and its anatomical relationship with RLN among the Nepalese population. Methods Study population The study was conducted in patients undergoing thyroid surgery in Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal from July 2018 to February 2020. Ethical approval was taken from the Institutional Review Committee of Kathmandu Medical College and Teaching Hospital. Inclusion and exclusion criteria All the patients who underwent thyroidectomy of any type in which ZT was identified were included in the study. The patients who had undergone previous radiation and thyroid cancer with gross extrathyroidal spread where ZT was difficult to locate or else involved by the tumor were excluded from the study. Informed written consent was taken from the participants. A convenience sampling technique was used. Preoperative assessment and other scoring system A detailed history was taken and a clinical examination of the thyroid swelling was done. The pre-operative assessment was done with the ultrasonography (USG) of the neck, thyroid function test, fine needle aspiration cytology (FNAC) and fiber-optic Naso-pharyngolaryngoscopy (NPL). Each side of the neck was taken as a separate entity. Under the aseptic condition, all the operations were performed according to standard surgical technique [ 7 ]. ZT, if present, was identified and graded according to Pelizzo's grading system into four types as grade 0, grade I, grade II and grade III.12 Grade 0 ZT is unidentified and was excluded from our study, grade I (ZT width ≤ _5 mm), grade II (ZT width 6–10 mm) and grade III (ZT width > 10 mm) were only included in the study. The width of the ZT was defined as the longest length between the upper and lower margins of the ZT. Sterile measuring tape was used. Per-operative documentation on the prevalence of ZT and its relation with RLN was recorded, its size and distance from the RLN measured, photograph taken and proforma filled. Statistical analysis The data were entered into Microsoft Excel and analyzed in the Statistical Package for the Social Sciences (SPSS) version 20. Percentage, mean and standard deviation of all was calculated. Statistical tools used were the chi-square test and Pearson Correlation test. Results Thirty-four patients who presented to KMC-TH, ENT-HNS department of surgery with benign or malignant thyroid disease and underwent thyroid surgery were enrolled in the study. During the study period, 44 ZTs were evaluated in 34 patients undergoing thyroid surgery. The age of the patients ranged from 23 to 61 years of age. The mean age ± S.D. of the patient enrolled in the study was 41.76 ± 10.76. Zuckerkandl’s tubercle was present in 14 patients (73.7%) in the right side and in 19 patients (76%) in the left side. (Table 1 ) Thus, applying the chi square test, p- value was calculated to be 0.86 (p > 0.05), which is statistically not significant. Table 1 Prevalence of Zuckerkandl’s Tubercle ZT Right (n = 19 ) Left (n = 25) Present 14 (73.68) 19 (76) Absent 5 (26.31) 6 (24) On the right side, 13 ZTs (92.9%) were unilobed in nature and 1 ZT (7.1%) was bilobed, while on the left side, all the 19 ZTs (100%) were unilobed in nature. (Table 2 ) Table 2 Lobularity of Zuckerkandl’s Tubercle Lobularity Right (n = 14) Left (n = 19) Uniloble 13 (92.9) 19 (100) Bilobe 1 (7.1) 0 (0) All the ZTs, 14 (100%) on right side and 19 (100%) on left side were sessile. On the right side, ZT was located in the posterior part of thyroid lobe in 10 cases (71.4%), lateral part in 3 cases (21.4%) and anterior part in 1 case (7.1%). On the left side, ZT was located in the posterior part of thyroid lobe in 15 cases (78.9%) and lateral part in 4 cases (21.1%). (Table 3 ) Table 3 Location of Zuckerkandl’s Tubercle Location of Zuckerkandl’s Tubercle Right (n = 14) Left (n = 19) Posterior 10 (71.4) 15 (78.9) Lateral 3 (21.4) 4 (21.1) Anterior 1 (7.1) 0 (0.0) The size of the ZT was graded according to Pelizzo's grading system for ZT into grade 0–3. On the right side, 5 ZTs (26.31%) were grade 0, 6 ZTs (31.57%) were grade 1, 7 ZTs (36.8%) were grade 2 and 1 ZT (5.2%) was grade 3. On the left side, 6 ZTs (24%) were grade 0, 5 ZTs (20.0%) were grade 1, 11 ZTs (44.0%) were grade 2 and 3 ZTs (12.0%) were grade 3. (Table 4 ) 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 16 cases (84.2%) and lateral to ZT in 3 cases (15.8%). Table 4 Pelizzo’s grading of Zuckerkandl’s Tubercle Pelizzo’s grading of Zuckerkandl’s Tubercle Right (n = 19) Left (n = 25) Grade 0 5 (26. 