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External Branch of Superior Laryngeal Nerve (EBSLN) Anatomic Classification

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The Recurrent and Superior Laryngeal Nerves

Abstract

The external branch of the superior laryngeal nerve (EBSLN) has a close anatomical relationship with the superior thyroid pedicle and is at risk of injury during dissection of these vessels. Thorough knowledge of the surgical anatomy of the EBSLN and its variations is mandatory to avoid damage to the nerve during thyroidectomy. In recent years, several EBSLN anatomical classification systems have been proposed including the Cernea classification, Kierner classification, Friedman classification, and Selvan classification. In this chapter, these classifications are presented and discussed on the background of the published research in the field. The most widely recognized surgical classification of the EBSLN was proposed in 1992 by Cernea. This classification is based on the potential risk of injury to the nerve during thyroid surgery. It categorizes the nerve in relation to superior thyroid vessels and the upper edge of the superior thyroid pole into three types. A type-1 nerve crosses the superior thyroid vessels more than 1 cm above the upper edge of the thyroid superior pole and occurs in 68 % of patients with small goiter and in 23 % of patients with large goiter. A type-2A nerve crosses the vessels less than 1 cm above the upper edge of the superior pole and occurs in 18 % of patients with small goiter and 15 % of patients with large goiter. A type-2B nerve crosses the superior thyroid pedicle below the upper border of the superior thyroid pole and occurs in 14 % of patients with small goiters and 54 % of patients with large goiters. Obviously, a type-2B nerve is most vulnerable to inadvertent injury. The remaining classification systems should be considered as complementary to Cernea’s classification system, providing useful information for intraoperative identification of the nerve.

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References

  1. Kocher ET. Indikationen und Resultäte bei Kropfoperation. In: Kocher ET, editor. Chirurgische operationslehre. 5th ed. Jena: Gustav Fischer; 1907.

    Google Scholar 

  2. Fort JA. Anatomie descriptive et dissection. Paris: Octave Doin; 1892.

    Google Scholar 

  3. Berlin DD, Lahey FH. Dissections of the recurrent and superior laryngeal nerves: the relation of the recurrent to the inferior thyroid artery and the relation of the superior to abductor paralysis. Surg Gynecol Obstet. 1929;49:102–4.

    Google Scholar 

  4. Vernetti L. Studio anatomo-chirurgico sui rapproti della branch esterna del nervo laringeo superior com il pedunculor vascolare superiore delle tiroid. Minerva Chir. 1947;2:427–32.

    CAS  PubMed  Google Scholar 

  5. Durham CF, Harrison TS. The surgical anatomy of the superior laryngeal nerve. Surg Gynecol Obstet. 1964;118:38–44.

    CAS  PubMed  Google Scholar 

  6. Moosman DA, DeWeese MS. The external laryngeal nerve as related to thyroidectomy. Surg Gynecol Obstet. 1968;129:1011–6.

    Google Scholar 

  7. Kambic V, Zargu M, Radsel Z. Topographic anatomy of the external branch of the superior laryngeal nerve: its importance in head and neck Surgery. J Laryngol Otol. 1984;98:1121–4.

    Article  CAS  PubMed  Google Scholar 

  8. Lennquist S, Cahlin C, Smeds S. The superior laryngeal nerve in thyroid surgery. Surgery. 1987;102:999–1008.

    CAS  PubMed  Google Scholar 

  9. Cernea C, Ferraz AR, Nishio S, Dutra Jr A, Hojaij FC, dos Santos LR. Surgical anatomy of the external branch of the superior laryngeal nerve. Head Neck. 1992;14:380–3.

    Article  CAS  PubMed  Google Scholar 

  10. Kark AE, Kissin MW, Auerbach R, Meikle M. Voice changes after thyroidectomy: role of the external laryngeal nerve. Br Med J. 1984;289:1412–5.

    Article  CAS  Google Scholar 

  11. Gregg RL. Avoiding injury to the extralaryngeal nerves. Ann Otol Rhinol Laryngol. 1957;66:656–78.

    CAS  PubMed  Google Scholar 

  12. Kirchner JA. Surgically induced disorders of the vocal folds. Conn Med. 1964;28:24–8.

    CAS  PubMed  Google Scholar 

  13. Ferraz AR, Toledo AC. Aspectos techicos no tratamento de bocio nodular. Rev Hosp Clin Fac Med Sao Paulo. 1979;34:88–92.

