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Triantafyllou G, Paschopoulos I, Duparc F, Tsakotos G, Tsiouris C, Olewnik Ł, Georgiev G, Zielinska N, Piagkou M. The superior thyroid artery origin pattern: a systematic review with meta-analysis. Surg Radiol Anat 2024:10.1007/s00276-024-03438-2. [PMID: 39043951 DOI: 10.1007/s00276-024-03438-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 07/08/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE The current systematic review with meta-analysis aimed to investigate the pooled prevalence of the superior thyroid artery (STA) pattern of origin (distinct or fused-common origin with adjacent arteries in the form of a common trunk). The standard and uncommon variants were also studied, considering the STA's exact surface of origin and the relationship with the upper border of the thyroid cartilage (TC, reference point), considering the laterality effect. Thus, the STA topographical anatomy was considered. METHODS An evidence-based systematic review with meta-analysis was performed according to the PRISMA 2020 guidelines. A literature search was conducted in four online databases using specific keywords, the pooled prevalence was calculated using statistical analysis in the R programming language, and multiple subgroup analyses were performed. RESULTS The most common distinct origin of the STA was from the external carotid artery (ECA) (56.94% pooled prevalence, 95%CI: 50.89-62.89), and the rarest one was from the internal carotid artery (ICA) (< 0.01%, 95%CI: 0.00-0.00). Common trunks were also investigated, with the thyrolingual trunk emanating from the ECA estimated at 0.61% (95%CI: 0.21-1.14), representing the most common. Subgroup analysis based on the nationality, type of study, and sample size, as well as a comparison between left and right sides and males and females, were investigated. CONCLUSIONS The most common STA origin was estimated as the ECA, the medial surface of origin, and above the TC upper border. Adequate knowledge of STA origin is paramount for surgeons, especially during thyroidectomy, not to cause iatrogenic injury to the external branch of the superior laryngeal nerve.
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Affiliation(s)
- George Triantafyllou
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias str, Goudi, Athens, 11527, Greece.
| | - Ioannis Paschopoulos
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias str, Goudi, Athens, 11527, Greece
| | - Fabrice Duparc
- Department of Anatomy, Faculty of Medicine-Pharmacy, University of Rouen-Normandy, Rouen, France
| | - George Tsakotos
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias str, Goudi, Athens, 11527, Greece
| | - Christos Tsiouris
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias str, Goudi, Athens, 11527, Greece
| | - Łukasz Olewnik
- Department of Clinical Anatomy, Masovian Academy in Płock, Płock, Poland
| | - Georgi Georgiev
- Department of Orthopaedics and Traumatology, University Hospital Queen Giovanna - ISUL, Medical University of Sofia, Sofia, Bulgaria
| | - Nicol Zielinska
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Lodz, Poland
| | - Maria Piagkou
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias str, Goudi, Athens, 11527, Greece
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Liang KY, Scharpf J. Avoiding Complications of Thyroidectomy: Recurrent Laryngeal Nerve and Superior Laryngeal Nerve Preservation. Otolaryngol Clin North Am 2024; 57:75-82. [PMID: 37741708 DOI: 10.1016/j.otc.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
Abstract
Both the superior and recurrent laryngeal nerves are at risk for injury during thyroid surgery. Comprehensive preoperative evaluation is key for surgical planning. Exposing nerves through careful dissection is the safest strategy to minimize injury risk. Intraoperative neural monitoring can be beneficial for both identifying and preserving the nerves.
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Affiliation(s)
- Kevin Y Liang
- Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA
| | - Joseph Scharpf
- Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA.
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Scott B, Wong RJ. Step-by-Step Thyroidectomy-Incision, Nerve Identification, Parathyroid Preservation, and Gland Removal. Otolaryngol Clin North Am 2024; 57:25-37. [PMID: 37748983 DOI: 10.1016/j.otc.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Thyroidectomy is a surgical procedure to remove part or all of the thyroid gland. Although the general tenets of surgery have remained the same, improvements in techniques, diagnostics, understanding of anatomy, and technology have allowed thyroid surgery to become a standard, effective, and safe surgery. For surgeons undertaking this procedure, it is imperative to have an in-depth knowledge of critical anatomy and a comprehensive understanding of surgical techniques to perform safe and effective surgery. This article aims to provide an overview of surgical techniques that may be applied in both benign and malignant disease settings.
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Affiliation(s)
- Britney Scott
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA
| | - Richard J Wong
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA.