31) 6 (24) Grade 1 6 (31.57) 5 (20) Grade 2 7 (36.8) 11(44) Grade 3 1 (5.2) 3 (12) Among the 14 cases on right side, RLN was adhered to ZT in 57.1% cases (n = 8) RLN was at the distance of less than 5 mm from ZT in 35.7% cases(n = 5), at distance of 5–10 mm from ZT in 7.1% cases (n = 1). On left side, RLN was adhered to ZT in 3 cases (15.8%), at the distance of less than 5 mm from ZT in 7 cases (36.8%), at distance of 5–10 mm from ZT in 6 cases (31.6%) and more than 10 mm distance from ZT in 3 case (15.8%). Distance between ZT and RLN and Grade of ZT is negatively correlated with p-value of 0.017 on the right side and P-value of < 0.001 on the left side, which is statistically significant. This shows that the distance between RLN and ZT decreases as the grade of the ZT increases and vice versa (using Pearson’s correlation test). (Table 5 ) Table 5 Distance between ZT and RLN Distance between ZT and RLN Right (n = 14) Left (n = 19) Adhered 8 (57.1) 3 (15.8) Less than 5 mm 5 (35.7) 7 (36.8) 5 to 10 mm 1 (7.1) 6 (31.6) More than 10 mm 0 (0.0) 3 (15.8) Discussion The RLN is an important anatomical structure in thyroid surgeries. The RLN palsy following its injury is one of the most common complications of these surgeries [ 8 ] which can cause severe vocal, breathing, and swallowing difficulties creating major psychological and social difficulties for the patient [ 9 ]. Although some surgeons avoid dissection near the RLN, others promote routine RLN identification, claiming that dissection throughout the nerve's full course can reduce nerve injury [ 10 ]. As the course of the RLN varies, many authors have researched for its relation to anatomic structures such as the inferior thyroid artery [ 11 ], the Berry’s ligament [ 12 ], the thyroid cartilage[ 13 ] and the Zuckerkandl's tubercle [ 12 ], to identify it. Until the mid-20th century, reports on the relationship between ZT and RLN evoked little interest [ 14 ]. Later in 1998, Pelizzo et al. [ 15 ]described “ When the ZT is encountered, it looks like an arrow pointing toward the nerve. If the ZT is mobilized medially, it allows easy identification of the nerve before it turns below the inferior cricothyroid articulation.” One might argue that nodules from diseased thyroids can cast a shadow on ZT. Nonetheless, ZT, which is made up of thyroid tissue, is predicted to have a role in hyperplastic or neoplastic disease. Also, ZT is embryologically identified as the main location for medullary cancer in particular [ 16 ]. In the present study, ZT was present in 75% cases (n = 33/44), 73.68% (n = 14/19) on the right side and 76.0% (n = 19/25) on the left side. Thus, applying the chi square test, p value was calculated to be 0.86 (p > 0.05), which is not statistically significant. The finding was similar to the study conducted by Singh et al where ZT was identified in 87.86% cases, with no significant difference in laterality [ 5 ]. In this study, among 33 identified ZT, 92.9 (n = 13/14) ZTs on the right side and 100% (n = 19/19) ZTs on the left side were unilobed in structure, whereas only 1 ZT (7.1%) on the right side was found bilobed in structure. A prospective study done by Mehanna et al among 156 patients undergoing thyroidectomy showed presence of bilobed ZT in 4.7% cases which is similar to findings of our study [ 17 ]. This can be explained by the fact that ZT develops as a single lateral projection from the thyroid lobe, therefore favoring the unilobed nature of the ZT. This study showed all the ZTs (n = 33/33) to be sessile in nature. In a study by Gil-Carcedo et al, the shape of the ZT was sessile in 70.96% cases and pedunculated in 29.03% cases [ 18 ]. This also may be contributed by the fact that ZT is a part of the thyroid lobe rather than a separate entity. Findings from this study showed that ZT is located at the posterior part of the thyroid lobe in 71.4% cases (n = 10/14), lateral part in 21.4% cases (n = 3/14) and anterior part in 7.1% cases (n = 1/14) on the right side. On the left side, ZT was located in the posterior part of thyroid lobe in 78.9% cases (n = 15/19) and lateral part in 21.1% cases (n = 4/19). Singh et al conducted a similar study which showed that ZT is located at the posterior part of thyroid lobe in 97.20%, anterior part in 0.56% and lateral part in 2.77% of the cases [ 5 ]. This may be due to attachment of ZT, connecting the thyroid lobe with pharynx posteriorly during the embryological period which gradually separates to become the swelling in the posterior part of the thyroid lobe. In this study, on the right side, 26.31% ZTs (n = 5/19) were grade 0, 31.57% ZTs (n = 6/19) were grade 1, 36.8% ZTs (n = 7/19) were grade 2 and 5.2% ZT (n = 1/19) was grade 3. On the left side, 24% ZTs (n = 6/25) were grade 0, 20% ZTs (n = 5/25) were grade 1, 44% ZTs ( n = 11/25) were grade 2 and 12% ZTs (n = 3/25) were grade 3. Moreover, results from previous studies support the finding of this study. Irawati et al conducted a similar study in which ZT was grade 0 in 9.5%, grade I in 28.9%, grade II in 50.5% and grade III in 11% [ 6 ]. Further studies with greater sample size are needed for more accurate results. In the present study, on the right side, RLN was present medial to the ZT in all cases (n = 14/14), while on the left side, RLN was present medial to ZT in 84.2% cases (n = 16/19) and lateral to ZT in 15.8% cases (n = 3/19). Similar finding was present in a study conducted by Gurleyik et al which showed a common relationship between RLN and ZT. In 