    CAS  PubMed  Google Scholar 

  14. Lekakos NL, Miligos ND, Tzardis PJ, Majiatis S, Patoulis J. The superior laryngeal nerve in thyroidectomy. Am Surg. 1987;53:610–2.

    Google Scholar 

  15. Teitelbaum BJ, Wenig BL. Superior laryngeal nerve injury from thyroid surgery. Head Neck. 1995;17: 36–40.

    Article  CAS  PubMed  Google Scholar 

  16. Loré Jr JM, Kokocharov SI, Kaufman S, Richmond A, Sundquist N. Thirty-eight-year evaluation of a surgical technique to protect the external branch of the superior laryngeal nerve during thyroidectomy. Ann Otol Rhinol Laryngol. 1998;107:1015–22.

    Article  PubMed  Google Scholar 

  17. Kratz RC. The identification and protection of the laryngeal motor nerves during thyroid and laryngeal surgery: a new microsurgical technique. Laryngoscope. 1973;83:59–78.

    Article  CAS  PubMed  Google Scholar 

  18. Barczyński M, Randolph GW, Cernea CR, Dralle H, Dionigi G, Alesina PF, Mihai R, Finck C, Lombardi D, Hartl DM, Miyauchi A, Serpell J, Snyder S, Volpi E, Woodson G, Kraimps JL, Hisham AN, International Neural Monitoring Study Group. External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: International Neural Monitoring Study Group standards guideline statement. Laryngoscope. 2013;123 Suppl 4:S1–14.

    Article  PubMed  Google Scholar 

  19. Sow ML, Koyalta M, Benchekroun A, Diop A. The external laryngeal nerve in surgical excision of the thyroid. Anatomo-surgical correlations apropos of 30 dissections. Dakar Med. 1982;27:177–86.

    CAS  PubMed  Google Scholar 

  20. Lang J, Nachbaur S, Fischer K, Vogel E. The superior laryngeal nerve and the superior laryngeal artery. Acta Anat (Basel). 1987;130:309–18.

    Article  CAS  Google Scholar 

  21. Wu BL, Sanders I, Mu L, Biller HF. The human communicating nerve. An extension of the external superior laryngeal nerve that innervates the vocal cord. Arch Otolaryngol Head Neck Surg. 1994;120: 1321–8.

    Article  CAS  PubMed  Google Scholar 

  22. Nasri S, Beizai P, Ye M, Sercarz JA, Kim YM, Berke GS. Cross-innervation of the thyroarytenoid muscle by a branch from the external division of the superior laryngeal nerve. Ann Otol Rhinol Laryngol. 1997;106:594–8.

    Article  CAS  PubMed  Google Scholar 

  23. Maranillo E, León X, Quer M, Orús C, Sañudo JR. Is the external laryngeal nerve an exclusively motor nerve? The cricothyroid connection branch. Laryngoscope. 2003;113:525–9.

    Article  PubMed  Google Scholar 

  24. Martin-Oviedo C, Maranillo E, Lowy-Benoliel A, Pascual-Font A, Martinez-Guirado T, Rodriguez-Niedenführ M, Sañudo J, Scola B, Vazquez T. Functional role of human laryngeal nerve connections. Laryngoscope. 2011;121:2338–43.

    Article  PubMed  Google Scholar 

  25. Masuoka H, Miyauchi A, Yabuta T, Fukushima M, Miya A. Innervation of the cricothyroid muscle by the recurrent laryngeal nerve. Head Neck. 2015. doi:10.1002/hed.24015.

    Google Scholar 

  26. Barczyński M, Konturek A, Stopa M, Honowska A, Nowak W. Randomized controlled trial of visualization versus neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy. World J Surg. 2012;36:1340–7.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Potenza AS, Phelan EA, Cernea CR, Slough CM, Kamani DV, Darr A, Zurakowski D, Randolph GW. Normative intra-operative electrophysiologic waveform analysis of superior laryngeal nerve external branch and recurrent laryngeal nerve in patients undergoing thyroid surgery. World J Surg. 2013;37:2336–42.

