Skip to main content
SpringerLink
Log in

Superior laryngeal nerve in thyroid surgery: anatomical identification and monitoring

  • Head and Neck
  • Published:
European Archives of Oto-Rhino-Laryngology Aims and scope Submit manuscript

Abstract

The aim of this study was to validate a procedure to identify and preserve the external branch of the superior laryngeal nerve (EBSLN) during thyroid surgery. The present study also aimed to analyze the EBSLN and the vagus nerve activities after stimulation and demonstrate an operative association between all the laryngeal muscles. Dissection of the cervical region was performed bilaterally in four adult cadavers. In a second step, 144 patients undergoing total thyroidectomy were included. Intraoperative stimulations of the cervical vagus nerve and the EBSLN in the sternothyroid–laryngeal triangle were performed bilaterally. Potentials in the thyroarytenoid muscle and the cricothyroid muscle were registered on each side using the NIM3 Medtronic System. EBSLN was identified according to Cernea’s classification as type 1 in 62.5%, type 2a in 25%, and type 2b in 12.5% of cadaver’s dissection. According to Friedman’s classification, 50% of EBSLN were classified type 1, 25% type 2 and 25% type 3. The EBSLN was identified in 267 cases out of 288 peroperative dissections (92.7%). Direct stimulation (1 mA) of this branch led to a recordable contraction of the cricothyroid muscle with a mean latency of 1.42 ± 0.66 ms on the right side and 1.43 ± 0.61 ms on the left side. The stimulation of the EBSLN also led to a recordable contraction of the thyroarytenoid muscle in 211 cases (73.3%) with the same latencies. A contraction of the cricothyroid muscle was also recorded when the vagus nerve was stimulated in 219 cases (76.0%). The sole visual identification of the EBSLN during thyroid surgery is not a reliable method to prevent nerve injury. Direct stimulation of the EBSLN in the sternothyroid–laryngeal triangle is a simple and rapid procedure to detect and preserve the nerve during surgery. Functional associations between vagus nerve and EBSLN in laryngeal muscles’ contractions were also identified.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Harrison DFN (1995) Morphology of the superior laryngeal nerve. In: Harrison DFN (ed) The anatomy and physiology of the mammalian larynx. Cambridge University Press, Cambridge, p 142

    Chapter  Google Scholar 

  2. Furlan JC, de Magalhães RP, de Aguiar ET, Shiroma S (2002) Localization of the superior laryngeal nerve during carotid endarterectomy. Surg Radiol Anat 24(3–4):190–193

    CAS  PubMed  Google Scholar 

  3. Cernea CR, Nishio S, Hojaij FC (1995) Identification of the external branch of the superior laryngeal nerve (EBSLN) in large goiters. Am J Otolaryngol 16(5):307–311

    Article  CAS  PubMed  Google Scholar 

  4. Kandil E, Mohamed SE, Deniwar A, Mohamed H, Friedlander P, Aslam R, Saeed A, Musa I, Randolph G (2015) Electrophysiologic identification and monitoring of the external branch of superior laryngeal nerve during thyroidectomy. Laryngoscope 125(8):1996–2000

    Article  PubMed  Google Scholar 

  5. Jansson S, Tisell LE, Hagne I, Sanner E, Stenborg R, Svensson P (1988) Partial superior laryngeal nerve (SLN) lesions before and after thyroid surgery. World J Surg 12(4):522–527

    Article  CAS  PubMed  Google Scholar 

  6. Arnold GE (1961) Physiology and pathology of the cricothyroid muscle. Laryngoscope 71:687–753

    Article  CAS  PubMed  Google Scholar 

  7. Faaborg-Andersen K, Jensen AM (1964) Unilateral paralysis of the superior laryngeal nerve. Acta Otolaryngol 57:155–159

    Article  CAS  PubMed  Google Scholar 

  8. Bevan K, Griffiths MV, Morgan MH (1989) Cricothyroid muscle paralysis: its recognition and diagnosis. J Laryngol Otol 103(2):191–195