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Aygun N, Unlu MT, Kostek M, Caliskan O, Isgor A, Uludag M. Intraoperative cricothyroid muscle electromyography may contribute to the monitorization of the external branch of the superior laryngeal nerve during thyroidectomy. Front Endocrinol (Lausanne) 2023; 14:1303159. [PMID: 38130395 PMCID: PMC10733446 DOI: 10.3389/fendo.2023.1303159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Background In thyroid surgery, both the recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN) should be preserved for maintaining the vocal cord functions. We aimed to evaluate whether EMG of the CTM applied after the superior pole dissection provided additional informative data to the IONM via ETT or not, regarding the EBSLN function. Methods The prospectively collected data of the patients, who have undergone thyroidectomy with the use of IONM for the exploration of both the RLN and EBSLN between October 2016 and March 2017, were evaluated retrospectively. Patients over 18 years of age with primary thyroid surgery for malignant or benign thyroid disease, and whom were applied CTM EMG with a needle electrode after the completion of thyroidectomy were included in the study. In the study, each neck side was evaluated as a separate entity considering the EBSLN at risk. Results The data of 41 patients (32 female, 9 male) (mean age, 46.7 + 9.1; range, 22-71) were evaluated. Sixty seven EBSLNs out of 26 bilateral and 15 unilateral interventions were evaluated. With EBSLN stimulation after the superior pole dissection, positive glottic EMG waveforms via ETT were obtained in 45 (67.2%) out of 67, and the mean glottic amplitude value was 261 + 191 μV (min-max: 116-1086 μV). Positive EMG responses via the CTM EMG were achieved from all of the 67 EBSLNs (100%) with stimulation using a monopolar probe at the most cranial portion above the area of divided superior pole vessels. The mean value of CTM amplitudes via CTM EMG obtained with EBSLN stimulation was 5268 + 3916 μV (min-max:1215 -19726 μV). With EBSLN stimulation, the mean CTM EMG amplitude was detected significantly higher than the mean vocal cord amplitude (p<0.0001). The CTM EMG provided more objective quantifiable data regarding the EBSLN function (100% vs 67,2%, p<0.001). Conclusion In addition to the IONM via ETT, intraoperative post-dissection CTM EMG via needle electrode is a safe, simple and applicable method that may provide significant additional informative data to IONM with ETT by obtaining and recording objective quantitative data related to the EBSLN function.
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Affiliation(s)
- Nurcihan Aygun
- General Surgery Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Taner Unlu
- General Surgery Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Kostek
- General Surgery Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Ozan Caliskan
- General Surgery Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Adnan Isgor
- General Surgery Department, Memorial Sisli Hospital, Sisli, Istanbul, Türkiye
| | - Mehmet Uludag
- General Surgery Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
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Ding Z, Sheng R, Zhang L, Han J, Chen M, Bi W, Zhao X, Zhang J, Nie C. Utility of video-assisted method for identifying and preserving the external branch of the superior laryngeal nerve during thyroidectomy. Front Surg 2023; 10:1118083. [PMID: 37143769 PMCID: PMC10151554 DOI: 10.3389/fsurg.2023.1118083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/03/2023] [Indexed: 05/06/2023] Open
Abstract
Background The EBSLN is vulnerable to damage during thyroidectomy, results in voice related complications, negatively affect patient quality of life, routine identification of the EBSLN prior to surgical manipulation is necessary for a complication-free thyroidectomy. We aimed to validate a video-assisted procedure for identifying and preserving the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy and analyze the EBSLN Cernea classification and the localization of the nerve entry point (NEP) from the insertion of the sternothyroid muscle. Methods A prospective descriptive study was performed; 134 patients, who scheduled for lobectomy with an intraglandular tumor max diameter ≤ 4 cm and without extrathyroidal extension, were randomly divided into the video-assisted surgery (VAS) and conventional open surgery (COS) groups. We used the video-assisted surgical procedure for visually identifying the EBSLN directly, and compared the differences in the visual identification rate and total identification rate of the two groups. We also measured the localization of the NEP using the insertion of the sternothyroid muscle as a reference. Results There was no statistically significant difference in clinical characteristics between the two groups. The visual identification rate and total identification rate were significantly higher in the VAS group than the COS group (91.04% vs. 77.61%, 100% vs. 89.6%). The EBSLN injury rate was 0 in both groups. The mean vertical distance (VD) of the NEP from the sternal thyroid insertion was 1.18 mm (SD 1.12 mm, range, 0-5 mm), with approximately 88.97% of the results occurring within the 0-2 mm range. The mean horizontal distance (HD) was 9.33 mm (SD 5.03 mm, range, 0-30 mm), with over 92.13% of the results occurring within the 5-15 mm range. Conclusion Both the visual and total identification rates of the EBSLN were significantly higher in the VAS group. This method provided a good visual exposure rate of the EBSLN, aiding in identifying and protecting the EBSLN during thyroidectomy.