94% tubercles, the nerve runs medial to the tubercle [ 19 ]. In this study, among the 14 cases on right side, RLN was adhered to ZT in 57.1% cases (n = 8) RLN was at the distance of less than 5 mm from ZT in 35.7% cases (n = 5), at distance of 5–10 mm from ZT in 7.1% cases (n = 1). Among the 19 patients on left side, RLN was adhered to ZT in 15.8% cases (n = 3), at the distance of less than 5 mm from ZT in 36.8% cases (n = 7), at distance of 5–10 mm from ZT in 31.6% cases (n = 6) and more than 10 mm distance from ZT in 15.8% cases (n = 3). The relationship between distance between Recurrent laryngeal nerve and ZT and the size of ZT was analyzed using Pearson’s correlation test which showed that these two factors are negatively correlated with P-value of 0.017 on the right side and P-value of < 0.001 on the left side, which is statistically significant. This means that as the size of the ZT increases, the distance between ZT and Recurrent laryngeal nerve decreases and vice versa. Identification of ZT after meticulous and deliberate dissection can be a useful method for the identification of RLN and prevention of its injury during thyroid surgery due to their consistent relationship. This can definitely add some additional prospect to the commonly used landmarks like Inferior thyroid artery, Berry’s ligament and inferior cornu of thyroid cartilage for the identification of RLN. Therefore, thorough anatomical understanding of the nerve, related vasculature and structure in close proximity with RLN like ZT in thyroid surgeries aids recognition and identification of RLN and helps in better functional outcome. Conclusion The study demonstrated Zuckerkandl’s tubercle as a common finding during thyroid surgeries. It showed a consistent anatomical relationship between ZT and recurrent laryngeal nerve, when ZT is identified. On the right side, RLN was present medial to the ZT in all cases, while on the left side, RLN was present medial to ZT in most of the cases. The prevalence of ZT was 75% and was more on the left side than on the right side. The most common type was grade 2 ZT followed by grade 1, grade 0 and grade 3. Despite this fact, the knowledge about their relationship has not been widely disseminated. Through this study, ZT can be regarded as an important anatomical landmark for identification and preservation of the RLN during thyroid surgeries. Abbreviations FNAC Fine needle aspiration cytology NPL Naso-pharyngolaryngoscopy RLN Recurrent Laryngeal Nerve SPSS Statistical Package of Social Science USG Ultrasonography ZT Zuckerkandl’s tubercle Declarations Author contribution Deepak Regmi, Rachana Baidhya, Suzit Bhusal, Apeksha Bista, and Reshika Shrestha contributed equally on this research completion. Deepak Regmi and Rachana Baidhya had full access to all the data in the study and took responsibility for integrity of data. Study concept and design: Deepak Regmi and Rachana Baidhya. Acquisition, analysis, or interpretation of data: Deepak Regmi, Rachana Baidhya, Suzit Bhusal, Apeksha Bista and Reshika Shrestha. Drafting of the manuscript: Deepak Regmi, Rachana Baidhya, Suzit Bhusal, Apeksha Bista, and Reshika Shrestha. Review and editing: Deepak Regmi, Rachana Baidhya, Suzit Bhusal, Apeksha Bista and Reshika Shresths. All authors have read and agreed to the published version of the manuscript. Funding None Data availability The datasets used and analyzed during the current study available from the corresponding author on reasonable request. Competing interests None reported Ethics approval and consent to participate This study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Committee of Kathmandu Medical College and Teaching Hospital. Informed consent was obtained from all participants. Consent for publication Not applicable. References Hayward NJ, Grodski S, Yeung M, Johnson WR, Serpell J. 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Acta Otorrinolaringologica (English Edition). 2012 Nov 1;63(6):443-9. Gurleyik E, Gurleyik G. Incidence and surgical importance of Zuckerkandl’s tubercle of the thyroid and its relations with recurrent laryngeal nerve. International Scholarly Research Notices. 2012;2012(1):450589. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4595496","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":326473909,"identity":"694f1258-a109-4fe0-828c-ab1167d62e76","order_by":0,"name":"Rachana Baidhya","email":"","orcid":"","institution":"Nepal Korean Friendship Municipality Hospital","correspondingAuthor":false,"prefix":"","firstName":"Rachana","middleName":"","lastName":"Baidhya","suffix":""},{"id":326473910,"identity":"b6efd4b0-4526-4c6b-955a-051789508524","order_by":1,"name":"Deepak Regmi","email":"","orcid":"","institution":"Amritam Gamaya Aadim Ent Care Private 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1","display":"","copyAsset":false,"role":"figure","size":57772,"visible":true,"origin":"","legend":"\u003cp\u003ePresence of ZT on both right and left