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Introduction: Vagal nerve stimulator (VNS) implantation is a vital therapy for epilepsy refractory to other treatments; however, it is associated with a very high rate of voice changes. Relatively few of these patients are evaluated for vocal fold motion impairments. In this series, we evaluate 5 such patients with a novel phenotype of forced abduction with VNS stimulation. Methods: Retrospective case series. Results: Five patients with a VNS implant who underwent operative direct or in-office rigid laryngoscopy and had vocal fold motion impairment associated with VNS activation are included. All 5 patients had vocal fold mobility with VNS off and a fixed with activation. All patients exhibited vocal fold abduction with VNS activation. Patient 2 has since undergone laryngeal reinnervation, which helped her intermittent dysphonia but left a small glottic gap. A type 1 thyroplasty corrected this gap and improved her voice further. Patient 3 has undergone laryngeal reinnervation for which early results show improvement in perceptual and patient reported outcomes. Patients 4 and 5 have both undergone laryngeal reinnervation with improvement in voice. Conclusion: Previous reported cases of stimulated immobility associated with VNS use describe only adduction of the vocal fold. This series expands the previous work showing the VNS activation can also cause stimulated immobility in an abducted position, for which reinnervation and other medialization procedures offer promising treatment. [ABSTRACT FROM AUTHOR]

Intraoperative nerve monitoring (INM) to assess for recurrent laryngeal nerve dysfunction during thyroid surgery is becoming the standard of care in many institutions. Successful provision of data analysis with the help of IONM requires complete relaxation of the larynx and suppression of the reflex. We investigated the role of intravenous lidocaine in providing such working conditions to ensure the least impact on hemodynamic changes and obtain better conditions for working with IONM. The study aims to evaluate the effect of lidocaine, administered intravenously in estimated doses, on the IONM and laryngotracheal reflexes during surgical interventions on the thyroid and parathyroid glands. Methods: Forty-six patients were randomly assigned to Group 1 where lidocaine was administered and Group 2 where no lidocaine was administered. All patients were anaesthetized with a narcotic analgesic and inhalation anaesthetic. The loading dose of lidocaine was administered at the rate of 1 mg/kg intravenously, and the maintenance dose was calculated at 1.5 mg/kg/hour. For IONM, a Dragonfly single-channel laryngeal surface electrode (C2 NerveMonitor; 8 channel system for intraoperative Neurophysiological Monitoring, GERMANY) attached to a cuffed ETT #7 (MEDICARE, China) was used during surgery the same to the manufacturer's instructions. Results: The number of patients who required StMC strength at 0.5 mA (the manufacturer's recommended strength is 1.5 mA) was significantly higher in the lidocaine group (P=0.001) than in the no lidocaine group (P=0, 00006). The same number of patients with < 50% DAIL at the end of surgery was significantly higher in group 1 than in group 2. In addition, the proportion of patients with hypotensive episodes and blood pressure medication requirements more than twice during surgery was significantly lower in group 1 than in group 2 (P < 0.05). Conclusions: Patients who were prescribed lidocaine intravenously were more resistant to laryngotracheal irritation during surgery, and this made it possible to maintain such a condition of the larynx, which was necessary to ensure increased relaxation of the larynx and suppression of reflexes when using IONM. Our ability to elicit a positive signal with StMC 0.5 mA intraoperatively and provide a DAIL < 50% before the end of surgery was statistically significant in the IV lidocaine group (group 1). [ABSTRACT FROM AUTHOR]

Although swallowing has been reviewed extensively, the coordination of the phases of swallowing have not. The phases are controlled by the brainstem, but peripheral factors help coordinate the phases. The occurrence, magnitude, and duration of esophageal phase depends upon peripheral feedback activated by the bolus. The esophageal phase does not occur without peripheral feedback from the esophagus. This feedback is mediated by esophageal slowly-adapting mucosal tension receptors through the recurrent and superior laryngeal nerves. A similar reflex mediated by the same peripheral pathway is the activation of swallowing by stimulation of the cervical esophagus. This reflex occurs primarily in human infants and animals, and this reflex may be important for protecting against aspiration after esophago-pharyngeal reflux. Not only are there inter-phase excitatory processes, but also inhibitory processes. A significant inhibitory process is deglutitive inhibition. When one swallows faster than peristalsis ends, peristalsis is inhibited by the new pharyngeal phase. This process prevents the ongoing esophageal peristaltic wave from blocking the bolus being pushed into the esophagus by the new wave. The esophageal phase returns during the last swallow of the sequence. This process is probably mediated by mucosal tension receptors through the superior laryngeal nerves. A similar reflex exists, the pharyngo-esophageal inhibitory reflex, but studies indicate that it is controlled by a different neural pathway. The pharyngo-esophageal inhibitory reflex is mediated by mucosal tension receptors through the glossopharyngeal nerve. In summary, there are significant peripheral processes that contribute to swallowing, whereby one phase of swallowing significantly affects the other. [ABSTRACT FROM AUTHOR]

Introduction: Nonrecurrent laryngeal nerve (NRLN), a rare anatomical variation of recurrent laryngeal nerve, is a branch of the vagus nerve (Morais M, Capela-Costa J, Matos-Lima L, Costa-Maia J (2015) Nonrecurrent Laryngeal Nerve and Associated Anatomical Variations: The Art of Prediction. Eur Thyroid J 4(4):234–238). On the right side, the prevalence of NRLN is 0.3–0.8%, while on the left side, it is extremely rare with a prevalence of 0.004%. Case-Report: A female in her twenties presented with thyroid swelling for 3 years with an ultrasound neck showing a TIRADS IV lesion in the left thyroid lobe. Contrast-enhanced tomography of the neck reported a lesion in the left thyroid lobe causing mass effect in the form of contralateral deviation of trachea and splaying of bilateral common carotid arteries from its common origin – probability of thyroid neoplasm along with aberrant right subclavian artery with a retroesophageal course was noted. Intraoperatively, the right laryngeal nerve was identified near its entry point in right cricothyroid joint and was traced laterally and was found to be nonrecurrent lying superior to inferior thyroid artery. Total thyroidectomy was done preserving the left recurrent laryngeal nerve and right non recurrent laryngeal nerve. Conclusion: NRLN should be suspected in cases with vascular anomalies based on preoperative imaging. Meticulous dissection during thyroid surgery for identification of the recurrent laryngeal nerve or NRLN is still considered to be the precise approach to avoid nerve injury. [ABSTRACT FROM AUTHOR]

