Objective: To investigate the application efficacy of the "classification of external branch of superior laryngeal nerve (EBSLN)" combined with intraoperative neuromonitoring (IONM) in the dissection of EBSLN for protecting the nerve from injuery, compared with ligation of branches of the superior thyroid vessels without attempts to visually identify the nerve. Methods: A prospective randomized controled study was performed in our center. Patients subjected to thyroidectomy from January 2017 to June 2019 were randomly divided into 2 groups, patients in experimental group underwent thyroidectomy and "classification of EBSLN" with IONM to dissect EBSLN, and patients in control group received synchronous surgery without attempts to visually identify the nerve. The anatomical subtypes of EBSLN in experimental group were recorded. The voice handicap index 10 (VHI-10) score was evaluated and the movement of bilateral vocal cords was examined by laryngoscope before surgery, 1 month, 3 months, and 6 months after surgery, respectively. SPSS 26.0 statistical software was used for statistical analysis. Results: Among the 1 377 EBSLN from 827 patients (317 males and 510 females, aged 24-58 years old), 691 EBSLNs in experimental group and 686 EBSLNs in control group. Totally 98.3% of EBSLNs in experimental group were identified by IONM including 16.4% (113/691) for type Ⅰ, 21.3% (147/691) for type Ⅱa, 31.4% (217/691) for type Ⅱb, 10.4% (72/691) for type Ⅲa, 3.9% (27/691) for type Ⅲb, 16.6% (115/691) for type Ⅲc. There was no statistical significance difference in baseline data between 2 groups (all P>0.05). All patients were followed up for more than 6 months. The postoperative nerve injury rate of experimental group was significantly lower than that of control group (1.2% vs. 7.5%, χ²=12.659, P<0.001), and the VHI-10 scores and laryngoscope results of experimental group were better than those of control group in three follow-up visits (P<0.001). With postoperative laryngoscope examination, 3 patients in the experimental group and 23 patients in the control group showed vocal cord relaxation, bilateral oblique asymmetry and other phenomena, which were considered as the results of permanent injury. Other patients with symptoms were relieved to varying degrees during the follow-up, and their symptoms were considered as the results of temporary injury. Conclusion: IONM combined with "classification of EBSLN" can reduce significantly the risk of EBSLN injury in thyroidectomy, which is better than direct ligation of branches without attempts to visually identify the nerve.
Adult ; Female ; Humans ; Laryngeal Nerve Injuries ; Laryngeal Nerves ; Male ; Middle Aged ; Monitoring, Intraoperative ; Prospective Studies ; Thyroid Gland ; Thyroidectomy ; Young Adult

Vagal paragangliomas (VPGLs) represent <5% of all head and neck paragangliomas (PGLs) and show a 17% to 20% risk of malignancy. We present a rare case of a 50-year-old gender with a left VPGL in her neck. To date, approximately 200 cases have been reported. The tumor showed web-like adhesions and arterial supply from the external carotid artery. We performed en bloc resection including a part of the vagus nerve. The superior laryngeal nerve was preserved with the “human communicating nerve” which maintains neural communication in >70% of humans, providing motor fibers to the larynx. The patient recovered uneventfully and was discharged on the 3rd postoperative day. These tumors are therapeutically challenging owing to their proximity to vital neck and skull base structures. Early detection decreases surgical morbidity and mortality. Preservation of viable neural tissue is important in advanced disease.
Carotid Artery, External ; Head ; Humans ; Laryngeal Nerves ; Larynx ; Middle Aged ; Mortality ; Neck ; Paraganglioma ; Skull Base ; Vagus Nerve

PURPOSE: Thyroid reoperations are surgically challenging because of significant anatomical variance. Visual and functional identification of the external branch of the superior laryngeal nerve (EBSLN) were studied in 2 groups of patients who underwent primary and redo thyroid surgery. METHODS: This study was conducted on 200 patients: 100 patients with redo and 100 patients with primary thyroid surgery. In addition to visual identification, nerve branches were functionally identified by intraoperative nerve monitoring (IONM). Visual, functional, and total identification rates of the EBSLN in both primary and redo surgery were determined and compared between the 2 groups. RESULTS: We attempted to identify 138 and 170 EBSLNs at risk in redo and primary surgery, respectively. Visual identification rates were 65.3% and 30.4% (P < 0.001) in primary and redo surgery groups, respectively. In total, 164 (96.5%) and 97 EBSLNs (70.3%) were identified in primary and redo surgery, respectively (P < 0.001), including the use of IONM. In primary surgery group, 53 nonvisualized EBSLNs of 164 identified nerves (32.3%) were determined by IONM alone. In redo surgery group, 55 of 97 identified nerves (56.7%) were determined by IONM alone (P < 0.001). CONCLUSION: Both visual and total identification rates of the EBSLN are significantly decreased in reoperative thyroidectomy. IONM increases the total identification rate of the EBSLN in primary and redo thyroid surgery. Electrophysiological monitoring makes a substantial contribution to the identification of the EBSLN both in primary and especially in redo thyroid surgery.
Goiter ; Humans ; Intraoperative Neurophysiological Monitoring ; Laryngeal Nerves ; Recurrence ; Thyroid Gland ; Thyroidectomy