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Głód M, Marciniak D, Kaliszewski K, Sutkowski K, Rudnicki J, Bolanowski M, Wojtczak B. Analysis of Risk Factors for Phonation Disorders after Thyroid Surgery. Biomedicines 2022; 10:biomedicines10092280. [PMID: 36140379 PMCID: PMC9496448 DOI: 10.3390/biomedicines10092280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/04/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Phonation disorders after thyroidectomy are among the most common complications and occur as a result of recurrent laryngeal nerve (RLN) injury. The multivariate analysis of risk factors for phonation disorders after thyroidectomy was assessed. A group of 830 patients with 1500 RLNs at risk of injury during thyroidectomy were analyzed retrospectively. The impact of the method of RLN identification, age, sex, BMI, kind of thyroid surgery, pathology, surgeon’s experience and thyroid volume on vocal cord paralysis was analyzed. We found that the retrosternal goiter and the volume above 100 mL were the most important risk factors for both transient and permanent paralysis. Thyroid cancer had a statistically significant impact on the increase in permanent paralysis, while this indication had practically no impact on transient paralysis. Among patients over 65 years with obesity, the probability of transient complications approximately doubled, with no effect on the permanent paralysis. Men were approximately 1.7 times more likely to develop any type of phonation disorder. Secondary operations more than doubled the risk of transient and permanent vocal cord paralysis. Thyroidectomy with only visual RLN identification was associated with a risk of both transient and permanent vocal cord paralysis almost two times higher, compared to neuromonitoring.
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Affiliation(s)
- Mateusz Głód
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland
| | - Dominik Marciniak
- Department of Dosage Form Technology, Wroclaw Medical University, Borowska Street 211 A, 50-556 Wroclaw, Poland
| | - Krzysztof Kaliszewski
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland
| | - Krzysztof Sutkowski
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland
| | - Jerzy Rudnicki
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Pasteura Street 4, 50-367 Wroclaw, Poland
| | - Beata Wojtczak
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland
- Correspondence: ; Tel./Fax: +48-71-734-30-00
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Gurleyik E, Gurleyik G. Anatomical and functional identification of the external branch of the superior laryngeal nerve: classification based on morphology and electrophysiological monitoring. Acta Chir Belg 2022; 122:185-191. [PMID: 33729893 DOI: 10.1080/00015458.2021.1894733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Motor function of the external branch of superior laryngeal nerve (EBSLN) is vital for voice quality. We studied the rate of EBSLN identification and integrity in the era of intraoperative neuromonitoring (IONM). METHODS Anatomic and functional identification of 515 EBSLNs-at-risk was performed under the guidance of IONM that motor integrity was electrophysiologically checked. The functional integrity was assessed with crico-thyroid muscle (CTM) twitches and/or recordable waveform amplitude. We tried to establish the systematic classification of EBSLN identification and integrity. RESULTS Visual, electrophysiological and total identification rates were 64.3%, 31.6% and 95.9%, respectively. We could identify 4.1% of EBSLNs neither anatomically nor electrophysiologically. We recorded CTM twitches alone or both CTM twitches and wave amplitude in 203(39.4%) and 291(56.5%) branches respectively. Identification features of EBSLNs were systematically classified under three main types: Visualized-monitored (1), non-visualized-monitored (2), unidentified (3), and electrophysiological integrity of EBSLNs under two subtypes: CTM twitches alone (a) and CTM twitches and wave amplitude (b). CONCLUSION Dedicated thyroid surgeon could visually identify EBSLNs. IONM contribution significantly increases the identification rate. Systematic classification of identification and electrophysiological integrity of EBSLNs may increase comprehensive knowledge about its motor function that is crucial for complication-free thyroidectomy.
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Affiliation(s)
- Emin Gurleyik
- Department of Surgery, Medical Faculty, Duzce University, Duzce, Turkey
| | - Gunay Gurleyik
- Department of Surgery, Haydarpasa Numune Teaching Hospital, Health Sciences University, Istanbul, Turkey
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Seeing Is Not Believing: Intraoperative Nerve Monitoring (IONM) in the Thyroid Surgery. Indian J Surg Oncol 2022; 13:121-132. [PMID: 35462673 PMCID: PMC8986933 DOI: 10.1007/s13193-021-01348-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/12/2021] [Indexed: 10/21/2022] Open
Abstract
Ensuring the integrity of the recurrent laryngeal nerve (RLN), the external branch of superior laryngeal nerve (EBSLN) and preservation of normal voice are the prime 'functional' goals of thyroid surgery. More in-depth knowledge of neuronal mechanisms has revealed that anatomical integrity does not always translate into functional integrity. Despite meticulous dissection, neural injuries are not always predictable or visually evident. Intraoperative nerve monitoring (IONM) is designed to aid in nerve identification and early detection of functional impairment. With the evolution of technique, intermittent monitoring has given way to continuous-IONM. Over the years, IONM gathered both support and flak. Despite numerous randomised studies, systematic reviews, and meta-analyses, there still prevails a state of clinical equipoise concerning the utility of IONM and its cost-effectiveness. This article inspects the true usefulness of IONM, elaborates on the optimal way to practice it, and presents a critical literature review.