Objective: Although radiofrequency ablation (RFA) is a safe and effective nonsurgical treatment for benign thyroid nodules, injury to the recurrent laryngeal nerve (RLN), is a potential and feared complication. Intermittent voice checks have been proposed to monitor vocal cord (VC) function during RFA, but such assessment is highly subjective and effort-dependent. Methods: We are here reporting the methodological use of flexible laryngoscopy (FL) for VC monitoring during bilateral thyroid RFA treatment. The patient, a 35-year-old woman, was referred to the Endocrinology Unit for subclinical hyperthyroidism due to bilateral autonomously functioning thyroid nodules. Results: At the end of the treatment of the first nodule, the FL performed by an otorhinolaryngologist specialist allowed evaluating VC function and ruling out possible paralysis before proceeding with the contralateral RFA treatment. The patient was awake during the entire procedure and well tolerated the laryngoscopic examination. The TSH serum evaluations performed one month and 9 months after the procedure assessed an euthyroid state (TSH 3.2 mIU/L and 2.8 mIU/L, respectively). Conclusion: During bilateral thyroid RFA the use of FL for VC monitoring treatment resulted in a safe, easy-to-perform, and effective strategy to minimize and anticipate RLN injury risk in the awake patient. The prevention of RLN damage is advisable in the case of single RFA treatment, while it should be strongly recommended when RFA is performed on bilateral nodules. [ABSTRACT FROM AUTHOR]

Introduction: To investigate the ultrasound characteristics of recurrent laryngeal nerves (RLNs) during radical surgery for thyroid cancer and to enhance the understanding of RLN ultrasound features. Methods: From October 2021 to December 2022, a prospective study was conducted involving 24 patients scheduled for bilateral thyroid surgery. Near the conclusion of the surgery, intraoperative ultrasonography of the RLN within the tracheoesophageal groove was performed using a 15-7 MHz transducer. The thickness and width of the RLN were measured during the procedure. Results: The internal architecture of the RLN was observed to consist of multiple hypoechoic, parallel, but discontinuous linear hyperechoic areas separated by bands. In the normal RLN group, the diameter of the RLN was relatively consistent, with thickness ranging from 2.20 to 2.71 mm (mean: 2.48 ± 0.14 mm) and width from 1.25 to 1.70 mm (mean: 1.45 ± 0.11 mm). Both weight and the body mass index (BMI) showed a statistically significant correlation with RLN thickness (Weight: r=0.544, P=0.001; BMI: r=0.605, P=0.001). The BMI also showed a statistically significant correlation with the RLN width (r=0.377, P=0.033). In the RLN invasion group, the width of invaded RLNs ranged from 1.9 to 2.3mm(mean: 2.10 ± 0.11 mm), while the width of noninvaded RLNs ranged from 2.6 to 3.2 mm (mean: 2.93 ± 0.20 mm). Conclusions: Ultrasound effectively reveals the structural features of the RLN and enhances sonographers' understanding of RLN characteristics. [ABSTRACT FROM AUTHOR]

Background/Objectives: This study aimed to evaluate and establish the incidence of all types of neurological complications at our high-volume reference center for open TAAA repair in the Netherlands and Germany. Additionally, we sought to identify predictors for various neurological complications. Methods: This retrospective study was conducted in accordance with the STROBE guidelines, with the aim of reporting neurological outcomes for all patients who underwent open thoracoabdominal aortic aneurysm repair at two centers (Maastricht-Aachen) from 2000 to 2023, and to examine the association between these outcomes and pre- and perioperative parameters. The primary endpoints of the study were all-cause mortality, spinal cord ischemia (SCI), stroke, intracerebral bleeding (ICB), critical illness polyneuropathy/myopathy (CIP/CIM), and recurrent laryngeal nerve paralysis. Results: A total of 577 patients were operated on for open TAAA repair in two centers. The total in-hospital mortality rate was 20.6%, while the elective cases in-hospital mortality rate was 14.6%. In all, 28.2% of patients experienced neurological complications. The spinal cord ischemia rate was 7.5%, intracerebral bleeding 3.6%, stroke 5.9%, critical illness polyneuropathy 3.5%, and laryngeal nerve paresis 5.7%. Crawford extent II was significantly associated with increased neurological complications (OR 2.05, 95% CI 1.39–3.03, p = 0.003), while Crawford extent III and IV were significantly associated with fewer postoperative neurological complications (OR 0.61 (0.38–0.98) p = 0.04) (OR 0.52 (0.30–0.92) p = 0.02). Preoperative ASA score > 3 (OR 1.76, 95% CI 1.16–2.67, p = 0.007), COPD (OR 1.82, 95% CI 1.19–2.78, p = 0.006), massive intraoperative transfusion (OR 1.48, 95% CI 1.01–2.17, p = 0.04), and reinterventions during hospital stay (OR 1.98, 95% CI 1.36–2.89, p < 0.001) and surgery time (p =< 0.001) were significantly associated with neurological complications. Patients with neurological complications had higher rates of other postoperative morbidities. Conclusions: Neurological complications after open TAAA repair remain a significant concern, with identified risk factors associated with increased morbidity, mortality, and resource utilization. Identifying at-risk patients could potentially lead to a reduction in neurological complications. [ABSTRACT FROM AUTHOR]