PURPOSE: The use of nondepolarizing neuromuscular blocking agents (NMBAs) may affect intraoperative neuromonitoring (IONM) during anesthesia used during thyroid and parathyroid surgery. METHODS: The use of sugammadex was evaluated in a prospective clinical study during thyroid surgery. Between July 2018 and January 2019, 129 patients were prospectively randomized to either the sugammadex group (group B) or the control group (group A). Group A patients underwent standardized IONM during thyroidectomy, while group B patients used an NMBA-reversal protocol comprised of rocuronium (0.6 mg/kg) in anesthesia induction and sugammadex (2 mg/kg) after first vagal stimulation (V0). A peripheral nerve stimulator was used to monitor the neuromuscular transmission. RESULTS: In our clinical study, it took 26.07 ± 3.26 and 50.0 ± 8.46 minutes to reach 100% recovery of laryngeal electromyography at injection of the sugammadex group (2 mg/kg) and the control group, respectively (P < 0.001). The train-of-four ratio recovered from 0 to >0.9 within 4 minutes after administering 2 mg/kg of sugammadex at the beginning of resection. Surgery time was significantly shorter in group B than in group A (P < 0.001). Transient recurrent laryngeal nerve (RLN) paralysis was detected in 4 patients from group A and in 3 patients from group B (P = 0.681). There was no permanent RLN paralysis in the 2 groups. CONCLUSION: Our clinical study showed that sugammadex effectively and rapidly improved the inhibition of neuromuscular function induced by rocuronium. The implementation of the nondepolarizing neuromuscular block recovery protocol may lead to tracheal intubation as well as favorable conditions for IONM in thyroid surgery.
Anesthesia ; Clinical Study ; Electromyography ; Humans ; Intubation ; Neuromuscular Blockade ; Neuromuscular Blocking Agents ; Paralysis ; Peripheral Nerves ; Prospective Studies ; Recurrent Laryngeal Nerve ; Thyroid Gland ; Thyroidectomy

Since the first use of the robot da Vinci system for thyroid surgery in 2007, robotic thyroidectomy (RT) via a bilateral axillo-breast approach (BABA) has become a popular surgical alternative for patients who wish to avoid scars on the neck. BABA RT provides excellent cosmetic satisfaction with surgical safety and oncologic completeness. Recently, the use of BABA RT has expanded beyond benign thyroid nodules and small-sized papillary thyroid carcinoma (PTC) to Graves' disease, relatively large PTCs, and PTC with lateral neck metastasis. Unfortunately, there are concerns about the use of this procedure for these additional indications. This review article summarizes postoperative outcomes of BABA RT for thyroid carcinoma, including quality of life, as well as expanding indications for BABA RT.
Cicatrix ; Graves Disease ; Humans ; Laryngeal Nerves ; Neck ; Neoplasm Metastasis ; Quality of Life ; Robotic Surgical Procedures ; Thyroid Gland* ; Thyroid Neoplasms ; Thyroid Nodule ; Thyroidectomy

OBJECTIVE: To analyze the clinical characteristics between neurogenic and non-neurogenic cause of vocal cord immobility (VCI). METHODS: The researchers retrospectively reviewed clinical data of patients who underwent laryngeal electromyography (LEMG). LEMG was performed in the bilateral cricothyroid and thyroarytenoid muscles. A total of 137 patients were enrolled from 2011 to 2016, and they were assigned to either the neurogenic or non-neurogenic VCI group, according to the LEMG results. The clinical characteristics were compared between the two groups and a subgroup analysis was done in the neurogenic group. RESULTS: Among the 137 subjects, 94 patients had nerve injury. There were no differences between the neurogenic and non-neurogenic group in terms of demographic data, underlying disease except cancer, and premorbid events. In general characteristics, cancer was significantly higher in the neurogenic group than non-neurogenic group (p=0.001). In the clinical findings, the impaired high pitched ‘e’ sound and aspiration symptoms were significantly higher in neurogenic group (p=0.039 for impaired high pitched ‘e’ sound; p=0.021 for aspiration symptoms), and sore throat was more common in the non-neurogenic group (p=0.014). In the subgroup analysis of neurogenic group, hoarseness was more common in recurrent laryngeal neuropathy group than superior laryngeal neuropathy group (p=0.018). CONCLUSION: In patients with suspected vocal cord palsy, impaired high pitched ‘e’ sound and aspiration symptoms were more common in group with neurogenic cause of VCI. Hoarseness was more frequent in subjects with recurrent laryngeal neuropathy. Thorough clinical evaluation and LEMG are important to differentiate underlying cause of VCI.
Electromyography ; Hoarseness ; Humans ; Laryngeal Muscles ; Laryngeal Nerves ; Pharyngitis ; Recurrent Laryngeal Nerve ; Retrospective Studies ; Vocal Cord Paralysis ; Vocal Cords*