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Zhao Y, Zhao Z, Zhang D, Han Y, Dionigi G, Sun H. Improving classification of the external branch of the superior laryngeal nerve with neural monitoring: a research appraisal and narrative review. Gland Surg 2021; 10:2847-2860. [PMID: 34733732 DOI: 10.21037/gs-21-518] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
Objective To review the published literature on external branch of superior laryngeal nerve (EBSLN) neural monitoring and propose a new EBSLN classification system using intraoperative neural monitoring (IONM). Background The injury rate of the external branch of the superior laryngeal nerve (EBSLN) in thyroid surgery is 0-58%. Symptoms of EBSLN injury are not consistent, and patients often complain of modification of the voice timbre with the preservation of vocal cord function. Standards for the diagnosis of EBSLN injury are lacking. Methods The PubMed database was searched using the terms 'External branch of the superior laryngeal nerve' and 'Intraoperative neuromonitoring' from 2010 through March 2020. Conclusions This paper reviewed the anatomy of the EBSLN, the diagnosis and treatment of injury, and the application of IONM in the EBSLN. The traditional EBSLN classification method was analyzed and compared with our new classification method. The diagnosis of EBSLN injury is a problem that still needs to be resolved. For anatomic classifications of the EBSLN, we found that the conventional classification systems may not accurately reflect the real status of the EBSLN and the surgical risks that may occur intraoperatively. Using IONM, we developed an EBSLN classification method that was consistent with conventional diagnosis and treatments and can be widely and easily utilized during surgery.
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Affiliation(s)
- Yishen Zhao
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Zihan Zhao
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Daqi Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Yujia Han
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Gianlorenzo Dionigi
- Division of General Surgery, Head, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
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Yuan Q, Zheng L, Hou J, Zhou R, Xu G, Li C, Wu G. Visual identification and neuromonitoring vs. no sighting the external branch of the superior laryngeal nerve in thyroid surgery: a randomized clinical trial. Updates Surg 2021; 74:727-734. [PMID: 34327667 DOI: 10.1007/s13304-021-01138-9] [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: 05/22/2021] [Accepted: 07/20/2021] [Indexed: 01/15/2023]
Abstract
To evaluate the incidence of external branch of the superior laryngeal nerve (EBSLN) injuries after thyroid surgical procedures with or without the functional and visual identification of the EBSLN before ligation at the superior thyroid pole. Patients with papillary thyroid carcinoma (PTC) enrolled from a single tertiary referral academic medical center were assigned to functional and visual identification of EBSLN group (study group) or no identification of EBSLN group (controlled group). The main outcome measures were the incidence of EBSLN injury detected by the intraoperative neuromonitoring and Voice Handicap Index-10 (VHI-10) and Impairment Index-5 (VII-5) valuation questionnaires. Postoperative complications were recorded. A total of 140 (50.4%) patients were enrolled in study group and 138 (49.6%) in controlled group. In the study group, 110 (39.3%) EBSLNs were direct visual recognized and 170 (60.7%) nerves were visually identified with the help of neuromonitoring. Three patients in the study group and two patients in the controlled group were diagnosed with vocal cord paralysis. Six (4.4%) patients in the identification group and 37 (27.2%) patients in the no identification group presented no response from the stimulation of sternothyroid-laryngeal triangle. The VII-5 scores of the study group were significantly higher than those of the controlled group at one and three months postoperatively (P = 0.024 and P = 0.034). With significant lower scores of VII-5 and VHI-10, functional and visual identification of EBSLN might be necessary during thyroid surgery to protect the structural integrity and motor activity of the nerve.
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Affiliation(s)
- Qianqian Yuan
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Lewei Zheng
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Jinxuan Hou
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Rui Zhou
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Gaoran Xu
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Chengxin Li
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Gaosong Wu
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China.