The recurrent laryngeal nerve is a bilateral branch of the vagus nerve that is mainly associated with the motor innervation of the intrinsic muscles of the larynx. Despite its bilateral distribution, the right and left recurrent laryngeal nerves display unequal length due to embryological processes related to the development of the aortic arches. This length asymmetry leads to theories about morphological compensations to provide symmetrical functions to the intrinsic muscles of the larynx. In this study we investigated the developmental and cross-sectional morphometrics of the recurrent laryngeal nerves in human fetuses. Fifteen stillbirth fetuses donated to anatomical and medical research were used for investigation. Fetuses had intrauterine age ranging from 30 to 40 weeks estimated by biometry methods. Specialized anatomical dissection of the visceral block of the neck was performed to prepare histological samples of the recurrent laryngeal nerves in its point of contact with the larynx, and morpho-quantitative techniques were applied to evaluate the epineurium and perineural space of the recurrent laryngeal nerves. No statistical difference in the cross-sectional morphology of the epineurium and perineural space between right and left recurrent laryngeal nerves intra-individually was confirmed, however, we found evidence that these structures are under greater development in the left recurrent laryngeal nerve during 30 to 40 weeks of intrauterine life. Our data suggest that the nerves are under morphological development that possibly set the stage for accommodation of larger diameter and myelinization of the left recurrent laryngeal nerve during post-natal life. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Impaired pharyngeal sensing of negative pressure (NP) can lead to a blunted response of the upper airway dilator muscles and contribute to the development of obstructive sleep apnea (OSA). This response is modulated by the nerve fibers in the internal branch of the superior laryngeal nerve (iSLN), mediating negative pressure sensation. Artificial excitation of these fibers could be a potential treatment target for OSA. To evaluate this, electrostimulation of the iSLN was performed in a porcine-isolated upper airway model. Artificial obstructions were induced by varying the levels of negative pressure, and the ability of the animal to resolve these obstructions was evaluated. The pressure at which the animal was still able to resolve the obstruction was quantified as "Resolvable Pressure." Thereby, the effects on pharyngeal patency (n = 35) and the duration of the therapeutic effect outlasting the stimulation (n = 6) were quantified. Electrostimulation before the introduction of an artificial obstruction improved the median resolvable pressure from −28.3 cmH2O [IQR: −45.9; −26.1] to −92.6 cmH2O [IQR: −105.1; −78.6]. The median therapeutic effect was found to outlast the last stimulation burst applied by 163 s when five stimulation bursts were applied in short succession [IQR: 58; 231], 58 s when two were applied [IQR: 7; 65], and 6 s when one was applied [IQR: 0; 51]. Stimulation of the iSLN increased electromyography (EMG) in the genioglossus (GG). The proposed treatment concept can improve pharyngeal patency in the model. Transfer of the results to clinical application could enable the development of a new neuromodulation therapy for OSA. NEW & NOTEWORTHY: Electrostimulation before the introduction of an artificial obstruction to induce artificial sleep apnea in the pig model improves the response of the upper airway to negative pressure (NP). The electrostimulation creates a sustained therapeutic effect that outlasts the initial electrostimulation. The use of this therapy in clinical practice has the potential to treat obstructive sleep apnea (OSA). [ABSTRACT FROM AUTHOR]

Chronic obstructive pulmonary disease (COPD) was previously known as chronic bronchitis and emphysema. It has various main symptoms, such as dyspnea, chronic cough, and sputum, and is often accompanied by dysphagia. Although many published clinical reports have described COPD-related dysphagia, the physiological mechanisms underlying swallowing changes due to COPD remain unclear. Therefore, we analyzed how COPD affects the swallowing reflex using COPD model rats. We performed an electrophysiological study of respiration and swallowing using COPD model induced by intratracheal administration of porcine pancreatic elastase and lipopolysaccharide in Sprague-Dawley male rats. To identify the respiration and swallowing responses, electromyographic activity was recorded from the diaphragm, digastric (Dig), and thyrohyoid (TH) muscles. We confirmed COPD using micro-computed tomography analysis and hematoxylin and eosin staining of the lungs. The duty cycle was defined as the ratio of the inspiration duration to the total respiratory duration. In COPD model rats, the duty cycle was significantly higher than that in control rats. The frequency of the swallowing reflex evoked by electrical stimulation of the superior laryngeal nerve during the inspiration phase was higher in COPD model rats than in control rats. Furthermore, long-term COPD altered Dig and TH muscle activity without pathological muscle change. Our results suggest that COPD increases the frequency of swallowing initiation during the inspiration phase. Furthermore, long-term COPD affects swallowing-related muscle activity without pathological muscle changes. These physiological changes may increase the risk of developing dysphagia. Further studies are necessary to clarify the mechanisms contributing to the functional changes in respiration and swallowing in COPD. [ABSTRACT FROM AUTHOR]

Recurrent laryngeal nerve (RLN) injury during neck surgery can cause significant morbidity related to vocal cord (VC) dysfunction. VC electromyography (EMG) is used to aid in the identification of the RLN and can reduce the probability of inadvertent surgical injury. Errors in the placement of specialized EMG endotracheal tubes (ETT) can result in unreliable signals, false-negative responses, or no response when stimulating the RLN. We describe a novel educational protocol developed to optimize uniformity in the placement of ETTs to improve the reliability of RLN monitoring. An intraoperative neuromonitoring database was queried for all neck surgeries requiring RLN monitoring. Data points extracted for all cases requiring EMG monitoring for neck procedures. Free running and stimulated EMG were monitored and continuously recorded by a certified technologist. Alerts were compared between 2013–14 and 2015–18 using a two-sample test of proportions. Significant reductions in alerts were demonstrated after protocol implementation (7.5% pre-implementation to 2.1% post). Alerts were compared between 2013–14 (overall alert rate of 1.8%, pre-implementation period) and 2015–18 (overall alert rate of 2.8%, post-implementation period). Protocolization for placement of EMG-ETT improved accuracy in EMG monitoring. In the follow-up cohort of 1,080 patients, use of this protocol continued to reduce the rate of alerts related to ETT malposition, confirming the sustainability of this intervention through routine education. The risk of nerve injury is reduced when the rate of alerts is minimized. Scheduled or continuous protocol education of anesthesia personnel should continue to ensure compliance with protocol. [ABSTRACT FROM AUTHOR]

