Aberrant Course of the Middle Thyroid Vein and Unusual Peripolar Branching of the Inferior Thyroid Artery Associated with a Quadrifurcation of the Recurrent Laryngeal Nerve: A Complex Anatomical Variant during Thyroidectomy

Introduction: The safety of thyroidectomy relies on a thorough knowledge of the anatomy of the thyroid bed. We report an exceptional case combining an aberrant course of the middle thyroid vein (MTV), peripolar branching of the inferior thyroid artery (ITA), and an early extralaryngeal quadrifurcation of the recurrent laryngeal nerve (RLN). Case Report: A 35-year-old female patient underwent total thyroidectomy for a compressive multinodular goiter evolving over 8 years. Intraoperative exploration revealed a complex, high-risk anatomical arrangement across three planes: 1) An aberrant ascending MTV creating a venous mask over the ITA; 2) An ITA with peripolar branches bypassing the lower pole; 3) An early extralaryngeal quadrifurcation of the RLN in a strictly retrovascular position. Results: Step-by-step ultraglandular capsular dissection enabled safe ligation of the aberrant MTV, preservation of the parathyroid vascular arcade, and individual visualization and tracking of all four RLN branches until their muscular entry. The postoperative course was uneventful, with complete resolution of compressive symptoms, no voice impairment, and no clinical signs of hypocalcemia. Conclusion: The concomitant presence of these three anatomical variants represents a significant surgical challenge. Early identification and meticulous capsular dissection are essential to prevent vascular, neurological, and parathyroid complications.