side\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4595496/v1/0a3baf97a7e3ca9687691606.jpg"},{"id":60617906,"identity":"0c63ca00-7566-4ef4-8394-c3c94ecbb453","added_by":"auto","created_at":"2024-07-18 20:32:29","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":40309,"visible":true,"origin":"","legend":"\u003cp\u003eEnlarged ZT on right side (with pyramidal lobe(\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4595496/v1/e70bb4b2c9f4035ae67df171.jpg"},{"id":60616050,"identity":"80069960-b5fd-4f02-b9a4-63777955533e","added_by":"auto","created_at":"2024-07-18 20:16:29","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":51588,"visible":true,"origin":"","legend":"\u003cp\u003ePelizzo’s Grade 3 ZT( right side(\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4595496/v1/f2ff407fc81f3ef05ceec48b.jpg"},{"id":60616778,"identity":"66b0cb39-68bb-4dba-a230-6c75f2e7733c","added_by":"auto","created_at":"2024-07-18 20:24:29","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":59036,"visible":true,"origin":"","legend":"\u003cp\u003eRLN running posteromedial to ZT\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4595496/v1/9e711bb987e99c28209576fa.jpg"},{"id":70656542,"identity":"969d90b0-bb01-4191-8abb-257a3b613e24","added_by":"auto","created_at":"2024-12-05 09:55:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":617866,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4595496/v1/6aaccea9-4d5d-4444-883b-493761f3300b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Zuckerkandl’s tubercle and its relation with recurrent laryngeal nerve during thyroid surgery in a tertiary care hospital in Nepal: A cross-sectional study","fulltext":[{"header":"Background","content":"\u003cp\u003eThyroid surgery is very common in our part of the world. One of the most serious complications of thyroid surgery is injury to Recurrent Laryngeal Nerve (RLN). RLN is very important for the airway and voice quality. Injury to RLN during thyroid surgery can cause hoarseness and stridor. The gold standard for its identification is through careful dissection across the various anatomical landmarks before proceeding with the removal of the thyroid gland.\u003c/p\u003e \u003cp\u003eAs a complication of thyroid surgery, permanent RLN palsy occurs in 0.3-3% of cases, with transient palsies in 5\u0026ndash;8% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, when the nerve is identified and dissected, the reported RLN injury rate during thyroidectomy is 0.2-1% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Therefore, it would be ideal to have some anatomical landmarks to help identify the RLN easily [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. When identified, Zuckerkandl\u0026rsquo;sTubercle (ZT) is a consistent landmark which can locate the RLN [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInspite of its surgical significance, the ZT is often ignored in the literature and underutilized as a surgical landmark. Because the ZT is present in more than 70% of patients, it may readily be used by surgeons to locate the RLN [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Hence the purpose of this study was to offer a complete evidence-based assessment of the prevalence and anatomical features of ZT, and its anatomical relationship with RLN among the Nepalese population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThe study was conducted in patients undergoing thyroid surgery in Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal from July 2018 to February 2020. Ethical approval was taken from the Institutional Review Committee of Kathmandu Medical College and Teaching Hospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eAll the patients who underwent thyroidectomy of any type in which ZT was identified were included in the study. The patients who had undergone previous radiation and thyroid cancer with gross extrathyroidal spread where ZT was difficult to locate or else involved by the tumor were excluded from the study. Informed written consent was taken from the participants. A convenience sampling technique was used.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative assessment and other scoring system\u003c/h2\u003e \u003cp\u003eA detailed history was taken and a clinical examination of the thyroid swelling was done. The pre-operative assessment was done with the ultrasonography (USG) of the neck, thyroid function test, fine needle aspiration cytology (FNAC) and fiber-optic Naso-pharyngolaryngoscopy (NPL). Each side of the neck was taken as a separate entity. Under the aseptic condition, all the operations were performed according to standard surgical technique [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eZT, if present, was identified and graded according to Pelizzo's grading system into four types as grade 0, grade I, grade II and grade III.12 Grade 0 ZT is unidentified and was excluded from our study, grade I (ZT width \u0026le; _5 mm), grade II (ZT width 6\u0026ndash;10 mm) and grade III (ZT width\u0026thinsp;\u0026gt;\u0026thinsp;10 mm) were only included in the study. The width of the ZT was defined as the longest length between the upper and lower margins of the ZT. Sterile measuring tape was used. Per-operative documentation on the prevalence of ZT and its relation with RLN was recorded, its size and distance from the RLN measured, photograph taken and proforma filled.