Introduction: Thyroid nodules are extremely common being detected by ultrasonography in up to 67% of the population, with current surgical tenet maintaining that lobectomy is required for large symptomatic benign nodules or autonomously functionally nodules resulting in a risk of hypothyroidism or recurrent laryngeal nerve injury even in high volume centres. The introduction of radiofrequency ablation (RFA) has allowed thermal ablation of both benign and autonomously functioning thyroid nodules with minimal morbidity. The moving shot technique is the most well-established technique in performing RFA of thyroid nodules, and has proven to be safe, efficacious, accurate and successful amongst experienced clinicians. The purpose of this article to propose the use of a novel guide when performing RFA of thyroid nodules in clinical practice utilizing the moving shot technique. Methods: The technique proposed of RFA involves the use of a 10MHz linear ultrasound probe attached to an 18G guide which provides robust in line visualisation of a 7cm or 10cm radiofrequency probe tip (STARmed, Seoul, Korea) utilizing the trans isthmic moving shot technique. A geometric analysis of the guide has been illustrated diagrammatically. Results: The use of an 18G radiofrequency probe guide (CIVCO Infiniti Plus™ Needle Guide) maintains in line visualisation of the radiofrequency probe over a cross-sectional area up to 28cm2, facilitating efficient and complete ablation of conceptual subunits during RFA of thyroid nodules. Discussion: Radiofrequency ablation of thyroid nodules can be performed safely and effectively using the novel radiofrequency probe guide proposed which we believe potentially improves both accuracy and overall efficiency, along with operator confidence in maintaining visualisation of the probe tip, and hence we believe provides a valuable addition to the armamentarium of clinicians wishing to embark on performing RFA of thyroid nodules. [ABSTRACT FROM AUTHOR]

As a variant of recurrent inferior laryngeal nerve (RILN), the nonrecurrent inferior laryngeal nerve (NRILN) is closely related to the occurrence of abnormal subclavian artery (ASA). The nonrecurrent inferior laryngeal nerve has been found in patients without arterial abnormalities, which is seen in the coexistence of NRILN and RILN, but it is easily confused with sympathetic-inferior laryngeal anastomosis branch (SILAB). We encountered 2 right NRILN patients without ASA during thyroid surgery. This article summarizes the characteristics of these cases and proposes methods to distinguish the coexistence of NRILN and RILN from SILAB. So far, 11 articles have reported 16 cases of NRILN without arterial abnormalities. In patients without artery abnormality, the vagus nerve could send out a descending branch NRILN at the bifurcation of the carotid artery and enter the larynx after anastomosis with RILN. Adequate dissection of the carotid sheath may avoid confusion with SILAB, and neural monitoring is also expected to provide a reference for the identification. [ABSTRACT FROM AUTHOR]

Non-recurrent laryngeal nerve (NRLN) is an anatomic variation seen in about 0.52–0.7% patients, generally on right side. It exits the vagus nerve having a direct route to the larynx, unlike usual recurrent laryngeal nerve, supplying intrinsic laryngeal muscles except cricothyroid. It is sited over left side on extremely rare occasions, that is, 0.04% of the cases. Some cases of NRLN co-exists with aberrant right subclavian artery which courses behind the esophagus, also known as 'arteria lusoria'. Here we present a case of 60-years old patient, diagnosed as goiter presented to us in june 2023 at the department of head and neck surgery at a tertiary care setup of Karachi Pakistan. Intra-operatively, non-recurrent nerve was encountered, whose association was found with arteria lusoria, observed in pre-operative CT-scan. The nerve was saved and no post-operative complications were seen in patient. The association of arteria lusoria in this case emphasize its importance in predicting NRLN via pre-operative imaging techniques which can prevent its injury intra-operatively. [ABSTRACT FROM AUTHOR]

Background: Different approach ultrasound-guided superior laryngeal nerve block was used to aid awake intubation, but little is known which approach was superior. We aimed to compare the parasagittal and transverse approaches for ultrasound-guided superior laryngeal nerve block in adult patients undergoing awake intubation. Methods: Fifty patients with awake orotracheal intubation were randomized to receive either a parasagittal or transverse ultrasound-guided superior laryngeal nerve block. The primary outcome was patient's quality of airway anesthesia grade during insertion of the tube into the trachea. The patients' tube tolerance score after intubation, total procedure time, mean arterial pressure, heart rate, Ramsay sedation score at each time point, incidence of sore throat both 1 h and 24 h after extubation, and hoarseness before intubation, 1 h and 24 h after extubation were documented. Results: Patients' quality of airway anesthesia was significantly better in the parasagittal group than in the transverse group (median grade[IQR], 0 [0–1] vs. 1 [0–1], P = 0.036). Patients in the parasagittal approach group had better tube tolerance scores (median score [IQR],1[1–1] vs. 1 [1–1.5], P = 0.042) and shorter total procedure time (median time [IQR], 113 s [98.5–125.5] vs. 188 s [149.5–260], P < 0.001) than those in the transverse approach group. The incidence of sore throat 24 h after extubation was lower in the parasagittal group (8% vs. 36%, P = 0.041). Hoarseness occurred in more than half of the patients in parasagittal group before intubation (72% vs. 40%, P = 0.023). Conclusions: Compared to the transverse approach, the ultrasound-guided parasagittal approach showed improved efficacy in terms of the quality of airway topical anesthesia and shorter total procedure time for superior laryngeal nerve block. Trial registration: This prospective, randomized controlled trial was approved by the Ethics Committee of Nanjing First Hospital (KY20220425-014) and registered in the Chinese Clinical Trial Registry (19/6/2022, ChiCTR2200061287) prior to patient enrollment. Written informed consent was obtained from all participants in this trial. [ABSTRACT FROM AUTHOR]