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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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Can we routinely identify the external branch of the superior laryngeal nerves with neural monitoring?: a prospective report on 176 consecutive nerves at risk. Updates Surg 2021; 73:2275-2281. [PMID: 34041716 PMCID: PMC8606392 DOI: 10.1007/s13304-021-01084-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/05/2021] [Indexed: 01/15/2023]
Abstract
The external branch of the superior laryngeal nerve (EBSLN) provides motor function to the cricothyroid muscle (CTM). EBSLN damage produces changes in voice quality and projection. Intraoperative neuromonitoring (IONM) in thyroid surgery aims to optimize EBSLN control during dissection. We prospectively collected the data of 88 consecutive patients who underwent total thyroidectomy with IONM from July 2019 to December 2019. IONM was offered in the intermittent mode of application. We routinely searched for the EBSLN electromyographic (EMG) signal before (S1) and after (S2) dissection of the superior vascular peduncle. In the absence of the EMG signal, we observed the CTM twitch. We identified 141 (80%) S1 EMG signals, while we recorded the CTM twitch in 15 cases (8.5%). In 20 (11.3%) cases, we were unable to identify the EMG signal. Analysing the S2 results, we found loss of EBSLN signal in 11/141 cases (7.8%) identified with IONM in pre-dissection stimulation. Among the 20 cases without pre-dissection identification (we had not identified the external branch of the superior laryngeal nerve or the muscle twitch), in the post-dissection evaluation, we confirmed the loss of signal in 17 of 20 cases, equal to 85% (p < 0.001). Our data clearly show that intraoperative stimulation and recognition of EBSLN, performed before any dissection manoeuvre to the superior vascular thyroid pole, leads to a much higher rate of nerve conservation.
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Buczek E, Hicks M, Moroco A, Cottrill E. Neuroanatomy and Monitoring of the External Branch of the Superior Laryngeal Nerve. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00349-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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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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15
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Lu KN, Ding JW, Zhang Y, Shi JJ, Zhou L, Peng Y, Shen J, Lu S, Sun SH, Ni YQ, Cui HR, Luo DC. The Anatomical and Clinical Significance of the Superior Laryngeal Nerve. Otolaryngol Head Neck Surg 2021; 165:690-695. [PMID: 33618572 DOI: 10.1177/0194599821989622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study summarizes the anatomical features of the superior laryngeal nerve in Chinese to enable the rapid location of the superior laryngeal nerve during an operation. STUDY DESIGN Retrospective analysis of anatomical data. SETTING Hangzhou First People's Hospital Affiliated to Nanjing Medical University. METHODS A total of 71 embalmed human cadavers (132 heminecks) were examined over 3 months. The length and diameter of the internal and external branches of the superior laryngeal nerve and their relationships with different landmarks were recorded. RESULTS The total length of the internal branch of the superior laryngeal nerve was 23.4 ± 6.9 mm. The length of the external branch of the superior laryngeal nerve was 47.7 ± 11.0 mm. Considering the midpoint of the lower edge of the thyroid cartilage as the starting point and using that edge as a horizontal line, when the entry point is above that line, the external branch of the superior laryngeal nerve can be found within 41.1 mm and at an angle of 57.2°. When the entry point is below the lower edge of the thyroid cartilage, the external branch of the superior laryngeal nerve can be found within 34.0 mm and at an angle of 36.5°. CONCLUSION The superior laryngeal nerve in Chinese people has distinct anatomical characteristics. This article provides a new method of quickly locating the external branch of the superior laryngeal nerve during the operation, which can reduce the probability of damaging the external branch of the superior laryngeal nerve.
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Affiliation(s)
- Kai-Ning Lu
- Hangzhou Hospital Affiliated to Nanjing Medical University (Hangzhou First People's Hospital), Hangzhou, Zhejiang, China
| | - Jin-Wang Ding
- Head and Neck Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Key Laboratory of Head & Neck Cancer Translational Research of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Yu Zhang
- Department of Oncological Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jing-Jing Shi
- Department of Oncological Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Li Zhou
- Department of Oncological Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - You Peng
- Department of Oncological Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jie Shen
- Department of Oncological Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Si Lu
- Institute of Translational Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Si-Han Sun
- Hangzhou Hospital Affiliated to Nanjing Medical University (Hangzhou First People's Hospital), Hangzhou, Zhejiang, China
| | - Ye-Qin Ni
- Zhejiang Chinese Medical University, The Fourth Clinical College, Hangzhou, Zhejiang, China
| | - Huai-Rui Cui
- Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ding-Cun Luo
- Hangzhou Hospital Affiliated to Nanjing Medical University (Hangzhou First People's Hospital), Hangzhou, Zhejiang, China
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16
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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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17
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Zhu Y, Gao DS, Lin J, Wang Y, Yu L. Intraoperative Neuromonitoring in Thyroid and Parathyroid Surgery. J Laparoendosc Adv Surg Tech A 2021; 31:18-23. [PMID: 32614658 DOI: 10.1089/lap.2020.0293] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yongman Zhu
- Department of Anesthesiology and The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Dave Schwinn Gao
- Department of Anesthesiology and The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Jiaqi Lin