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data were entered into Microsoft Excel and analyzed in the Statistical Package for the Social Sciences (SPSS) version 20. Percentage, mean and standard deviation of all was calculated. Statistical tools used were the chi-square test and Pearson Correlation test.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThirty-four patients who presented to KMC-TH, ENT-HNS department of surgery with benign or malignant thyroid disease and underwent thyroid surgery were enrolled in the study. During the study period, 44 ZTs were evaluated in 34 patients undergoing thyroid surgery. The age of the patients ranged from 23 to 61 years of age. The mean age\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D. of the patient enrolled in the study was 41.76\u0026thinsp;\u0026plusmn;\u0026thinsp;10.76.\u003c/p\u003e \u003cp\u003eZuckerkandl\u0026rsquo;s tubercle was present in 14 patients (73.7%) in the right side and in 19 patients (76%) in the left side. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) Thus, applying the chi square test, p- value was calculated to be 0.86 (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), which is statistically not significant.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence of Zuckerkandl\u0026rsquo;s Tubercle\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight (n\u0026thinsp;=\u0026thinsp;19 )\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (73.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (26.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOn the right side, 13 ZTs (92.9%) were unilobed in nature and 1 ZT (7.1%) was bilobed, while on the left side, all the 19 ZTs (100%) were unilobed in nature. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLobularity of Zuckerkandl\u0026rsquo;s Tubercle\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLobularity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniloble\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (92.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAll the ZTs, 14 (100%) on right side and 19 (100%) on left side were sessile. On the right side, ZT was located in the posterior part of thyroid lobe in 10 cases (71.4%), lateral part in 3 cases (21.4%) and anterior part in 1 case (7.1%). On the left side, ZT was located in the posterior part of thyroid lobe in 15 cases (78.9%) and lateral part in 4 cases (21.1%). (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLocation of Zuckerkandl\u0026rsquo;s Tubercle\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation of Zuckerkandl\u0026rsquo;s Tubercle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (78.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (21.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe size of the ZT was graded according to Pelizzo's grading system for ZT into grade 0\u0026ndash;3. On the right side, 5 ZTs (26.31%) were grade 0, 6 ZTs (31.57%) were grade 1, 7 ZTs (36.8%) were grade 2 and 1 ZT (5.2%) was grade 3. On the left side, 6 ZTs (24%) were grade 0, 5 ZTs (20.0%) were grade 1, 11 ZTs (44.0%) were grade 2 and 3 ZTs (12.0%) were grade 3. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) 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 16 cases (84.2%) and lateral to ZT in 3 cases (15.8%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePelizzo\u0026rsquo;s grading of Zuckerkandl\u0026rsquo;s Tubercle\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelizzo\u0026rsquo;s grading of Zuckerkandl\u0026rsquo;s Tubercle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (26. 31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (31.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong the 14 cases on right side, RLN was adhered to ZT in 57.1% cases (n\u0026thinsp;=\u0026thinsp;8) RLN was at the distance of less than 5 mm from ZT in 35.7% cases(n\u0026thinsp;=\u0026thinsp;5), at distance of 5\u0026ndash;10 mm from ZT in 7.1% cases (n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e \u003cp\u003eOn left side, RLN was adhered to ZT in 3 cases (15.8%), at the distance of less than 5 mm from ZT in 7 cases (36.8%), at distance of 5\u0026ndash;10 mm from ZT in 6 cases (31.6%) and more than 10 mm distance from ZT in 3 case (15.8%).