Background: To review the changes and survey on status quo of the surgical treatment for esophageal cancer in China. The differences in diagnosis and treatment for esophageal cancer among hospitals in different regions across China were also investigated. Methods: We sent questionnaires to 46 hospitals across China, investigating the volume of esophageal cancer surgeries, surgical procedures, and perioperative management under the guidance of esophageal surgery chiefs. Results: A total of 46 questionnaires were sent out and collected. The survey results showed that in the past 5 years, the volume of surgeries for esophageal cancer remained stable by 23.9% of those hospitals, increased by 30.4%, and decreased by 45.7%. Of those patients treated by surgery, 19.1% were in the early stages, and 80.9% were in locally advanced stages. In terms of surgical procedures, 73.4% of the patients were treated by minimally invasive surgery and 85.7% of esophageal substitutes were a gastric conduit, 93.1% of the substitutes were pulled to the neck through the esophageal bed. For the lymph node dissection, 78.5% of the patients had a complete two‐field lymph node dissection including the para‐recurrent laryngeal nerve lymph nodes. Of the patients with neoadjuvant therapy, 53.5% received chemotherapy or chemotherapy plus immunotherapy (47.0%), and 43.5% had chemoradiation. Conclusions: Currently, in China, minimally invasive surgery‐oriented multimodality treatment, including complete two‐field lymph node dissection, has become the standard approach for esophageal cancer management. Over the past decade, this standardized approach has significantly improved prognosis compared to previous decades. [ABSTRACT FROM AUTHOR]

Objective: Endotracheal tube (ETT) surface electrodes are used to monitor the vagus nerve (VN), recurrent laryngeal nerve (RLN), and external branch of the superior laryngeal nerve (EBSLN) during thyroid and parathyroid surgery. Alternative nerve monitoring methods are desirable when intubation under general anesthesia is not desirable or possible. In this pilot study, we compared the performance of standard ETT electrodes to four different noninvasive cutaneous recording electrode types (two adhesive electrodes and two needle electrodes) in three different orientations. Methods: The VN was stimulated directly during thyroid and parathyroid surgery using a Prass stimulator probe. Electromyographic (EMG) responses for each patient were recorded using an ETT plus one of the following four cutaneous electrode types: large‐foot adhesive, small‐foot adhesive, long‐needle and short‐needle. Each of the four electrode types was placed in three orientations: (1) bilateral, (2) ipsilateral mediolateral, and (3) ipsilateral craniocaudal. Results: Four surgical cases were utilized for data collection with the repetitive measures obtained in each subject. Bilateral electrode orientation was superior to ipsilateral craniocaudal and ipsilateral mediolateral orientations. Regardless of electrodes type, all amplitudes in the bilateral orientation were >100 μV. When placed bilaterally, the small‐foot adhesive and the long‐needle electrodes obtained the highest EMG amplitudes as a percentage of ETT amplitudes. Conclusion: Cutaneous electrodes could potentially be used to monitor the VN during thyroid and parathyroid procedures. Different electrode types vary in their ability to record amplitudes and latencies. Bilateral orientation improves EMG responses in all electrode types. Additional validation of cutaneous electrodes as an alternative noninvasive method to monitor the VN is needed. [ABSTRACT FROM AUTHOR]

Laryngeal electromyography (LEMG) is a technique used to characterize neuropathic injuries to the recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN). The RLN and SLN innervate the laryngeal muscles to produce vocal fold (VF) motion and elongation, respectively. VF motion deficiencies can affect voice, swallowing, and breathing, which can greatly affect a patient's quality of life. Neuropathy‐related VF motion deficiencies most often result from surgical interventions to the skull base, neck, or chest likely due to the circuitous route of the RLN. LEMG is ideally conducted by an electromyographer and an otolaryngologist using a team‐approach. LEMG is a powerful diagnostic tool to better characterize the extent of neuropathic injury and thus clarify the prognosis for VF motion recovery. This updated review discusses current techniques to improve the positive and negative predictive values of LEMG using laryngeal synkinesis and quantitative LEMG. Synkinesis can be diagnosed by comparing motor unit potential amplitude during vocalization and sniff maneuvers when recording within adductor muscles. Quantitative turns analysis can measure motor unit recruitment to avoid subjective descriptions of reduced depolarization during vocalization, and normal values are >400 turns/s. By integrating qualitative, quantitative, and synkinetic data, a robust prognosis can help clinicians determine if VF weakness will recover. Based on LEMG interpretation, patient‐centered treatment can be developed to include watchful waiting, temporary VF augmentation, or definitive medialization procedures and laryngeal reinnervation. [ABSTRACT FROM AUTHOR]