- Department of Anesthesiology and The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Yong Wang
- Department of Thyroid Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Lina Yu
- Department of Anesthesiology and The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
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18
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van Rooijen JJ, van Trotsenburg ASP, van de Berg DJ, Zwaveling-Soonawala N, Nieveen van Dijkum EJM, Engelsman AF, Derikx JPM, Mooij CF. Complications After Thyroidectomy in Children: Lymph Node Dissection Is a Risk Factor for Permanent Hypocalcemia. Front Endocrinol (Lausanne) 2021; 12:717769. [PMID: 34659111 PMCID: PMC8511766 DOI: 10.3389/fendo.2021.717769] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/14/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Thyroidectomy is a treatment option in some benign thyroid disorders and the definitive treatment option for thyroid cancer. As postoperative mortality is extremely rare data on postoperative complications and long-term health consequences are important. OBJECTIVE To evaluate the frequencies of short- and long-term complications, and their risk factors in pediatric patients (0-18 years) who underwent a thyroidectomy in a tertiary children's hospital. METHODS A retrospective single center study was performed including all pediatric patients who underwent a thyroidectomy between January 2013 and February 2020. RESULTS Forty-eight patients were included in this study (mean age 14.6 years). Twenty-nine total thyroidectomies and 19 hemithyroidectomies were conducted. Thyroid carcinoma was the indication to perform a thyroidectomy in 12 patients, 36 patients underwent a thyroidectomy because of a benign thyroid disorder. Postoperative hypocalcemia was evaluated in patients who underwent a total thyroidectomy. Rapidly resolved hypocalcemia was observed in three patients (10.3%), transient hypocalcemia in 10 patients (34.5%) and permanent hypocalcemia in six patients (20.7%). Permanent hypocalcemia was only seen in patients who underwent a thyroidectomy combined with additional lymph node dissection because of thyroid carcinoma [thyroid carcinoma: OR 43.73, 95% CI (2.11-904.95); lymph node dissection: OR 76.14, 95% CI (3.49-458.98)]. Transient and permanent recurrent laryngeal nerve injury was reported in four (8.3%) and one (2.1%) of all patients, respectively. CONCLUSION Permanent postoperative complications after thyroidectomy are rare in pediatric patients undergoing a thyroidectomy without lymph node dissection. However, in this age group permanent hypocalcemia occurs more frequently after thyroidectomy with additional lymph node dissection because of thyroid cancer. With respect to quality of life, especially of pediatric thyroid cancer patients, reducing this complication is an important goal.
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Affiliation(s)
- Jesse J. van Rooijen
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - A. S. Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Daniël J. van de Berg
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam and Vrije Universiteit, Amsterdam, Netherlands
| | - Nitash Zwaveling-Soonawala
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Els J. M. Nieveen van Dijkum
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam and Vrije Universiteit, Amsterdam, Netherlands
| | - Anton F. Engelsman
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam and Vrije Universiteit, Amsterdam, Netherlands
| | - Joep P. M. Derikx
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam and Vrije Universiteit, Amsterdam, Netherlands
| | - Christiaan F. Mooij
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- *Correspondence: Christiaan F. Mooij,
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19
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Factors Influencing the Relationship of the External Branch of the Superior Laryngeal Nerve with the Superior Pole Vessels of the Thyroid Gland. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 54:469-474. [PMID: 33364889 PMCID: PMC7751235 DOI: 10.14744/semb.2020.27448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022]
Abstract
Objectives: In a thyroidectomy, the external branch of the superior laryngeal nerve (EBSLN) is a potential risk during the superior pole dissection due to its close anatomical relationship with the superior thyroid artery and its highly variable anatomy. In this study, we aimed to evaluate the relationship of EBSLN with the superior pole considering Cernea classification and the factors affecting this relationship. Methods: The data of thyroidectomized 126 patients (95 female, 31 male) with 200 neck sides (mean age of 45.6±12.1 years) using intraoperative neuromonitoring (IONM) for the EBSLN exploration were evaluated retrospectively. During the superior pole dissection, the EBSLN course was classified according to Cernea classification after being confirmed with IONM. It was defined as a large goiter in the case of the thyroid lobe volume being >50 cc. The factors influencing the presence of type 2b, which has the highest risk of injury, were evaluated using logistic regression analysis. Results: Of the 200 EBSLNs evaluated, 52 (26%) were type 1, 134 (68%) were type 2a, and 14 (7%) were type 2b. The mean volumes of the resected thyroid lobes were 22±25 cc (min-max: 2-136), 23±20 cc (3-163), and 39±24 cc (3-65) in type 1, 2a and 2b, respectively, which was significantly higher in type 2b (p=0.035). Presence of large goiter rates were 5.8% (n=3), 8.2% (n=11), 64.3% (n=9) in type 1, 2a, and 2b, respectively, and was significantly higher in type 2b (p=0.0001). There was no significant difference between EBSLN Cernea types concerning age, sex, nerve side, presence of cancer and hyperthyroidism. In logistic regression analysis, large goiter was the only independent factor associated with Cernea type 2b. In case of a lobe volume greater than 50 cc, the probability of type 2b presence was approximately 25 times higher (p<0.001, odds ratio: 25.262). Conclusion: Type 2b course of EBSLN is more common in large goiters, and it is 25 times more likely to be seen in the presence of a lobe volume over 50 cc. Thus, it should be considered that the probability of this high-risk course is significantly higher in large goiters.
