Cernea's classification of the External Branch of the Superior Laryngeal Nerve during Microscopic Thyroidectomy at Gandaki Medical College, Pokhara

Background: Preservation of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy is important because its injury may lead to frequent occurrence of vocal fatigue and the inability to perform phonation. The objective of the study was to identify and classify the nerve as per Cernea's classification using operating microscope during thyroidectomy Method: Between January 2017 to December 2019, we evaluated 50 patients for the position of external branch of superior laryngeal nerve, who underwent microscopic thyroid surgeries in the department of ENT- head and neck surgery at Gandaki Medical College. Results: In our study, we dissected a total 59 superior poles of thyroid from 50 patients and identified the nerve in all the cases. Of the total superior poles, 36 (61.01%) had type IIa EBSLN among which 24 was on the right side and 12 on the left followed by 19 (32.20%) patients with type IIb EBSLN among which 8 on right and 11 on left side. There were only 4 poles (6.77%) of type I with 3 on the right and 1 on the left side. Conclusion: The EBSLN can be very efficaciously identified during a microscope assisted thyroidectomy. Cernea type 2a and 2b EBSLNs are in position to be at high risk of injury during ligation of the superior vascular pedicle, which can be avoided by prompt identification through a microscope and a meticulous extra capsular dissection technique.

A Predictable Approach of a Rare and Frequently Misdiagnosed Entity: Laryngeal Nerve Schwannoma

(1) Background: Schwannoma, a mesenchymal neoplasm derived from Schwann cells that line peripheral nerve sheaths, has a challenging diagnosis, due to the non-specific medical history and clinical examination. Nowadays, virtual reality (VR) is increasingly more used for enhancing diagnosis and for preoperative planning of surgical procedures. With VR, the surgeon can interact, before any surgery, with a virtual environment that is completely generated by a computer, offering them a real experience inside a virtual 3D model. (2) Methods and Results: The aim of the present paper was to present a case of surgically removal of a schwannoma, which originated from the fibers of the superior laryngeal nerve, in a predictable and minimally invasive fashion, upon using VR for diagnosis and surgical procedure planning. (3) Conclusions: The current clinical report attracted the attention of including schwannoma in the possible differential diagnosis of a swelling in the anterior cervical region, mainly when a nonspecific radiological appearance is noticed, even with the use of multiple imaging modalities. Virtual reality can increase the predictability and success rate of the surgical procedure, being in the meantime a good tool for communication with the patient.

Correlation Between Objective and Subjective High-Pitched Voice Impairment in Patients After Thyroid Surgery

ObjectivesHigh-pitched voice impairment (HPVI) is not uncommon in patients without recurrent laryngeal nerve (RLN) or external branch of superior laryngeal nerve (EBSLN) injury after thyroidectomy. This study evaluated the correlation between subjective and objective HPVI in patients after thyroid surgery.MethodsThis study analyzed 775 patients without preoperative subjective HPVI and underwent neuromonitored thyroidectomy with normal RLN/EBSLN function. Multi-dimensional voice program, voice range profile and Index of voice and swallowing handicap of thyroidectomy (IVST) were performed during the preoperative(I) period and the immediate(II), short-term(III) and long-term(IV) postoperative periods. The severity of objective HPVI was categorized into four groups according to the decrease in maximum frequency (Fmax): <20%, 20-40%, 40-60%, and >60%. Subjective HPVI was evaluated according to the patient’s answers on the IVST.ResultsAs the severity of objective HPVI increased, patients were significantly more to receive bilateral surgery (p=0.002) and have subjective HPVI (p<0.001), and there was no correlation with IVST scores. Among 211(27.2%) patients with subjective HPVI, patients were significantly more to receive bilateral surgery (p=0.003) and central neck dissection(p<0.001). These patients had very similar trends for Fmax, pitch range, and mean fundamental frequency as patients with 20-40% Fmax decrease (p>0.05) and had higher Jitter, Shimmer, and IVST scores than patients in any of the objective HPVI groups; subjective HPVI lasted until period-IV.ConclusionThe factors that affect a patient’s subjective HPVI are complex, and voice stability (Jitter and Shimmer) is no less important than the Fmax level. When patients have subjective HPVI without a significant Fmax decrease after thyroid surgery, abnormal voice stability should be considered and managed. Fmax and IVST scores should be interpreted comprehensively, and surgeons and speech-language pathologists should work together to identify patients with HPVI early and arrange speech therapy for them. Regarding the process of fibrosis formation, anti-adhesive material application and postoperative intervention for HPVI require more future research.