We investigated the use patterns and indications of intraoperative neural monitoring (IONM) among endocrine surgeons in Spain. We sent an anonymous web-based survey to endocrine surgeons' members of the Spanish Association of Surgery by email. We analysed 79/ 269 surveys. Respondents had a median age of 52 years and 13 years of surgical experience. Only 32% of respondents performed routinely preoperative laryngoscopy in all thyroidectomies and 19% in all parathyroidectomies. Seventy-five percent of respondents used the intermittent-IONM, and 9.7% used the continuous-IONM. All respondents identified recurrent laryngeal nerve during surgery, and 40% of surgeons routinely identified external branch superior laryngeal nerve (EBSLN) during thyroidectomy. Seventy-eight percent of respondents used IONM always for all thyroidectomies. Only 11% stimulated EBSLN in all cases. Forty-nine percent used IONM always for all parathyroidectomies. The most frequent reasons for not using IONM were the unavailability of IONM, the high cost, and the lack of adding value to their clinical practice. Almost 10% declared not having IONM. The IONM is a reality in Spain, especially the intermittent mode. Its use is superior in thyroid surgery than in parathyroid. Its standardized use is not yet fully established, and routine adherence to standardized guidelines should increase. [ABSTRACT FROM AUTHOR]

Objectives: A risk-adjusted analysis was completed using data from the National Surgical Quality Improvement Program (NSQIP) to compare the rates of recurrent laryngeal nerve injury in thyroid surgery using traditional versus alternative sources of cautery (defined as Harmonic Scalpel© and LigaSure©). Methods: A retrospective cohort study was completed using the NSQIP database on adult patients who underwent total thyroidectomy, subtotal thyroidectomy, or completion thyroidectomy between 2016 and 2018. The primary outcome measure was recurrent laryngeal nerve injury. The exposure variable was use of conventional or alternative sources of cautery. Multivariable linear and logistic regression analyses were performed to control for potentially confounding variables. Results: A total of 13,961 cases were analyzed; 9450 used alternative sources of cautery compared to 4511 where traditional cautery was used. There was no significant difference in rates of postoperative recurrent laryngeal nerve injury between the 2 sources of cautery compared. Conclusions: Risk of recurrent laryngeal nerve injury should not be a factor when choosing method of cautery for thyroid surgery. Therefore, other factors like cost-effectiveness can be considered. [ABSTRACT FROM AUTHOR]

Bioelectronic therapies modulating the vagus nerve are promising for cardiovascular, inflammatory, and mental disorders. Clinical applications are however limited by side-effects such as breathing obstruction and headache caused by non-specific stimulation. To design selective and functional stimulation, we engineered VaStim, a realistic and efficient in-silico model. We developed a protocol to personalize VaStim in-vivo using simple muscle responses, successfully reproducing experimental observations, by combining models with trials conducted on five pigs. Through optimized algorithms, VaStim simulated the complete fiber population in minutes, including often omitted unmyelinated fibers which constitute 80% of the nerve. The model suggested that all Aα-fibers across the nerve affect laryngeal muscle, while heart rate changes were caused by B-efferents in specific fascicles. It predicted that tripolar paradigms could reduce laryngeal activity by 70% compared to typically used protocols. VaStim may serve as a model for developing neuromodulation therapies by maximizing efficacy and specificity, reducing animal experimentation. Advancements in bioelectronic therapies offer new hope for treating various disorders. Here, the authors present an accurate, subject-specific model of vagus nerve stimulation for enhancing efficacy and reducing side effects. [ABSTRACT FROM AUTHOR]

A twenty-one-year-old 420 kg pony underwent general anaesthesia for colic surgery. After recovery, the pony developed severe inspiratory stridor and collapsed. Emergency tracheotomy was performed immediately. Endoscopic examination of upper airways confirmed total bilateral laryngeal paralysis. For three months, the pony was kept alive with a non-permanent tracheostomy. Unilateral (left) laryngeal nerve recovery occurred after three months. The tracheostomy tube was removed and secondary intention healing allowed. Tracheostomy site healed uneventfully. [ABSTRACT FROM AUTHOR]

Malignant peripheral nerve sheath tumors (MPNST) are rare, aggressive soft tissue sarcomas that arise from peripheral nerves and often present a diagnostic and therapeutic challenge. They can occur sporadically or in association with neurofibromatosis type 1 (NF1), a genetic disorder caused by mutations in the NF1 gene. This report presents the unique case of a 33-year-old male with progressive dry cough, hoarseness, and neck swelling who underwent a total thyroidectomy, revealing a high-grade malignant peripheral nerve sheath tumor invading the thyroid. FDG PET/CT led to the additional diagnosis of NF1. This case stands out due to the rarity of finding an MPNST within the thyroid and the simultaneous identification of NF1. It underscores the importance of screening MPNST patients for NF1 and vice versa, spotlighting the expanding role of FDG PET/CT in comprehensive evaluations. To our knowledge, this report presents the first case of NF1-associated MPNST with thyroid involvement worldwide. [ABSTRACT FROM AUTHOR]

