Ann Surg Treat Res.  2019 Jun;96(6):269-274. 10.4174/astr.2019.96.6.269.

Visual and electrophysiological identification of the external branch of superior laryngeal nerve in redo thyroid surgery compared with primary thyroid surgery

• Gurleyik E
• Dogan S
• Cetin F
• Gurleyik G

• KMID: 2447950
• DOI: http://doi.org/10.4174/astr.2019.96.6.269

Abstract

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.

Keyword

Intraoperative neurophysiological monitoring; Laryngeal nerves; Recurrence; Goiter; Surgery

MeSH Terms

Goiter
Humans
Intraoperative Neurophysiological Monitoring
Laryngeal Nerves*
Recurrence
Thyroid Gland*
Thyroidectomy

Reference

1. Hurtado-Lopez LM, Diaz-Hernandez PI, Basurto-Kuba E, Zaldivar-Ramirez FR, Pulido-Cejudo A. Efficacy of intraoperative neuro-monitoring to localize the external branch of the superior laryngeal nerve. Thyroid. 2016; 26:174–178.

2. Barczynski M, Randolph GW, Cernea C. International Neural Monitoring Study Group in Thyroid and Parathyroid Surgery. International survey on the identification and neural monitoring of the EBSLN during thyroidectomy. Laryngoscope. 2016; 126:285–291.

3. Gurleyik E, Gurleyik G. Intraoperative monitoring of external branch of the superior laryngeal nerve: functional identification, motor integrity, and its role on vocal cord function. J Invest Surg. 2017; 09. 27. 1–6. DOI: 10.1080/08941939.2017.1362489. [Epub].

4. Sung ES, Chang JH, Kim J, Cha W. Is cricothyroid muscle twitch predictive of the integrity of the EBSLN in thyroid surgery? Laryngoscope. 2018; 128:2654–2661.

5. Liddy W, Barber SR, Cinquepalmi M, Lin BM, Patricio S, Kyriazidis N, et al. The electrophysiology of thyroid surgery: electrophysiologic and muscular responses with stimulation of the vagus nerve, recurrent laryngeal nerve, and external branch of the superior laryngeal nerve. Laryngoscope. 2017; 127:764–771.

6. Gurleyik E, Cetin F, Dogan S, Yekenkurul E, Onsal U, Gursoy F, et al. Displacement of the recurrent laryngeal nerve in patients with recurrent goiter undergoing redo thyroid surgery. J Thyroid Res. 2018; 2018:4763712.

7. Sakorafas GH, Kokoropoulos P, Lappas C, Sampanis D, Smyrniotis V. External branch of the superior laryngeal nerve: applied surgical anatomy and implications in thyroid surgery. Am Surg. 2012; 78:986–991.

8. Hwang SB, Lee HY, Kim WY, Woo SU, Lee JB, Bae JW, et al. The anatomy of the external branch of the superior laryngeal nerve in Koreans. Asian J Surg. 2013; 36:13–19.

9. Potenza AS, Araujo Filho VJF, Cernea CR. Injury of the external branch of the superior laryngeal nerve in thyroid surgery. Gland Surg. 2017; 6:552–562.

10. Wojtczak B, Barczynski M. Intermittent neural monitoring of the recurrent laryngeal nerve in surgery for recurrent goiter. Gland Surg. 2016; 5:481–489.

11. Sopinski J, Kuzdak K, Hedayati M, Kolomecki K. Role of intraoperative neuromonitoring of the recurrent laryngeal nerves during thyroid reoperations of recurrent goiter. Pol Przegl Chir. 2017; 89:11–15.

12. Barczynski M, Konturek A, Pragacz K, Papier A, Stopa M, Nowak W. Intraoperative nerve monitoring can reduce prevalence of recurrent laryngeal nerve injury in thyroid reoperations: results of a retrospective cohort study. World J Surg. 2014; 38:599–606.