Rheumatoid arthritis (RA) is a connective tissue disease involving the larynx in 30% of the patients. Foreign body sensation, hoarseness, and cough are common symptoms in laryngeal involvement. An urgent tracheostomy is required when acute airway obstruction occurs in case of bilateral vocal fold paralysis. The most common cause of bilateral vocal fold paralysis in RA patients is a cricoarytenoid joint arthritis. Laryngeal nerve degeneration is rare cause of bilateral vocal fold paralysis in RA patients. In this case report, an emergent tracheostomy was performed on a 64-years-old male patient with acute dyspnea, and concurrent involvement of RA on laryngeal nerve and cricoarytenoid joint was revealed by laryngeal electromyography and histopathology. The vocal fold mobility was restored after 3-months medical treatment.
Airway Obstruction ; Arthritis ; Arthritis, Rheumatoid* ; Connective Tissue Diseases ; Cough ; Dyspnea ; Electromyography ; Foreign Bodies ; Hoarseness ; Humans ; Joints* ; Laryngeal Nerves* ; Larynx ; Male ; Paralysis* ; Sensation ; Tracheostomy ; Vocal Cords*

BACKGROUND AND OBJECTIVES: The inferior parathyroid glands receive their blood supply from the inferior thyroid artery. The anatomic relationship of this artery and the recurrent laryngeal nerve can assume three different patterns. To maintain the vascular supply of the inferior parathyroid glands during central neck dissection, we considered the anatomic relationship of these structures in our surgical approach. MATERIALS AND METHODS: Fibrofatty tissue in the central neck compartment was removed by dissection proceeding along the recurrent laryngeal nerve. During the dissection, care was taken not to injure the vascular supply of the inferior parathyroid gland. RESULTS: For an inferior parathyroid gland that receives its blood supply from the posterolateral vascular pedicle, preservation is achieved by performing the dissection along the recurrence laryngeal nerve on the gland's medial side. In patients in whom the inferior thyroid artery travels deep to the right recurrent laryngeal nerve, such that the right parathyroid gland receives its blood supply from the posteromedial vascular pedicle, central neck dissection should be performed carefully along the lateral side of the gland to preserve the pedicle. CONCLUSION: Preservation of inferior parathyroid gland function requires a detailed understanding of the anatomic relationship between the inferior thyroid artery and recurrent laryngeal nerve. The direction of the dissection along the nerve should be adjusted according to its anatomic relationship to the inferior thyroid artery.
Arteries ; Humans ; Hypoparathyroidism ; Laryngeal Nerves ; Neck ; Neck Dissection ; Parathyroid Glands* ; Recurrence ; Recurrent Laryngeal Nerve ; Thyroid Gland

Hoarseness is a postoperative complication of thyroidectomy, mostly due to damage to the recurrent laryngeal nerve (RLN). Hoarseness may also be brought about via vocal cord dysfunction (VCD) due to injury of the vocal cords from manipulations during anesthesia, as well as from psychogenic disorders and respiratory and upper-GI related infections. The clinician or surgeon should 1) document assessment of the patient's voice once a decision has been made to proceed with thyroid surgery ; 2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility 3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery 4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery ; 5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery ; 6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery ; 7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery ; 8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery ; 9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery ; 10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation.
Anesthesia ; Dysphonia* ; Hoarseness ; Humans ; Laryngeal Nerves ; Laryngoscopy ; Postoperative Complications ; Recurrent Laryngeal Nerve ; Rehabilitation ; Thyroid Gland ; Thyroidectomy ; Vocal Cord Dysfunction ; Vocal Cords ; Voice*

A non-recurrent laryngeal nerve is a rare anatomical variant that entails considerable risk for iatrogenic injury during thyroid surgery. We encountered a patient with a non-recurrent laryngeal nerve that went unnoticed on preoperative imaging but was discovered incidentally during robotic thyroidectomy. A 44 year old woman presented at our department with papillary thyroid microcarcinoma, diagnosed by ultrasonography-guided fine needle aspiration cytology. During robotic right thyroidectomy and central lymph node dissection, we could not detect any structure resembling the recurrent laryngeal nerve around the inferior thyroid artery. Thus, we suspected the existence of a non-recurrent laryngeal nerve, and successfully identified a nerve entering the larynx directly from the vagus nerve without recurring. A three-dimensional high magnification view via a robotic endoscope can aid thyroid surgeons to safely identify and preserve a non-recurrent laryngeal nerve.
Arteries ; Biopsy, Fine-Needle ; Endoscopes ; Female ; Humans ; Laryngeal Nerves* ; Larynx ; Lymph Node Excision ; Recurrent Laryngeal Nerve ; Robotics ; Thyroid Gland* ; Thyroid Neoplasms* ; Thyroidectomy* ; Vagus Nerve