    Article  CAS  PubMed  Google Scholar 

  9. Delbridge L (2001) The ‘neglected’ nerve in thyroid surgery: the case for routine identification of the external laryngeal nerve. ANZ J Surg 71(4):199

    Article  CAS  PubMed  Google Scholar 

  10. Cernea CR, Ferraz AR, Nishio S, Dutra A Jr, Hojaij FC, dos Santos LR (1992) Surgical anatomy of the external branch of the superior laryngeal nerve. Head Neck 14(5):380–383

    Article  CAS  PubMed  Google Scholar 

  11. Friedman M, LoSavio P, Ibrahim H (2002) Superior laryngeal nerve identification and preservation in thyroidectomy. Arch Otolaryngol Head Neck Surg 128(3):296–303

    Article  PubMed  Google Scholar 

  12. Barczyński M, Randolph GW, Cernea CR, International Neural Monitoring Study Group et al (2013) External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: International Neural Monitoring Study Group standards guideline statement. Laryngoscope 123(Suppl 4):S1–S14

    Article  PubMed  Google Scholar 

  13. R Core Team (2017) R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna. https://www.R-project.org/. Accessed May 2017

  14. Moosman DA, DeWeese MS (1968) The external laryngeal nerve as related to thyroidectomy. Surg Gynecol Obstet 127(5):1011–1016

    CAS  PubMed  Google Scholar 

  15. Cernea CR, Ferraz AR, Furlani J, Monteiro S, Nishio S, Hojaij FC, Dutra Júnior A, Marques LA, Pontes PA, Bevilacqua RG (1992) Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Am J Surg 164(6):634–639

    Article  CAS  PubMed  Google Scholar 

  16. Ozlugedik S, Acar HI, Apaydin N, Tekdemir I, Elhan A, Comert A (2007) Surgical anatomy of the external branch of the superior laryngeal nerve. Clin Anat 20(4):387–391

    Article  PubMed  Google Scholar 

  17. Barczyński M, Konturek A, Stopa M, Honowska A, Nowak W (2012) Randomized controlled trial of visualization versus neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy. World J Surg 36(6):1340–1347

    Article  PubMed  PubMed Central  Google Scholar 

  18. Dionigi G, Boni L, Rovera F, Bacuzzi A, Dionigi R (2009) Neuromonitoring and video-assisted thyroidectomy: a prospective, randomized case–control evaluation. Surg Endosc 23(5):996–1003

    Article  PubMed  Google Scholar 

  19. Pagedar NA, Freeman JL (2009) Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Arch Otolaryngol Head Neck Surg 135(4):360–362

    Article  PubMed  Google Scholar 

  20. Bellantone R, Boscherini M, Lombardi CP, Bossola M, Rubino F, De Crea C, Alesina P, Traini E, Cozza T, D’alatri L (2001) Is the identification of the external branch of the superior laryngeal nerve mandatory in thyroid operation? Results of a prospective randomized study. Surgery 130(6):1055–1059

    Article  CAS  PubMed  Google Scholar 

  21. Chandrasekhar SS, Randolph GW, Seidman MD et al (2013) Clinical practice guideline: improving voice outcomes after thyroid surgery. Otol Head Neck Surg 148(6S):1–37

    Article  Google Scholar 

  22. Barczyński M, Randolph GW, Cernea C, International Neural Monitoring Study Group in Thyroid and Parathyroid Surgery et al (2016) International survey on the identification and neural monitoring of the EBSLN during thyroidectomy. Laryngoscope 126(1):285–291

    Article  PubMed  Google Scholar 

  23. Selvan B, Babu S, Paul MJ, Abraham D, Samuel P, Nair A (2009) Mapping the compound muscle action potentials of cricothyroid muscle using electromyography in thyroid operations: a novel method to clinically type the external branch of the superior laryngeal nerve. Ann Surg 250(2):293–300