13. Cappellani A, Zanghi A, Cardi F, Cavallaro A, Piccolo G, Palmucci S, et al. Total thyroidectomy: the first, the best. The recurrent goiter issue. Clin Ter. 2017; 168:e194–e198.

14. Barczynski M, Konturek A, Hubalewska-Dydejczyk A, Gołkowski F, Nowak W. Tenyear follow-up of a randomized clinical trial of total thyroidectomy versus dunhill operation versus bilateral subtotal thyroidectomy for multinodular non-toxic goiter. World J Surg. 2018; 42:384–392.

15. Miccoli P, Frustaci G, Fosso A, Miccoli M, Materazzi G. Surgery for recurrent goiter: complication rate and role of the thyroid-stimulating hormone-suppressive therapy after the first operation. Langenbecks Arch Surg. 2015; 400:253–258.

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

17. Friedman M, LoSavio P, Ibrahim H. Superior laryngeal nerve identification and preservation in thyroidectomy. Arch Otolaryngol Head Neck Surg. 2002; 128:296–303.

18. Lifante JC, McGill J, Murry T, Aviv JE, Inabnet WB 3rd. A prospective, randomized trial of nerve monitoring of the external branch of the superior laryngeal nerve during thyroidectomy under local/regional anesthesia and IV sedation. Surgery. 2009; 146:1167–1173.

19. Barczynski 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; 36:1340–1347.

20. Glover AR, Norlen O, Gundara JS, Morris M, Sidhu SB. Use of the nerve integrity monitor during thyroid surgery aids identification of the external branch of the superior laryngeal nerve. Ann Surg Oncol. 2015; 22:1768–1773.

21. Ravikumar K, Sadacharan D, Muthukumar S, Mohanpriya G, Hussain Z, Suresh RV. EBSLN and factors influencing its identification and its safety in patients undergoing total thyroidectomy: a study of 456 cases. World J Surg. 2016; 40:545–550.

22. Aleksova L, Ali MM, Chakarov DI, Yozgyur ZM. Identification of the external branch of the superior laryngeal nerve during thyroid surgery. Folia Med (Plovdiv). 2018; 60:154–157.

23. Engelsman AF, Warhurst S, Fraser S, Novakovic D, Sidhu SB. Influence of neural monitoring during thyroid surgery on nerve integrity and postoperative vocal function. BJS Open. 2018; 2:135–141.

24. Lee J, Fraser S, Glover A, Sidhu S. Prospective evaluation of the utility of routine neuromonitoring for an established thyroid surgical practice. ANZ J Surg. 2017; 87:E138–E142.

25. 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; 124:1035–1041.

26. Menon RR, Murali S, Nair CG, Babu MJC, Jacob P. Correlation between the Cernea classification of external branch of superior laryngeal nerve in relation to the ultrasound-based volume of thyroid gland. Indian J Endocrinol Metab. 2017; 21:845–847.

27. Kim SJ, Lee KE, Oh BM, Oh EM, Bae DS, Choi JY, et al. Intraoperative neuromonitoring of the external branch of the superior laryngeal nerve during robotic thyroid surgery: a preliminary prospective study. Ann Surg Treat Res. 2015; 89:233–239.

28. Gavid M, Dubois MD, Larive E, Prades JM. Superior laryngeal nerve in thyroid surgery: anatomical identification and monitoring. Eur Arch Otorhinolaryngol. 2017; 274:3519–3526.

29. Sun W, Liu J, Zhang H, Zhang P, Wang Z, Dong W, et al. A meta-analysis of intraoperative neuromonitoring of recurrent laryngeal nerve palsy during thyroid reoperations. Clin Endocrinol (Oxf). 2017; 87:572–580.

30. Hei H, Zhou B, Qin J, Song Y. Intermittent intraoperative nerve monitoring in thyroid reoperations: preliminary results of a randomized, single-surgeon study. Head Neck. 2016; 38:Suppl 1. E1993–E1997.