    Article  PubMed  Google Scholar 

  28. Masuoka H, Miyauchi A, Higashiyama T, Yabuta T, Fukushima M, Ito Y, Kihara M, Kobayashi K, Yamada O, Nakayama A, Miya A. Prospective randomized study on injury of the external branch of the superior laryngeal nerve during thyroidectomy comparing intraoperative nerve monitoring and a conventional technique. Head Neck. 2015;37(10):1456–60.

    Article  PubMed  Google Scholar 

  29. Darr EA, Tufano RP, Ozdemir S, Kamani D, Hurwitz S, Randolph G. Superior laryngeal nerve quantitative intraoperative monitoring is possible in all thyroid surgeries. Laryngoscope. 2014;124:1035–41.

    Article  PubMed  Google Scholar 

  30. Cernea CR, Nishio S, Hojaij FC. Identification of the external branch of the superior laryngeal nerve (EBSLN) in large goiters. Am J Otolaryngol. 1995;16:307–11.

    Article  CAS  PubMed  Google Scholar 

  31. Pagedar NA, Freeman JL. Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Arch Otolaryngol Head Neck Surg. 2009;135:360–2.

    Article  PubMed  Google Scholar 

  32. Cernea CR, Ferraz AR, Furlani J, Monteiro S, Nishio S, Hojaij FC, Dutra Júnior A, Marques LA, Pontes PA, Bevilacqua RG. Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Am J Surg. 1992;164:634–9.

    Article  CAS  PubMed  Google Scholar 

  33. Hwang SB, Lee HY, Kim WY, Woo SU, Lee JB, Bae JW, Kim HY. The anatomy of the external branch of the superior laryngeal nerve in Koreans. Asian J Surg. 2013;36:13–9.

    Article  PubMed  Google Scholar 

  34. Kierner AC, Aigner M, Burian M. The external branch of the superior laryngeal nerve: its topographical anatomy as related to surgery of the neck. Arch Otolaryngol Head Neck Surg. 1998;124:301–3.

    Article  CAS  PubMed  Google Scholar 

  35. Friedman M, Wilson MN, Ibrahim H. Superior laryngeal nerve identification and preservation in thyroidectomy. Oper Tech Otolaryngol. 2009;20:145–51.

    Article  Google Scholar 

  36. Selvan B, Babu S, Paul MJ, Abraham D, Samuel P, Nair A. Mapping the compound muscle action potentials of cricothyroid muscle using electromyography in thyroid operations: a novel method to clinically type the external branch of the superior laryngeal nerve. Ann Surg. 2009;250:293–300.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Endocrine Surgery, Jagiellonian University Medical College, 37 Pradnicka Street, Krakow, 31-202, Poland

    Marcin Barczyński M.D., Ph.D.

  2. Department of Otolaryngology—Head & Neck Surgery, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada

    Jeremy L. Freeman M.D., F.R.C.S.C., F.A.C.S.

  3. Department of Head and Neck Surgery, University of São Paulo Medical School, São Paulo, Brazil

    Claudio R. Cernea M.D., Ph.D.

Authors
  1. Marcin Barczyński M.D., Ph.D.
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  2. Jeremy L. Freeman M.D., F.R.C.S.C., F.A.C.S.
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  3. Claudio R. Cernea M.D., Ph.D.
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Corresponding author

Correspondence to Marcin Barczyński M.D., Ph.D. .

Editor information

Editors and Affiliations

  1. The Claire and John Bertucci Endowed Cha, Harvard Medical School, Boston, Massachusetts, USA

    Gregory W. Randolph

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Barczyński, M., Freeman, J.L., Cernea, C.R. (2016). External Branch of Superior Laryngeal Nerve (EBSLN) Anatomic Classification. In: Randolph, G. (eds) The Recurrent and Superior Laryngeal Nerves. Springer, Cham. https://doi.org/10.1007/978-3-319-27727-1_16

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  • DOI: https://doi.org/10.1007/978-3-319-27727-1_16

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  • Publisher Name: Springer, Cham

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