Advertisement

World Journal of Surgery

, Volume 41, Issue 10, pp 2521–2529 | Cite as

The Identification, Preservation and Classification of the External Branch of the Superior Laryngeal Nerve in Thyroidectomy

  • Kun Wang
  • Huilan Cai
  • Deguang Kong
  • Qiuxia Cui
  • Dan Zhang
  • Gaosong WuEmail author
Original Scientific Report with Video

Abstract

Background

Avoiding injury to the external branch of the superior laryngeal nerve is one of the major challenges during thyroid operation. The aim of this study was to propose a practical classification of the external branch of the superior laryngeal nerve.

Methods

A retrospective study of total thyroidectomy was performed. Totally 240 patients were included, with 480 external branches of the superior laryngeal nerves explored by intraoperative neuromonitoring. The classification of the external branch of the superior laryngeal nerve was determined by the distance between the upper edge of the superior thyroid pole and the lowest point of the nerve when the thyroid lobe was retracted in the lateral and inferior direction. Multinomial logistic regression analysis was run to predict the type of the nerve from several variables.

Results

The identification rate of the external branch of the superior laryngeal nerve was 98.54% (473 of 480 nerves). Higher ratio of longitudinal size of the thyroid lobe to ipsilateral neck length increased the likelihood of that both the type 2 and 3 nerve with respect to type 1 nerve, with OR 2.72, 95% CI = 1.21–6.12 and OR 5.30, 95% CI = 2.09–13.44, respectively. (1a) The nerve whose lowest point (entry into the muscle) was located more than 1 cm above the horizontal plane passing the upper border of superior thyroid pole. (1b) The nerve whose lowest point (the point right above the superior thyroid pole) was located more than 1 cm above the plane. (2a) The nerve whose lowest point (entry into the muscle) was located within 1 cm above the plane. (2b) The nerve whose lowest point (the point right above the superior thyroid pole) was located within 1 cm above the plane. (3a) The nerve whose lowest point (entry into the muscle) was located below the plane. (3b) The nerve whose lowest point (the point right below the superior thyroid pole) was located anterior to the gland. (3c) The nerve whose lowest point (the point right below the superior thyroid pole) was located posterior to the gland.

Conclusions

Identification rate of the external branch of the superior laryngeal nerve by intraoperative neuromonitoring was significantly high. Understanding the new practical classification of the nerve allows for better identification and function preservation of this nerve during thyroidectomy.

Keywords

Total Thyroidectomy Thyroid Operation Thyroid Lobe Superior Laryngeal Nerve Multinomial Logistic Regression Analysis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Funding

Hubei Province health and family planning scientific Research Project (WJ2015MA003); Natural science foundation of Hubei province (No. 2008CDB179); China international medical foundation (Research Projects of the thyroid gland disease undertook by young and middle-aged doctors in 2015).

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflicts of interest.

Supplementary material

Partial or discrete contraction of the cricothyroid muscle (MP4 24059 kb)

Cricothyroid muscle twitch (MP4 11607 kb)

Nerve mapping (MP4 42024 kb)