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20
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Yuan Q, Hou J, Liao Y, Zheng L, Wang K, Wu G. Selective vagus-recurrent laryngeal nerve anastomosis in thyroidectomy with cancer invasion or iatrogenic transection. Langenbecks Arch Surg 2020; 405:461-468. [PMID: 32504208 DOI: 10.1007/s00423-020-01906-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/28/2020] [Indexed: 02/01/2023]
Abstract
PURPOSE Immediate recurrent laryngeal nerve (RLN) reconstruction at the time of thyroid cancer extirpation can provide excellent postoperative phonatory function. This study is to present our experience with the methods of RLN reconstruction, and to evaluate the role of selective vagus to RLN anastomosis (SVR) in thyroidectomy. METHODS Respective review of RLN reconstruction in thyroid surgery from January 2004 to October 2018 was conducted in two tertiary referral academic medical centers. Immediate RLN reconstruction was performed for primary thyroidectomy patients with intraoperative nerve tumor invasion or iatrogenic transection. Laryngofiberoscopic examination, voice evaluation of maximum phonation time, and GRBAS scale were performed preoperatively, on the second day after surgery, and monthly postoperatively for the first year. RESULTS A total of 37 patients were enrolled. Twenty-nine RLNs were resected caused by tumor-associated trauma; the other nerves were inadvertently transected. Direct anastomosis (DA) was performed in eight patients, free nerve graft (FNG) was performed in four patients, ansa cervicalis to RLN anastomosis (ARA) was performed in eight patients, and SVR was performed in 17 patients. The mean periods from the reinnervation surgery of DA, SVR, ARA, and FNG to the phonation recovery were 46 ± 19 (days), 41 ± 29 (days), 83 ± 21 (days), and 137 ± 32 (days), respectively. There were improvements in the GRBAS scale of perceptual voice quality at 1 month for DA and SVR, 2months for ARA. CONCLUSIONS Intraoperative SVR reinnervation demonstrated voice improvement postoperatively and might be an effective treatment for thyroidectomy-related permanent unilateral vocal cord paralysis.
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Affiliation(s)
- Qianqian Yuan
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Jinxuan Hou
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Yiqin Liao
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Lewei Zheng
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Kun Wang
- Department of Thyroid and Breast Surgery, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei, 430030, People's Republic of China
| | - Gaosong Wu
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China.
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21
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Settell ML, Pelot NA, Knudsen BE, Dingle AM, McConico AL, Nicolai EN, Trevathan JK, Ezzell JA, Ross EK, Gustafson KJ, Shoffstall AJ, Williams JC, Zeng W, Poore SO, Populin LC, Suminski AJ, Grill WM, Ludwig KA. Functional vagotopy in the cervical vagus nerve of the domestic pig: implications for the study of vagus nerve stimulation. J Neural Eng 2020; 17:026022. [PMID: 32108590 PMCID: PMC7306215 DOI: 10.1088/1741-2552/ab7ad4] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Given current clinical interest in vagus nerve stimulation (VNS), there are surprisingly few studies characterizing the anatomy of the vagus nerve in large animal models as it pertains to on-and off-target engagement of local fibers. We sought to address this gap by evaluating vagal anatomy in the pig, whose vagus nerve organization and size approximates the human vagus nerve. APPROACH Here we combined microdissection, histology, and immunohistochemistry to provide data on key features across the cervical vagus nerve in a swine model, and compare our results to other animal models (mouse, rat, dog, non-human primate) and humans. MAIN RESULTS In a swine model we quantified the nerve diameter, number and diameter of fascicles, and distance of fascicles from the epineural surface where stimulating electrodes are placed. We also characterized the relative locations of the superior and recurrent laryngeal branches of the vagus nerve that have been implicated in therapy limiting side effects with common electrode placement. We identified key variants across the cohort that may be important for VNS with respect to changing sympathetic/parasympathetic tone, such as cross-connections to the sympathetic trunk. We discovered that cell bodies of pseudo-unipolar cells aggregate together to form a very distinct grouping within the nodose ganglion. This distinct grouping gives rise to a larger number of smaller fascicles as one moves caudally down the vagus nerve. This often leads to a distinct bimodal organization, or 'vagotopy'. This vagotopy was supported by immunohistochemistry where approximately half of the fascicles were immunoreactive for choline acetyltransferase, and reactive fascicles were generally grouped in one half of the nerve. SIGNIFICANCE The vagotopy observed via histology may be advantageous to exploit in design of electrodes/stimulation paradigms. We also placed our data in context of historic and recent histology spanning multiple models, thus providing a comprehensive resource to understand similarities and differences across species.