Post-thyroidectomy complications in southwestern Saudi Arabia: a retrospective study of a 6-year period

BACKGROUND: Thyroidectomy is the surgical removal of all or part of the thyroid gland for non-neoplastic and neoplastic thyroid diseases. Major postoperative complications of thyroidectomy, including recurrent laryngeal nerve injury, hypocalcemia, and hypothyroidism, are not infrequent. OBJECTIVE: Summarize the frequency of surgical complications of thyroidectomy. DESIGN: Retrospective. SETTING: Secondary health facility in southwestern Saudi Arabia. PATIENTS AND METHODS: We collected data from the records of patients who were managed for thyroid diseases between December 2013 and December 2019. MAIN OUTCOME MEASURE: Complications following thyroidectomy. SAMPLE SIZE: 339 patients, 280 (82.6%) females and 59 (17.4%) males. RESULTS: We found 311 (91.7%) benign and 28 (8.3%) malignant thyroid disorders. Definitive management included 129 (38.1%) total thyroidectomies, 70 (20.6%) hemithyroidectomies, 10 (2.9%) subtotal thyroidectomies and 5 (1.5%) near-total thyroidectomies with 125 (36.9%) patients treated non-surgically. The overall complication rate was 11.3%. There were 4 (1.9%) patients with recurrent laryngeal nerve palsy, 16 (7.5%) patients with temporary hypoparathyroidism, 1 (0.5%) patient with paralysis of the external branch of the superior laryngeal nerve and 3 (1.4%) patients with wound hematoma. CONCLUSION: The rate of complications following thyroidectomy is still high. There is a need for emphasis on comprehensive measures to control the high rate of complications. LIMITATIONS: Retrospective design and no long-term follow up to monitor late complications. CONFLICT OF INTEREST: None.

Comparison between ultrasound-guided and anatomical landmark-guided block of internal branch of the superior laryngeal nerve for awake fiber-optic intubation in suspected difficult intubation: a randomized controlled study

Background Airway anesthesia is pivotal for successful awake intubation provided either topically or by nerve blocks. The widespread use of ultrasonography allows anesthesiologists to evaluate complex and varied anatomy before needle insertion. This study aims to evaluate the effect of ultrasound-guided technique for the block of the internal branch of the superior laryngeal nerve in difficult airway patients in comparison to blind anatomical technique. Sixty patients aged 18–60 years, of either sex, with the American Society of Anesthesiologists’ physical status (ASA) I–II were divided into two groups 30 patients of each. Group (L): using anatomical landmark technique to bilateral block internal branch of the superior laryngeal nerve (ibSLN) with 1 mL 2% Lidocaine and group (U): using ultrasound technique to bilateral block the ibSLN with 1 mL 2% Lidocaine. Assessment of the excellence of airway anesthesia during intubation by using the 5 points grading scale, time for intubation, effects on hemodynamic variables, and evaluation of patient awareness of pain and discomfort during fiber-optic intubation using numerical rating scale were compared. Results The duration of tracheal intubation was shorter in the ultrasound group as compared to the anatomical group; also, patient comfort was significantly better in the ultrasound group besides the effect of tracheal intubation on hemodynamics which was significant with a higher peak value during intubation and post-intubation in the anatomical group compared to the ultrasound group. Conclusions This study concludes that an ultrasound-guided block of ibSLN used as a part of the preparation of the airway for awake fiber-optic intubation enhances the quality of airway anesthesia and patient tolerance during the procedure.

Safety and Feasibility of the Transoral Endoscopic Thyroidectomy Vestibular Approach With Neuroprotection Techniques for Papillary Thyroid Carcinoma

Background: This study aimed to evaluate the feasibility and safety of the trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) with neuroprotection techniques for the surgical management of papillary thyroid carcinoma (PTC). Methods: Patients with PTC who underwent TOETVA between December 2016 and July 2020 were included in this study, and their relevant clinical characteristics, operational details, and surgical outcomes were reviewed and extracted from their medical records for further analysis. Results: A total of 75 patients successfully underwent TOETVA with zero conversions. Unilateral lobectomy with isthmectomy and total thyroidectomy were completed for 58 and 17 patients, respectively, all using our unique neuroprotective procedure and ipsilateral central neck dissection (CND). The mean number of retrieved lymph nodes versus positive lymph nodes was 6.8 ± 3.7 vs. 1.5 ± 2.3. Postoperative complications included three cases of transient superior laryngeal nerve (SLN) palsy (4.0%), five cases of transient recurrent laryngeal nerve (RLN) palsy (6.7%), 14 cases of transient hypoparathyroidism (18.7%), and two cases of lap perforation (2.7%). The follow-up period for patients with PTC lasted for 15.6 ± 10.9 months, during which no other complications or tumor recurrence were observed.Conclusion: TOETVA can be safely performed for patients with PTC with satisfactory results during the short-term follow-up period. Our neuroprotection techniques can be integrated into TOETVA, which is worth recommending for PTC patients who desire better cosmetic surgical outcomes.