References

  1. 1.
    Morton RP, Whitfield P, Al-Ali S (2006) Anatomical and surgical considerations of the external branch of the superior laryngeal nerve: a systematic review. Clin Otolaryngol 31:368–374CrossRefPubMedGoogle Scholar
  2. 2.
    Soylu L, Ozbas S, Uslu HY et al (2007) The evaluation of the causes of subjective voice disturbances after thyroid surgery. Am J Surg 194:317–322CrossRefPubMedGoogle Scholar
  3. 3.
    Kark AE, Kissin MW, Auerbach R et al (1984) Voice changes after thyroidectomy: role of the external laryngeal nerve. Br Med J (Clin Res Ed) 289:1412–1415CrossRefGoogle Scholar
  4. 4.
    Aluffi P, Policarpo M, Cherovac C et al (2001) Post-thyroidectomy superior laryngeal nerve injury. Eur Arch Otorhinolaryngol 258:451–454CrossRefPubMedGoogle Scholar
  5. 5.
    Friedman M, LoSavio P, Ibrahim H (2002) Superior laryngeal nerve identification and preservation in thyroidectomy. Arch Otolaryngol Head Neck Surg 128:296–303CrossRefPubMedGoogle Scholar
  6. 6.
    Barczynski M, Randolph GW, Cernea C et al (2016) International survey on the identification and neural monitoring of the EBSLN during thyroidectomy. Laryngoscope 126:285–291CrossRefPubMedGoogle Scholar
  7. 7.
    Barczynski M, Randolph GW, Cernea CR et al (2013) External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: International Neural Monitoring Study Group standards guideline statement. Laryngoscope 123:S1–S14CrossRefPubMedGoogle Scholar
  8. 8.
    Barczynski M, Konturek A, Stopa M et al (2012) Randomized controlled trial of visualization versus neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy. World J Surg 36:1340–1347. doi: 10.1007/s00268-012-1547-7 CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Sanabria A, Ramirez A, Kowalski LP et al (2013) Neuromonitoring in thyroidectomy: a meta-analysis of effectiveness from randomized controlled trials. Eur Arch Otorhinolaryngol 270:2175–2189CrossRefPubMedGoogle Scholar
  10. 10.
    Cernea CR, Ferraz AR, Nishio S et al (1992) Surgical anatomy of the external branch of the superior laryngeal nerve. Head Neck 14:380–383CrossRefPubMedGoogle Scholar
  11. 11.
    Kierner AC, Aigner M, Burian M (1998) The external branch of the superior laryngeal nerve: its topographical anatomy as related to surgery of the neck. Arch Otolaryngol Head Neck Surg 124:301–303CrossRefPubMedGoogle Scholar
  12. 12.
    Selvan B, Babu S, Paul MJ et al (2009) 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 250:293–300CrossRefPubMedGoogle Scholar
  13. 13.
    Wu G, Kong D (2016) Thyroidectomy with Wu Gaosong’s Procedure. VideoEndocrinology. doi: 10.1089/ve.2015.0050 Google Scholar
  14. 14.
    Randolph GW, Dralle H, International Intraoperative Monitoring Study Group et al (2011) Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope 121(Suppl 1):S1–S16Google Scholar
  15. 15.
    Furlan JC, Cordeiro AC, Brandao LG (2003) Study of some “intrinsic risk factors” that can enhance an iatrogenic injury of the external branch of the superior laryngeal nerve. Otolaryngol Head Neck Surg 128:396–400CrossRefPubMedGoogle Scholar
  16. 16.
    Pagedar NA, Freeman JL (2009) Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Arch Otolaryngol Head Neck Surg 135:360–362CrossRefPubMedGoogle Scholar
  17. 17.
    Bevan K, Griffiths MV, Morgan MH (1989) Cricothyroid muscle paralysis: its recognition and diagnosis. J Laryngol Otol 103:191–195CrossRefPubMedGoogle Scholar
  18. 18.
    Teitelbaum BJ, Wenig BL (1995) Superior laryngeal nerve injury from thyroid surgery. Head Neck 17:36–40CrossRefPubMedGoogle Scholar
  19. 19.
    Hurtado-Lopez LM, Diaz-Hernandez PI, Basurto-Kuba E et al (2016) Efficacy of intraoperative neuro-monitoring to localize the external branch of the superior laryngeal nerve. Thyroid 26:174–178CrossRefPubMedGoogle Scholar
  20. 20.
    Glover AR, Norlen O, Gundara JS et al (2015) Use of the nerve integrity monitor during thyroid surgery aids identification of the external branch of the superior laryngeal nerve. Ann Surg Oncol 22:1768–1773CrossRefPubMedGoogle Scholar
  21. 21.
    Wu G, Wang K (2016) Intraoperative neuromonitoring and protection of the superior laryngeal nerve with Wu Gaosong’s procedure. VideoEndocrinology. doi: 10.1089/ve.2016.0070 Google Scholar
  22. 22.
    Potenza AS, Phelan EA, Cernea CR et al (2013) Normative intra-operative electrophysiologic waveform analysis of superior laryngeal nerve external branch and recurrent laryngeal nerve in patients undergoing thyroid surgery. World J Surg 37:2336–2342. doi: 10.1007/s00268-013-2148-9 CrossRefPubMedGoogle Scholar
  23. 23.
    Yalcin B, Develi S, Tubbs RS et al (2013) A detailed study of the relationship between the external laryngeal nerve and superior thyroid artery, including its glandular branches. Clin Anat 26:814–822PubMedGoogle Scholar
  24. 24.
    Cernea CR, Nishio S, Hojaij FC (1995) Identification of the external branch of the superior laryngeal nerve (EBSLN) in large goiters. Am J Otolaryngol 16:307–311CrossRefPubMedGoogle Scholar
  25. 25.
    Ravikumar K, Sadacharan D, Muthukumar S et al (2016) EBSLN and factors influencing its identification and its safety in patients undergoing total thyroidectomy: a study of 456 cases. World J Surg 40:545–550. doi: 10.1007/s00268-015-3383-z CrossRefPubMedGoogle Scholar
  26. 26.
    Bellantone R, Boscherini M, Lombardi CP et al (2001) Is the identification of the external branch of the superior laryngeal nerve mandatory in thyroid operation? Results of a prospective randomized study. Surgery 130:1055–1059CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2017

Authors and Affiliations

  • Kun Wang
    • 1
  • Huilan Cai
    • 1
  • Deguang Kong
    • 2
  • Qiuxia Cui
    • 1
  • Dan Zhang
    • 1
  • Gaosong Wu
    • 1
    Email author
  1. 1.Department of Thyroid and Breast SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanPeople’s Republic of China
  2. 2.Department of Thyroid and Breast SurgeryZhongnan Hospital of Wuhan UniversityWuhanPeople’s Republic of China

Personalised recommendations