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Affiliation(s)
- Megan L Settell
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States of America
- Mayo Clinic, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, United States of America
| | - Nicole A Pelot
- Department of Biomedical Engineering, Duke University, Durham, NC, United States of America
| | - Bruce E Knudsen
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States of America
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States of America
| | - Aaron M Dingle
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Andrea L McConico
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States of America
| | - Evan N Nicolai
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States of America
- Mayo Clinic, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, United States of America
| | - James K Trevathan
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States of America
- Mayo Clinic, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, United States of America
| | - J Ashley Ezzell
- Histology Research Core, University of North Carolina School of Medicine, Durham, NC, United States of America
- Department of Cell Biology and Physiology, University of North Carolina School of Medicine, Durham, NC, United States of America
| | - Erika K Ross
- Abbott Neuromodulation, Plano, TX, United States of America
| | - Kenneth J Gustafson
- Department of Biomedical Engineering, Western Reserve University, Cleveland, OH, United States of America
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, United States of America
| | - Andrew J Shoffstall
- Department of Biomedical Engineering, Western Reserve University, Cleveland, OH, United States of America
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, United States of America
| | - Justin C Williams
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States of America
- Department of Neurosurgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Weifeng Zeng
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Samuel O Poore
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States of America
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Luis C Populin
- Department of Neuroscience, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Aaron J Suminski
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States of America
- Department of Neurosurgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Warren M Grill
- Department of Biomedical Engineering, Duke University, Durham, NC, United States of America
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, United States of America
- Department of Neurobiology, Duke University, Durham, NC, United States of America
- Department of Neurosurgery, Duke University, Durham, NC, United States of America
| | - Kip A Ludwig
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States of America
- Department of Neurosurgery, University of Wisconsin-Madison, Madison, WI, United States of America
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22
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Minuto MN, Reina S, Monti E, Ansaldo GL, Varaldo E. Morbidity following thyroid surgery: acceptable rates and how to manage complicated patients. J Endocrinol Invest 2019; 42:1291-1297. [PMID: 31124043 DOI: 10.1007/s40618-019-01064-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 05/14/2019] [Indexed: 12/01/2022]
Abstract
PURPOSE The endocrine surgeon and the endocrinologist should standardize how they deal with patients with an indication for thyroidectomy, as the road to surgery starts well before the operation itself. The patient should be thoroughly informed about where and how surgery will be performed, the postoperative improvements that can be expected, and the possibility and incidence of relevant complications. This short review aims at identifying the most common postoperative issues after thyroidectomy, with the relevant therapeutic suggestions. METHODS A revision of studies reporting the morbidity of thyroid surgery, involving the largest numbers of patients. RESULTS It has been clearly demonstrated that the outcome of thyroid surgery is significantly better when the procedure is performed by an experienced surgeon. Thus, the number of thyroidectomies performed by a surgeon should drive the endocrinologist when referring a patient. CONCLUSIONS Despite the surgeon's experience, thyroidectomy is burdened by a relatively high rate of postoperative issues ranging from less severe ones to others causing significant changes in the patient's quality of life. Minor, non-invalidating symptoms have been described in 40% of patients after thyroidectomy (e.g. hoarseness, mild dysphagia, some degree of voice alteration); however, these symptoms usually resolve within a few months of surgery, with or without early treatment. On the other hand, major postoperative complications are observed in a limited number of patients, but in these cases early diagnosis is important to provide the most appropriate postoperative treatment, and thus hasten full recovery or at least achieve the greatest possible improvement.
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Affiliation(s)
- M N Minuto
- Dipartimento di Scienze Chirurgiche (DISC), Università degli Studi di Genova, V.le Benedetto XV 6, 16132, Genoa, Italy.
- U.O. Chirurgia 1, Dipartimento di Chirurgia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - S Reina
- Dipartimento di Scienze Chirurgiche (DISC), Università degli Studi di Genova, V.le Benedetto XV 6, 16132, Genoa, Italy
- U.O. Chirurgia 1, Dipartimento di Chirurgia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - E Monti
- Dipartimento di Medicina Interna (DIMI), Università degli Studi di Genova, Genoa, Italy
| | - G L Ansaldo
- U.O. Chirurgia 1, Dipartimento di Chirurgia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - E Varaldo
- Dipartimento di Scienze Chirurgiche (DISC), Università degli Studi di Genova, V.le Benedetto XV 6, 16132, Genoa, Italy
- U.O. Chirurgia 1, Dipartimento di Chirurgia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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