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Dekhou AS, Morrison RJ, Gemechu JM. The Superior Laryngeal Nerve and Its Vulnerability in Surgeries of the Neck. Diagnostics (Basel) 2021; 11:1243. [PMID: 34359326 PMCID: PMC8305207 DOI: 10.3390/diagnostics11071243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/07/2021] [Accepted: 07/10/2021] [Indexed: 11/25/2022] Open
Abstract
Anatomical considerations of the superior laryngeal nerve (SLN), a branch of the vagus, provides information to minimize the potential for iatrogenic intraoperative injury, thereby preventing motor and sensory dysfunctions of the larynx. The present study aims to assess the variation of the SLN and its relationship to the superior thyroid artery (STA) and superior laryngeal artery (SLA). The study was done on 35 formalin-fixed cadavers at Oakland University in 2018-2019. In our study, we found that out of 21 cadavers, 52.4% of the external laryngeal branches (ebSLN) are related posteromedial to the STA, while 47.6% are related anteromedial to it. Out of 14 cadavers, 64.3% of the internal laryngeal branches (ibSLN) are related superoposterior to the SLA, while 35.7% are inferoposterior to it. In most cases, the SLA crosses above the ebSLN while traveling to pierce the thyrohyoid membrane to reach the larynx. The data demonstrate that both the ebSLN and ibSLN display variation in their relationship with the STA and the SLA, respectively. Awareness of these variable relationships is critical for identification and isolation of these structures in order to prevent consequences of nerve injury, primarily a reduction in the highest attainable frequency of the voice and aspiration pneumonia.
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Affiliation(s)
- Antonio S. Dekhou
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA;
| | - Robert J. Morrison
- Department of Otolaryngology-Head & Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Jickssa M. Gemechu
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA;
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Abstract
Currently, thyroid surgery is the most common and safe operation worldwide. However, thyroidectomy is still not free from the risks of complications and death due to the anatomical structure and physiological function particularity of the thyroid gland. Postoperative complications affect the life quality and life safety of patients after surgery. The common complications include hypoparathyroidism (HP), recurrent laryngeal nerve (RLN) injury, injury to the external branch of the superior laryngeal nerve (EBSLN), postoperative bleeding (PB), thoracic duct injury, laryngeal edema, tracheospasm, tracheal injury, and esophageal injury. A severe complication, such as dyspnea, asphyxia, or thyroid crisis, might cause the death of the patient. Therefore, every thyroid surgeon's responsibility is to remain alert and aware of the occurrence of various intraoperative and postoperative complications and exercise effective prevention and treatment. This is closely related to the advancement in thyroid disease research, the increase in local anatomy knowledge, the standardization of surgical approaches, the improvement in operating skills, the application of new technologies, and the emphasis on specialty training. In addition, many complications that effect patients are much better tolerated if the patient has appropriate expectations of what the complications are and how to treat them. Open communication between surgeon and patient optimizes the potential negative effects that complications may have on patients' quality of life. This paper discusses the prevention, recognition and therapy of intraoperative and postoperative complications in thyroid surgery.
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Affiliation(s)
- Shan Jin
- Department of General Surgery, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China.,Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Iwao Sugitani
- Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
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Sagheer SH, Swendseid B, Evans J, Rabinowitz M, Nyquist G, Rosen MR, Toskala E, Heffelfinger R, Luginbuhl AJ, Curry JM. Free tissue transfer for central skull base defect reconstruction: Case series and surgical technique. Oral Oncol 2021; 115:105220. [PMID: 33592564 DOI: 10.1016/j.oraloncology.2021.105220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Local reconstruction of central skull base defects may be inadequate for large defects or reoperative cases; free tissue transfer may be necessary. Inset of the flap and management of the pedicle can be challenging. We report our experience and approaches. METHODS Retrospective review identifying seven patients with central skull base defects who underwent free flap reconstruction from 2016 to 2020. RESULTS Four patients with recurrent nasopharyngeal carcinoma, one with recurrent craniopharyngioma, one with clival-cervical chordoma, and one with meningioma of the middle cranial fossa were analyzed. Six defects were closed with an anterolateral thigh free flap and one with a radial forearm free flap. In two patients, the flap was secured in an onlay fashion to the defect via a Caldwell-Luc transmaxillary approach. In one patient, the flap was passed transorally, and the pedicle was delivered into the neck via Penrose drain. In two patients, a parapharyngeal technique and in two others, a retropharyngeal was used for nasopharyngeal inset with endoscopic assistance. There were no flap failures, with an average follow-up time of 20.1 (range 3.2-47.1) months. One patient required flap repositioning on postoperative day three due to midline shift and intracranial contents compression. The transoral inset flap necessitated flap repositioning on postoperative day 13 to improve the nasopharyngeal airway. CONCLUSION Free flap reconstruction of the central skull base is challenging, but transmaxillary, transoral, parapharyngeal, and retropharyngeal approaches can be used with endoscopic assistance to ensure secure inset flap and avoid airway obstruction.
