# Recurrent Laryngeal Nerve Stretching in Tracheal Diverticulum: First Documented Mechanism of Hoarseness and Systematic Review of Literatures

## TL;DR

This paper presents the first documented case of hoarseness caused by recurrent laryngeal nerve stretching due to a tracheal diverticulum and shows successful treatment with surgery.

## Contribution

First documented mechanism of RLN stretching in tracheal diverticulum causing hoarseness with quantitative functional improvement.

## Key findings

- Tracheal diverticulum can cause hoarseness via RLN stretching, not just compression.
- Open excision with RLN preservation leads to rapid voice recovery and improved lung function (FEV1 +10%).
- Systematic review shows 80% of similar cases had complete recovery after open surgery.

## Abstract

Tracheal diverticulum is a rare paratracheal air cyst. It is often asymptomatic. Large symptomatic cases may compress the recurrent laryngeal nerve (RLN) and cause hoarseness. It is a rare presentation, in < 0.2 cases per year in the world. We present a 45‐year‐old woman that had 6 months of chronic cough, dysphagia, odynophagia, dyspnea, hoarseness, hemoptysis, choking, and neck pain. She was not a smoker. Spirometry showed mild obstruction pattern (FEV1 78%). CT with 3D reconstruction revealed a 4 × 5 cm right posterolateral tracheal diverticulum (fifth–seventh rings, 8 mm communication). Bronchoscopy confirmed limited right vocal cord mobility. We did an open cervical excision that preserved the RLN. Histopathology confirmed acquired diverticulum. Hoarseness resolved in 3 weeks; repeat bronchoscopy showed normal vocal cord mobility. 3‐month CT confirmed resolution; 1‐year FEV1 improved. Asymptomatic at 12 months. Systematic review (1998–2025) found 4 prior hoarseness cases (total n = 5): 60% female, 80% right posterolateral, mean size 3.0 cm, 80% complete recovery in 3 weeks via open surgery. Largest reported diverticulum is with hoarseness. This is the first case with documentation of RLN stretching and quantitative improvement with spirometry. Multimodal imaging and early open excision with nerve preservation can cause excellent outcomes.

Tracheal diverticulum causes recurrent laryngeal nerve (RLN) involvement by stretching rather than compression. Multimodal imaging and bronchoscopy help us to make the accurate diagnosis. Early open excision and nerve preservation provide rapid voice recovery. Besides, it also improves objective functional (FEV1 + 10%), by preventing irreversible neural damage.