The diagnosis of pheochromocytoma or paraganglioma (PGL) during pregnancy is extremely rare, with 2 large case series suggesting that the prevalence is between 0.0002% and 0.007%. Here, we present a case of a 38-year-old woman who presented during pregnancy with clinical features suggestive of preeclampsia and was found to have a norepinephrine-secreting inferior laryngeal nerve PGL, which was diagnosed after pregnancy. She underwent uncomplicated surgical resection and genetic testing revealed a succinate dehydrogenase subunit B (SDHB) pathogenic variant. In conclusion, PGLs diagnosed during pregnancy and hypersecreting head and neck PGLs are both rare clinical entities. Hyperfunctioning PGLs may mimic pregnancy-induced hypertension or preeclampsia. Metanephrine testing should be considered in patients with atypical features and can be reliably assessed using nonpregnant reference ranges. Overall, maternal and fetal mortality has improved considerably with early diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Background: Skip metastases, node metastases in the lateral neck sparing the ipsilateral central neck, challenge the current concept of central-to-lateral lymphatic spread. This study sought to delineate patterns of central and lateral neck involvement in unilateral papillary thyroid cancer (PTC) and medullary thyroid cancer (MTC). Methods: This was a retrospective correlative analysis of nodal patterns in surgical specimens from patients with unilateral PTC or MTC who had undergone thyroidectomy with at least ipsilateral central neck dissection between November 1994 and January 2024 at a tertiary referral center. Results: Included were 833 patients with unilateral PTC and 640 patients with unilateral MTC. Simultaneous presence or absence of node metastases was noted in ipsilateral central and lateral neck compartments in 76.6–78.1% of patients with PTC (both node positive in 27.0–54.7% and both node negative in 23.4–49.6%) and 77.3–80.0% of patients with MTC (both node positive in 26.6–33.2% and both node negative in 44.1–53.4%). Only one ipsilateral neck compartment was node positive in 21.9–23.4% of patients with PTC and 20.0–22.7% of patients with MTC. The ipsilateral central, but not the ipsilateral lateral compartment, was node positive in 8.8–16.9% with PTC and 8.6–8.8% of patients with MTC, whereas the ipsilateral lateral, but not the ipsilateral central compartment, was node positive in 6.5–13.1% with PTC and 11.3–14.1% with MTC. Ipsilateral lateral neck involvement sparing the ipsilateral central neck was 1.5–2 times more frequent in patients with node positive MTC than patients with node positive PTC (24.2–25.2% vs. 12.9–17.1%). Greater numbers of node metastases in the ipsilateral central neck compartment were associated with more frequent involvement of the ipsilateral lateral, contralateral central, and contralateral lateral neck compartments. Thyroid tumor diameter intensified nodal spread without changing nodal spread patterns. Conclusions: These histopathological findings, which need to be interpreted in light of the respective tumor biology, offer an unprecedented glimpse at the metastatic patterns of unilateral PTC and MTC. Customizing neck dissection to the patterns of nodal spread, considering operative status (initial vs. reoperative surgery) and experience with neck dissection, may require more frequent concomitant dissections of ipsilateral central and ipsilateral lateral neck compartments. [ABSTRACT FROM AUTHOR]

Background: Iatrogenic hypoparathyroidism is a common cause of postthyroidectomy hypocalcaemia. It has varying incidence rates after neck surgery in Saudi Arabia, ranging from 0.07% to 65.30%. Hypoparathyroidism can manifest with a spectrum of symptoms, ranging from mild to severe and life‐threatening. This study aimed to assess the rate and predictors of iatrogenic hypoparathyroidism after thyroid surgery and its natural course. Methods: This retrospective cohort study used a data collection form to extract patient information from the electronic healthcare system (Best‐Care) for patients treated from 2017 to 2022. Patients' demographics, surgical specifics and biochemical profiles were recorded for subsequent analysis. Results: Among the 343 patients who underwent thyroidectomy, 130 (37.9%) developed hypoparathyroidism, primarily within the first day after surgery. Calcium or vitamin D supplementation before surgery did not significantly influence hypoparathyroidism development. Notably, extensive combined lymph node dissection was significantly associated with postoperative hypoparathyroidism development (p = 0.0004). More patients who underwent central and lateral lymph node dissection (n = 19, 79.17%) developed hypoparathyroidism than patients who underwent central (n = 18, 40.91%) or lateral (n = 8, 38.10%) dissection alone. Permanent hypoparathyroidism was observed in 40 patients (11.66%). Conclusion: This study revealed a high incidence of iatrogenic hypoparathyroidism and high rates of permanent hypoparathyroidism. Further research is warranted to better comprehend the risk factors and optimise management strategies for iatrogenic hypoparathyroidism. Overall, our findings emphasise the need for vigilant monitoring and effective management of patients undergoing thyroidectomy and the significance of postoperative replacement therapies. [ABSTRACT FROM AUTHOR]

Introduction: This study aims to evaluate the predictive value of color Doppler ultrasound for the diagnosis of aberrant right subclavian artery (ARSA) with a co-occurring non-recurrent right laryngeal nerve (NRLN). Material and methods: In the present study, 58 patients with ARSA (ARSA group) and 1,280 patients without ARSA (controls) were diagnosed by ultrasonography. In addition, 32 patients with ARSA (ARSA operation group) and controls underwent thyroidectomy with surgical exploration with or without NRLN. Then, the incidence of NRLN was analyzed. The right common carotid artery (RCCA) and right subclavian artery (RSA) trends were observed by ultrasound, and classified into two types: RCCA and RSA originating from the innominate artery (IA) (type I), and IA could not be detected (type II). Results: A total of 32 cases of NRLN were found in the ARSA operation group, but no case was found in controls, and the difference was statistically significant (p = 0.0006). The difference in the constituent ratio of type I and type II was statistically significant between the ARSA group and controls (p = 0.0002). That is, the IA could not be detected in the ARSA group, which was accompanied by the RCCA that originated from the aortic arch, while the IA was detected in most patients in the control group at the level of the sternoclavicular joints. Conclusions: Aberrant right subclavian artery can be rapidly detected by ultrasonography. Aberrant right subclavian artery occurs when the RCCA originates from the aortic arch during detection. Patients with ARSA sometimes have co-occurring NRLN. Hence, vigilance in protecting the NRLN is needed during an operation. [ABSTRACT FROM AUTHOR]

Objectives: The objectives were to determine the surgical modality with the lowest aerosol and droplets generated by commonly used modalities in oropharyngeal and laryngeal surgery. Methods: A simulation of oropharyngeal and laryngeal surgery was set up using fresh sheep heads. Four common surgical modalities were utilized: cold steel, electrocautery, coblation, and microdebrider. The resultant aerosol generated was evaluated using two measurement modalities at two key positions in the theater. (1) DustTrak Pro Aerosol Monitor was used to measure the concentration of particles. (2) Fluorescein dye coated on the oropharynx and larynx, and the resultant scatter on paper. Results: Electrocautery and coblation produced statistically significant increases in the concentration of aerosols (p < .001). Microdebrider and cold steel instrumentation produced the least aerosols. No measurable fluorescein droplets were noted for all four modalities. Conclusion: Electrocautery and coblation produced higher concentrations of aerosols. Mitigation factors should be considered with instruments with increased aerosolization. These modalities show low droplet-related infection risk. [ABSTRACT FROM AUTHOR]