\u003c/p\u003e \u003cp\u003eDistance between ZT and RLN and Grade of ZT is negatively correlated with p-value of 0.017 on the right side and P-value of \u0026lt;\u0026thinsp;0.001 on the left side, which is statistically significant. This shows that the distance between RLN and ZT decreases as the grade of the ZT increases and vice versa (using Pearson\u0026rsquo;s correlation test). (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistance between ZT and RLN\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistance between ZT and RLN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdhered\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (15.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 5 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (36.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5 to 10 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (31.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 10 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (15.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe RLN is an important anatomical structure in thyroid surgeries. The RLN palsy following its injury is one of the most common complications of these surgeries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] which can cause severe vocal, breathing, and swallowing difficulties creating major psychological and social difficulties for the patient [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Although some surgeons avoid dissection near the RLN, others promote routine RLN identification, claiming that dissection throughout the nerve's full course can reduce nerve injury [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs the course of the RLN varies, many authors have researched for its relation to anatomic structures such as the inferior thyroid artery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], the Berry\u0026rsquo;s ligament [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], the thyroid cartilage[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and the Zuckerkandl's tubercle [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], to identify it. Until the mid-20th century, reports on the relationship between ZT and RLN evoked little interest [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Later in 1998, Pelizzo et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]described \u0026ldquo; When the ZT is encountered, it looks like an arrow pointing toward the nerve. If the ZT is mobilized medially, it allows easy identification of the nerve before it turns below the inferior cricothyroid articulation.\u0026rdquo;\u003c/p\u003e \u003cp\u003eOne might argue that nodules from diseased thyroids can cast a shadow on ZT. Nonetheless, ZT, which is made up of thyroid tissue, is predicted to have a role in hyperplastic or neoplastic disease. Also, ZT is embryologically identified as the main location for medullary cancer in particular [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present study, ZT was present in 75% cases (n\u0026thinsp;=\u0026thinsp;33/44), 73.68% (n\u0026thinsp;=\u0026thinsp;14/19) on the right side and 76.0% (n\u0026thinsp;=\u0026thinsp;19/25) on the left side. Thus, applying the chi square test, p value was calculated to be 0.86 (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), which is not statistically significant. The finding was similar to the study conducted by Singh et al where ZT was identified in 87.86% cases, with no significant difference in laterality [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, among 33 identified ZT, 92.9 (n\u0026thinsp;=\u0026thinsp;13/14) ZTs on the right side and 100% (n\u0026thinsp;=\u0026thinsp;19/19) ZTs on the left side were unilobed in structure, whereas only 1 ZT (7.1%) on the right side was found bilobed in structure. A prospective study done by Mehanna et al among 156 patients undergoing thyroidectomy showed presence of bilobed ZT in 4.7% cases which is similar to findings of our study [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This can be explained by the fact that ZT develops as a single lateral projection from the thyroid lobe, therefore favoring the unilobed nature of the ZT.\u003c/p\u003e \u003cp\u003eThis study showed all the ZTs (n\u0026thinsp;=\u0026thinsp;33/33) to be sessile in nature. In a study by Gil-Carcedo et al, the shape of the ZT was sessile in 70.96% cases and pedunculated in 29.03% cases [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This also may be contributed by the fact that ZT is a part of the thyroid lobe rather than a separate entity.\u003c/p\u003e \u003cp\u003eFindings from this study showed that ZT is located at the posterior part of the thyroid lobe in 71.4% cases (n\u0026thinsp;=\u0026thinsp;10/14), lateral part in 21.4% cases (n\u0026thinsp;=\u0026thinsp;3/14) and anterior part in 7.1% cases (n\u0026thinsp;=\u0026thinsp;1/14) on the right side. On the left side, ZT was located in the posterior part of thyroid lobe in 78.9% cases (n\u0026thinsp;=\u0026thinsp;15/19) and lateral part in 21.1% cases (n\u0026thinsp;=\u0026thinsp;4/19). Singh et al conducted a similar study which showed that ZT is located at the posterior part of thyroid lobe in 97.20%, anterior part in 0.56% and lateral part in 2.77% of the cases [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This may be due to attachment of ZT, connecting the thyroid lobe with pharynx posteriorly during the embryological period which gradually separates to become the swelling in the posterior part of the thyroid lobe.