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Affiliation(s)
- S Hamad Sagheer
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, United States.
| | - Brian Swendseid
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, United States.
| | - James Evans
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, United States; Department of Neurological Surgery, Thomas Jefferson University Hospital, United States.
| | - Mindy Rabinowitz
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, United States.
| | - Gurston Nyquist
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, United States.
| | - Marc R Rosen
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, United States.
| | - Elina Toskala
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, United States.
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, United States.
| | - Adam J Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, United States.
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, United States.
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Devaraja K, Punja R, Kalthur SG, Pujary K. Unmapped landmarks around branches of the Superior Laryngeal Nerve: An exploratory cadaveric study. J Taibah Univ Med Sci 2021; 16:328-335. [PMID: 34140858 PMCID: PMC8178688 DOI: 10.1016/j.jtumed.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/30/2020] [Accepted: 01/07/2021] [Indexed: 11/05/2022] Open
Abstract
Objectives Preserving the External Branch of Superior Laryngeal Nerve (EBSLN) and Internal Branch of Superior Laryngeal Nerve (IBSLN) is essential during thyroidectomy. However, due to potential distortions caused by large goitres, the present anatomical landmarks used to identify these nerves are flawed. Although under such circumstances, bony landmarks may offer more stable reference points, not much has been explored in this regard. This study measures the distance between the most vulnerable points of the EBSLN and IBSLN and their relatively unexplored bony landmarks, such as the hyoid bone and thyroid notch as well as soft-tissue landmarks like the origin of the Superior Thyroid Artery (STA) and carotid bifurcation. Methods An exploratory cadaveric study was conducted in a medical school affiliated with a tertiary care hospital. The detailed analysis included 13 sides from 8 cadavers. Results The average distance from the EBSLN piercing site to the greater cornua of the hyoid bone, thyroid cartilage prominence, origin of the STA, and carotid bifurcation was 35.1(±7.2) mm, 33.3(±3.8) mm, 25.7(±6.3) mm, and 31.5(±5.0) mm, respectively and from the IBSLN piercing site was 15.9(±5.9) mm, 32.9(±4.7) mm, 16.3(±4.2) mm, and 20.7(±5.9) mm, respectively. For most cadavers, the distal EBSLN had Cernea type 2a-like relationship with the STA. Certain variations were also observed in the way these nerves branched with respect to the origin of the STA. Conclusions This study provides metric information (linear measurements) regarding the distance between the branches of SLN and certain unique landmarks. This could potentially aid in minimising intraoperative trauma to these branches.
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Affiliation(s)
- K Devaraja
- Department of Otorhinolaryngology and Head and Neck Surgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Rohini Punja
- Department of Anatomy, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Sneha G Kalthur
- Department of Anatomy, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Kailesh Pujary
- Department of Otorhinolaryngology and Head and Neck Surgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
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Ng SK, Li HN, Chan JYK, Wong EWY, Vlantis AC. A useful landmark to locate the external branch of the superior laryngeal nerve during thyroidectomy. Gland Surg 2020; 9:647-652. [PMID: 32775254 DOI: 10.21037/gs.2020.03.25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To determine whether the insertion of the sternothyroid muscle onto the oblique line of the thyroid cartilage can be used to reliably locate the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy. Methods This is a prospective descriptive case series. The EBSLN was identified and confirmed with a nerve stimulator during thyroid surgery. The entry point of the EBSLN into the inferior constrictor/cricothyroid muscle was measured in relation to the insertion and anterior border of the sternothyroid muscle. The perpendicular distance from the insertion of the sternothyroid muscle onto the oblique line was designated the vertical distance (VD) of the nerve entry point (NEP), and the perpendicular distance from the anterior border of the sternothyroid muscle was designated the horizontal distance. Results Ninety patients underwent 130 thyroid lobectomies (60 female, 30 male) (mean age 53.5 years, range, 18-91 years). An attempt to identify the nerve was made in 127 thyroid lobectomies. The EBSLN was identified in 111 cases (87.4%). The mean VD of the NEP from the muscle insertion was 1.1 mm (SD 1.1 mm, range, 0-5 mm) and the mean horizontal distance (HD) was 9.5 mm (SD 3.8 mm, range, 2-21 mm). Conclusions The EBSLN muscle entry point usually lies 1.1 mm from the sternothyroid insertion onto the oblique line, and 5-12 mm from the anterior border of the muscle. These useful landmarks allow the nerve to be consistently located, identified and preserved during thyroid surgery prior to ligating the superior thyroid vessels.
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Affiliation(s)
- Siu-Kwan Ng
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong, China
| | - Hok-Nam Li
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong, China
| | - Jason Ying-Kuen Chan
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong, China
| | - Eddy W Y Wong
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong, China
| | - Alexander C Vlantis
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong, China
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