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Intraoperative neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy: the need for evidence-based data and perioperative technical/technological standardization.

ABSTRACT: The external branch of the superior laryngeal nerve (EBSLN) is surgically relevant since its close anatomical proximity to the superior thyroid vessels. There is heterogeneity in the EBSLN anatomy and EBSLN damage produces changes in voice that are very heterogenous and difficult to diagnose. The reported prevalence of EBSLN injury widely ranges. EBSLN iatrogenic injury is considered the most commonly underestimated complication in endocrine surgery because vocal assessment underestimates such event and laryngoscopic postsurgical evaluation does not show standardized findings. In order to decrease the risk for EBSLN injury, multiple surgical approaches have been described so far. IONM provides multiple advantages in the EBSLN surgical approach. In this review, we discuss the current state of the art of the monitored approach to the EBSLN. In particular, we summarize, providing our additional remarks, the most relevant aspects of the standardized technique brilliantly described by the INMSG (International Neuromonitoring Study Group). In conclusion, in our opinion, there is currently the need for more prospective randomized trials investigating the electrophysiological and pathological aspects of the EBSLN for a better understanding of the role of IONM in the EBSLN surgery.

SUBMITTER: Mangano A

PROVIDER: S-EPMC4265369 | biostudies-other | 2014

REPOSITORIES: biostudies-other

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Project description:IntroductionUltrasound-guided internal branch of the upper laryngeal nerve block (USG-guided iSLN block) have been used to decrease the perioperative stress response of intubation. It is more likely to be successful than blindly administered superior laryngeal nerve blocks with fewer complications. Here, we evaluated the efficacy of USG-guided iSLN block to treat postoperative sore throat (postoperative sore throat, POST) after extubation.Methods100 patients, aged from 18 to 60 years old, ASA I~II who underwent general anesthesia and suffered from the moderate to severe postoperative sore throat after extubation were randomized into two groups(50 cases per group). Patients in group S received USG-guided iSLN block bilaterally (60mg of 2% lidocaine, 1.5ml each side), whereas those in group I received inhalation with 100 mg of 2% lidocaine and 1mg of budesonide suspension diluted with normal saline (oxygen flow 8 L /min, inhalation for 15 minutes). The primary outcome were VAS scores in both groups before treatment (T0), 10 min (T1), 30 min(T2), 1h(T3), 2 h(T4), 4h(T5), 8h(T6), 24h(T7), and 48h(T8) after treatment. The secondary outcome were satisfaction scores after treatment, MAP, HR, and SPO2 fromT0 to T8. The adverse reactions such as postoperative chocking or aspiration, cough, hoarseness, dyspnea were also observed in both groups.ResultsPatients in group S had significantly lower VAS score than that in group I at points of T1 ~ T6 (P < 0.01). HR of group S was lower than that of group I at points of T1 ~ T2and T4 (P < 0.05), and MAP was lower than that of group I at points of T1 ~ T3 (P < 0.05). Satisfaction scores of group S were higher than that of group I (P <0.05), In group S, 2 case (4%) needed to intravenous Flurbiprofen Injection 50 mg to relieve pain; in group I, 13 cases (26%) received Flurbiprofen Injection. 2 case of group S appeared throat numbness after treatment for 3 hours; 2 patients have difficult in expectoration after treatment recovered after 3hour. No serious adverse events were observed in both groups.ConclusionCompared with inhalation, USG-guided iSLN block may effectively relieve the postoperative sore throat after extubation under general anesthesia and provided an ideal treatment for POST in clinical work.

Project description:BackgroundTo explore whether the medial branch block of superior laryngeal nerve can reduce the stress response of patients undergoing intubation and further reduce the dosage of opioids.Methods80 patients undergoing gynecological laparoscopic surgery were selected, and randomly divided into 4 groups. All patients in the experimental groups received bilateral internal branch of superior laryngeal nerve block and transversus abdominis plane block. But the dosage of sufentanil used for anesthesia induction in the group A, B, and C was 0.4, 0.2, and 0μg/kg, respectively. Group D do not underwent supralaryngeal nerve block and the dosage of sufentanil was 0.4μg/kg. The heart rate (HR) and mean arterial pressure(MAP) were recorded at the time of entering the operating room(T1), before intubation after induction(T2), immediately after intubation(T3), 5min after intubation(T4), before extubation(T5), immediately after extubation(T6), 5min after extubation(T7). We also recorded the stay time in the recovery room, the number of cases of postoperative sore throat, the number of cases of nausea and vomiting, the first intestinal exhaust time, the length of hospital stay after operation.ResultsThe HR of group A, C and D at T3 was significantly higher than that at T2(P < 0.01), while the HR of group B had no significant change. The HR of group A, C and D at T4 was lower than that at T3(P < 0.01), while the HR of group B had no obvious change. The HR of group C and D at T3 was significantly higher than that at T1 (P < 0.01). The MAP of group A and D at T4 was significantly lower than that at T1 (P<0.001). The first postoperative intestinal exhaust time in group A, B and C was significantly shorter than that in group D. The length of hospital stay after operation in group B and C was shorter than that in group D.ConclusionsUltrasound-guided superior laryngeal nerve block combined with 0.2μg/kg sufentanil can reduce the intubation reaction, have better hemodynamic stability, reduce the first postoperative intestinal exhaust time and postoperative hospital stay, thereby accelerating the postoperative recovery of patients.

Project description:Background Thyroid surgery is increasingly demanding in terms of cosmetic neck outcomes and protection of anterior neck function, so we have adopted an alternative sternocleidomastoid intermuscular approach (SMIA) for open/conventional thyroidectomy. The protection of recurrent laryngeal nerve (RLN) and external branch of superior laryngeal nerve (EBSLN) is the key and difficult point in thyroid surgery. The aim of this study was to testify the feasibility of RLN and EBSLN functional protection during SMIA thyroidectomy with the intraoperative neuromonitoring. Methods A total of 39 patients and 39 RLN and EBSLNs who underwent monitored SMIA thyroidectomy were included. Thyroid gland is revealed and excised anterior to the cervical sheath between the sternal and clavicular heads of the sternocleidomastoid muscle. Standardized intraoperative neuromonitoring (IONM) procedures and postoperative laryngeal examination were performed to audit the SMIA. Following the four-step method, V1, R1, R2, and V2 were monitored and the signal values were recorded. Statistical analysis was used to evaluate the change of IONM amplitude of RLN, combined with the results of laryngoscopy before and after operation to determine the status of RLN. EBSLN injuries were identified from changes in cricothyroid muscle (CTM) twitch and EMG. SMIA video vignette is detailed. Results All RLN and EBSLNs [17 on the left and 22 on the right] were monitored in 39 patients [5 men, 34 women; mean age 34.1±8.7 years; mean body mass index 22.5 (±3.0, 17.0–30.8) kg/m2] undergoing SMIA. For RLN of the affected side, we compared the V2 and V1 (1,236±672 vs. 1,240±428, P=0.973), R2 and R1 (1,676±778 vs. 1,656±765, P=0.849) signals separately, and the results were not statistically different (P>0.05). Comparing the V1 (1,240±428 vs. 1,309±395, P=0.601) signals of the bilateral recurrent laryngeal nerve, there was no statistical difference (P>0.05). CTM twitch and EMG were preserved. Conclusions The SMIA technique appears feasible. RLN and EBSLN are easier to be exposed during thyroid surgery of SMIA, which is beneficial to the neuroprotection during the operation. At the same time, it can protect the anterior cervical function and improve the cosmetic effect after operation.

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Intraoperative neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy: the need for evidence-based data and perioperative technical/technological standardization.

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