    Article  PubMed  Google Scholar 

  24. Julien N, Ferrary E, Sokoloff A, Lamas G, Sterkers O, Bernardeschi D (2017) Vagal and recurrent laryngeal nerves neuromonitoring during thyroidectomy and parathyroidectomy: a prospective study. Eur Ann Otorhinolaryngol Head Neck Dis 134(2):77–82

    Article  CAS  PubMed  Google Scholar 

  25. Darr EA, Tufano RP, Ozdemir S, Kamani D, Hurwitz S, Randolph G (2014) Superior laryngeal nerve quantitative intraoperative monitoring is possible in all thyroid surgeries. Laryngoscope 124(4):1035–1041

    Article  PubMed  Google Scholar 

  26. Farizon B, Gavid M, Karkas A, Dumollard JM, Peoc’h M, Prades JM (2017) Intraoperative monitoring of the recurrent laryngeal nerve by vagal nerve stimulation in thyroid surgery. Eur Arch Otorhinolaryngol 274:421–426

    Article  PubMed  Google Scholar 

  27. Liddy W, Barber SR, Cinquepalmi M et al (2017) 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 127(3):764–771

    Article  PubMed  Google Scholar 

  28. Dilworth TF (1921) The nerves of the human larynx. J Anat 56(Pt 1):48–52

    CAS  PubMed  PubMed Central  Google Scholar 

  29. Maranillo E, León X, Quer M, Orús C, Sañudo JR (2003) Is the external laryngeal nerve an exclusively motor nerve? The cricothyroid connection branch. Laryngoscope 113(3):525–529

    Article  PubMed  Google Scholar 

  30. Sañudo JR, Maranillo E, León X, Mirapeix RM, Orús C, Quer M (1999) An anatomical study of anastomoses between the laryngeal nerves. Laryngoscope 109(6):983–987

    Article  PubMed  Google Scholar 

  31. Mu L, Sanders I, Wu BL, Biller HF (1994) The intramuscular innervation of the human interarytenoid muscle. Laryngoscope 104(1 Pt 1):33–39

    CAS  PubMed  Google Scholar 

  32. Miyauchi A, Masuoka H, Nakayama A, Higashiyama T (2016) Innervation of the cricothyroid muscle by extralaryngeal branches of the recurrent laryngeal nerve. Laryngoscope 126(5):1157–1162

    Article  PubMed  Google Scholar 

  33. Masuoka H, Miyauchi A, Yabuta T, Fukushima M, Miya A (2016) Innervation of the cricothyroid muscle by the recurrent laryngeal nerve. Head Neck 38(Suppl 1):E441–E445

    Article  PubMed  Google Scholar 

  34. Martin-Oviedo C, Maranillo E, Lowy-Benoliel A, Pascual-Font A, Martinez-Guirado T, Rodriguez-Niedenführ M, Sañudo J, Scola B, Vazquez T (2011) Functional role of human laryngeal nerve connections. Laryngoscope 121(11):2338–2343

    Article  PubMed  Google Scholar 

  35. Randolph G (2013) Surgery of the thyroid and parathyroid glands, 2nd edn. Saunders, Philadelphia

    Google Scholar 

  36. Mu L, Sanders I (2010) Sihler’s whole mount nerve staining technique: a review. Biotech Histochem 85(1):19–42

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anatomy, School of Medicine, Saint-Etienne University, Saint-Étienne, France

    M. Gavid, E. Larivé & J. M. Prades

  2. Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Saint-Etienne, 42055, Saint-Étienne Cedex 2, France

    M. Gavid, M. D. Dubois & J. M. Prades

Authors
  1. M. Gavid
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. D. Dubois
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. E. Larivé
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. J. M. Prades
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to M. Gavid.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gavid, M., Dubois, M.D., Larivé, E. et al. Superior laryngeal nerve in thyroid surgery: anatomical identification and monitoring. Eur Arch Otorhinolaryngol 274, 3519–3526 (2017). https://doi.org/10.1007/s00405-017-4666-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00405-017-4666-9

Keywords

Search

Navigation