\u003c/p\u003e \u003cp\u003eIn this study, on the right side, 26.31% ZTs (n\u0026thinsp;=\u0026thinsp;5/19) were grade 0, 31.57% ZTs (n\u0026thinsp;=\u0026thinsp;6/19) were grade 1, 36.8% ZTs (n\u0026thinsp;=\u0026thinsp;7/19) were grade 2 and 5.2% ZT (n\u0026thinsp;=\u0026thinsp;1/19) was grade 3. On the left side, 24% ZTs (n\u0026thinsp;=\u0026thinsp;6/25) were grade 0, 20% ZTs (n\u0026thinsp;=\u0026thinsp;5/25) were grade 1, 44% ZTs ( n\u0026thinsp;=\u0026thinsp;11/25) were grade 2 and 12% ZTs (n\u0026thinsp;=\u0026thinsp;3/25) were grade 3. Moreover, results from previous studies support the finding of this study. Irawati et al conducted a similar study in which ZT was grade 0 in 9.5%, grade I in 28.9%, grade II in 50.5% and grade III in 11% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Further studies with greater sample size are needed for more accurate results.\u003c/p\u003e \u003cp\u003eIn the present study, on the right side, RLN was present medial to the ZT in all cases (n\u0026thinsp;=\u0026thinsp;14/14), while on the left side, RLN was present medial to ZT in 84.2% cases (n\u0026thinsp;=\u0026thinsp;16/19) and lateral to ZT in 15.8% cases (n\u0026thinsp;=\u0026thinsp;3/19). Similar finding was present in a study conducted by Gurleyik et al which showed a common relationship between RLN and ZT. In 94% tubercles, the nerve runs medial to the tubercle [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, among the 14 cases on right side, RLN was adhered to ZT in 57.1% cases (n\u0026thinsp;=\u0026thinsp;8) RLN was at the distance of less than 5 mm from ZT in 35.7% cases (n\u0026thinsp;=\u0026thinsp;5), at distance of 5\u0026ndash;10 mm from ZT in 7.1% cases (n\u0026thinsp;=\u0026thinsp;1). Among the 19 patients on left side, RLN was adhered to ZT in 15.8% cases (n\u0026thinsp;=\u0026thinsp;3), at the distance of less than 5 mm from ZT in 36.8% cases (n\u0026thinsp;=\u0026thinsp;7), at distance of 5\u0026ndash;10 mm from ZT in 31.6% cases (n\u0026thinsp;=\u0026thinsp;6) and more than 10 mm distance from ZT in 15.8% cases (n\u0026thinsp;=\u0026thinsp;3). The relationship between distance between Recurrent laryngeal nerve and ZT and the size of ZT was analyzed using Pearson\u0026rsquo;s correlation test which showed that these two factors are negatively correlated with P-value of 0.017 on the right side and P-value of \u0026lt;\u0026thinsp;0.001 on the left side, which is statistically significant. This means that as the size of the ZT increases, the distance between ZT and Recurrent laryngeal nerve decreases and vice versa.\u003c/p\u003e \u003cp\u003eIdentification of ZT after meticulous and deliberate dissection can be a useful method for the identification of RLN and prevention of its injury during thyroid surgery due to their consistent relationship. This can definitely add some additional prospect to the commonly used landmarks like Inferior thyroid artery, Berry\u0026rsquo;s ligament and inferior cornu of thyroid cartilage for the identification of RLN. Therefore, thorough anatomical understanding of the nerve, related vasculature and structure in close proximity with RLN like ZT in thyroid surgeries aids recognition and identification of RLN and helps in better functional outcome.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study demonstrated Zuckerkandl\u0026rsquo;s tubercle as a common finding during thyroid surgeries. It showed a consistent anatomical relationship between ZT and recurrent laryngeal nerve, when ZT is identified. On the right side, RLN was present medial to the ZT in all cases, while on the left side, RLN was present medial to ZT in most of the cases. The prevalence of ZT was 75% and was more on the left side than on the right side. The most common type was grade 2 ZT followed by grade 1, grade 0 and grade 3.\u003c/p\u003e \u003cp\u003eDespite this fact, the knowledge about their relationship has not been widely disseminated. Through this study, ZT can be regarded as an important anatomical landmark for identification and preservation of the RLN during thyroid surgeries.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eFNAC \u0026nbsp;Fine needle aspiration cytology\u003c/p\u003e\n\u003cp\u003eNPL \u0026nbsp; \u0026nbsp; \u0026nbsp;Naso-pharyngolaryngoscopy\u003c/p\u003e\n\u003cp\u003eRLN \u0026nbsp; \u0026nbsp; Recurrent Laryngeal Nerve\u003c/p\u003e\n\u003cp\u003eSPSS \u0026nbsp; \u0026nbsp;Statistical Package of Social Science\u003c/p\u003e\n\u003cp\u003eUSG \u0026nbsp; \u0026nbsp; \u0026nbsp;Ultrasonography\u003c/p\u003e\n\u003cp\u003eZT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Zuckerkandl\u0026rsquo;s tubercle\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeepak Regmi, Rachana Baidhya, Suzit Bhusal, Apeksha Bista, and Reshika Shrestha contributed equally on this research completion. Deepak Regmi and Rachana Baidhya had full access to all the data in the study and took responsibility for integrity of data. Study concept and design: Deepak Regmi and Rachana Baidhya. Acquisition, analysis, or interpretation of data: Deepak Regmi, Rachana Baidhya, Suzit Bhusal, Apeksha Bista and Reshika Shrestha. Drafting of the manuscript: Deepak Regmi, Rachana Baidhya, Suzit Bhusal, Apeksha Bista, and Reshika Shrestha. Review and editing: Deepak Regmi, Rachana Baidhya, Suzit Bhusal, Apeksha Bista and Reshika Shresths. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone reported\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Committee of Kathmandu Medical College and Teaching Hospital. \u0026nbsp;Informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHayward NJ, Grodski S, Yeung M, Johnson WR, Serpell J. Recurrent laryngeal nerve injury in thyroid surgery: a review. ANZ journal of surgery. 2013 Jan;83(1-2):15-21.\u003c/li\u003e\n\u003cli\u003eReady AR, Barnes AD. Complications of thyroidectomy. Journal of British Surgery. 1994 Nov;81(11):1555-6.\u003c/li\u003e\n\u003cli\u003eHisham AN, Lukman MR. Recurrent laryngeal nerve in thyroid surgery: a critical appraisal. ANZ journal of surgery. 2002 Dec;72(12):887-9.\u003c/li\u003e\n\u003cli\u003ePelizzo MR, Toniato A, Gemo G. Zuckerkandl\u0026rsquo;s tuberculum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark). Journal of the American College of Surgeons. 1998 Sep 1;187(3):333-6.\u003c/li\u003e\n\u003cli\u003eSingh P, Sharma K, Agarwal S. Per operative study of relation of Zuckerkandl tubercle with recurrent laryngeal nerve in thyroid surgery. Indian Journal of Otolaryngology and Head \u0026amp; Neck Surgery. 2017 Sep;69:351-6.\u003c/li\u003e\n\u003cli\u003eIrawati N, Vaish R, Chaukar D, Deshmukh A, D\u0026rsquo;Cruz A. The tubercle of Zuckerkandl: an important landmark revisited. Indian journal of surgical oncology. 2016 Sep;7:312-5.\u003c/li\u003e\n\u003cli\u003eBliss RD, Gauger PG, Delbridge LW. Surgeon\u0026apos;s approach to the thyroid gland: surgical anatomy and the importance of technique. World journal of surgery. 2000 Aug;24(8):891-7.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Neill JP, Fenton JE. The recurrent laryngeal nerve in thyroid surgery. The Surgeon. 2008 Dec 1;6(6):373-7.\u003c/li\u003e\n\u003cli\u003eSturniolo G, D\u0026rsquo;Alia C, Tonante A, Gagliano E, Taranto F, Schiavo MG. The recurrent laryngeal nerve related to thyroid surgery. The American journal of surgery. 1999 Jun 1;177(6):485-8.\u003c/li\u003e\n\u003cli\u003eJatzko GR, Lisborg PH, M\u0026uuml;ller MG, Wette VM. Recurrent nerve palsy after thyroid operations--principal nerve identification and a literature review. Surgery. 1994 Feb 1;115(2):139-44.\u003c/li\u003e\n\u003cli\u003eCampos BA, Henriques PR. Relationship between the recurrent laryngeal nerve and the inferior thyroid artery: a study in corpses. Revista do Hospital das Cl\u0026iacute;nicas. 2000;55:195-200.\u003c/li\u003e\n\u003cli\u003eHisham AN, Lukman MR. Recurrent laryngeal nerve in thyroid surgery: a critical appraisal. ANZ journal of surgery. 2002 Dec;72(12):887-9.\u003c/li\u003e\n\u003cli\u003eWang CA. The use of the inferior cornu of the thyroid cartilage in identifying the recurrent laryngeal nerve. Surgery, Gynecology \u0026amp; Obstetrics. 1975 Jan 1;140(1):91-4.\u003c/li\u003e\n\u003cli\u003eYal\u0026ccedil;in B, Poyrazoǧlu Y, Ozan H. Relationship between Zuckerkandl\u0026apos;s tubercle and the inferior laryngeal nerve including the laryngeal branches. 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Incidence and surgical importance of Zuckerkandl\u0026rsquo;s tubercle of the thyroid and its relations with recurrent laryngeal nerve. International Scholarly Research Notices. 2012;2012(1):450589.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Inferior thyroid artery, Recurrent laryngeal nerve, Thyroid surgeries, Zuckerkandl’s tubercle","lastPublishedDoi":"10.21203/rs.3.rs-4595496/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4595496/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003eThyroid 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eIdentification 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.\u003c/p\u003e","manuscriptTitle":"Zuckerkandl’s tubercle and its relation with recurrent laryngeal nerve during thyroid surgery in a tertiary care hospital in Nepal: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:16:24","doi":"10.21203/rs.3.rs-4595496/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a5373de9-1d27-4f73-801a-10c7120991ac","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-05T09:54:44+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 20:16:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4595496","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4595496","identity":"rs-4595496","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}