Objective The objective of this prospective study was to assess longitudinal variations in health-related quality of life (HR-QOL) in patients diagnosed with differentiated thyroid cancer (DTC) before and after thyroidectomy. Methods A cohort of 185 DTC patients who underwent thyroidectomy between January 2013 and December 2017 and who completed all necessary questionnaires was evaluated. Their HR-QOL was gauged using the University of Washington Quality of Life questionnaire (UW-QOL) and the City of Hope Quality of Life-Thyroid Version questionnaire (QOL-TV) both prior to surgery and at 3 months, 6 months, 1 year, 2 years, 3 years, and 5 years postoperatively. Results Out of 185 patients, 150 (81.1%) were female, with an average age of 48.7 ± 12.9 years. For both UW-QOL and QOL-TV, the total composite QOL scores notably declined from preoperative levels to 3 months postoperatively, then gradually improved over 5 years, ultimately exceeding preoperative scores. Factors such as total thyroidectomy, radioactive iodine (RAI) ablation, and postoperative hypoparathyroidism were associated with lower physical composite QOL scores. Patients who underwent remote-access thyroidectomy expressed significantly higher satisfaction with appearance compared with those who had conventional thyroidectomy. Mood and anxiety were major clinical concerns both before and after surgery, showing considerable improvement postoperatively. Conclusion For DTC patients, HR-QOL experienced a significant drop 3 months postsurgery, subsequently showing gradual improvement, surpassing preoperative QOL by 5 years. Factors contributing to improved physical QOL included the utilization of remote-access thyroidectomy, less extensive thyroidectomy, and the absence of RAI ablation and hypoparathyroidism. [ABSTRACT FROM AUTHOR]

Aspiration pneumonia is the leading cause of death in patients with Parkinson's disease. The incidence of silent aspiration is high in such patients owing to decreased pharyngeal and laryngeal sensation; thus, interventions for this condition may help prevent pneumonia. In this single-arm, open-label study, we used a cervical percutaneous interferential current stimulation device to activate pharyngeal and laryngeal sensory nerves. We evaluated its effectiveness in patients with Hoehn–Yahr stages 2–4 Parkinson's disease. The primary endpoint was the proportion of patients with a normal cough reflex after consuming 1% citric acid at the end of the intervention compared with baseline measurements. In total, 25 patients received neck percutaneous interferential current stimulation for 20 min twice weekly for 8 weeks. Afterward, the proportion of patients with a normal cough reflex after 1% citric acid consumption increased significantly (p = 0.001), whereas other indicators, such as tongue pressure, peak expiratory flow, and penetration or aspiration during videofluoroscopic examination, remained unchanged. A longer duration of illness, higher Unified Parkinson's Disease Rating Scale total scores, and higher levodopa equivalent daily doses were significantly associated with improved cough test outcomes. Hence, cervical percutaneous interferential current stimulation significantly improved cough reflexes and may improve silent aspiration. Trial Registration: Japan Registry of Clinical Trials, jRCTs062220013, first registered 09/05/2022. [ABSTRACT FROM AUTHOR]

Introduction: Chronic refractory cough is defined as cough lasting greater than 8 weeks and with an unclear etiology. Blockade of the internal branch superior laryngeal nerve (iSLN) has been shown to be safe and effective in the treatment of chronic cough. It remains unknown, however, if underlying comorbidities impact patient response to iSLN blockade. Methods: A total of 44 patients aged 18 years and older were seen at our institution's Laryngology clinics between 2019 and 2022 and treated with iSLN blockade. Patient demographics, comorbidities, and pre- and post-treatment cough severity index (CSI) scores were collected from electronic medical records. Two-tailed independent T tests were used to compare CSI scores between groups with and without 4 underlying comorbidities: GERD, pulmonary history, smoking history, and evidence of vocal fold paresis or asymmetry on stroboscopy. Results: Patients with a history of GERD or smoking and those with evidence of glottic insufficiency had similar improvements in CSI compared to those who did not (22.5 ± 26.4 vs 45.0 ± 47.1, P =.36; 32.7 ± 27.8 vs 29.0 ± 38, P =.85; 41.3 ± 18.8 vs 27.2 ± 37.7, P =.195). Patients with underlying pulmonary conditions had a significantly reduced response to iSLN blockade than did patients without underlying disease (9.85 ± 15.0 vs 47.4 ± 38.1, P =.028). Conclusion: Underlying lung pathology may contribute to decreased iSLN blockade efficacy in the treatment of chronic refractory cough from laryngeal hypersensitivity and its treatment is likely necessary for optimal symptom reduction. Characterizing patient comorbidity profiles can help guide patient counseling on expected treatment efficacy. [ABSTRACT FROM AUTHOR]

Background: The advantages of the dissecting the metastatic lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN) remain a great deal of controversies in papillary thyroid carcinoma (PTC) patients without clinical evidence. The purpose of our retrospective research was to investigate the predictive factors of the LN-prRLN in cN0 PTC patients. Methods and Materials: Altogether 251 consecutive cN0 PTC participants accepted unilateral or bilateral thyroidectomy accompanied with LN-prRLN dissection between June 2020 and May 2023 were included in the research. Then, univariate and multivariate logical regression analysis were conducted to analyze the relationship between the LN-prRLN and these predictive factors, and a predictive model was also developed. Surgical complications of LN-prRLN dissection were also presented. Results: The rate of LN-prRLN was 17.9% (45/251) in cN0 PTC patients after the analysis of postoperative histology. The age < 55 years, multifocality, microcalcification, and BRAFV600E mutation were identified to be predictive factors of LN-prRLN in cN0 PTC patients. The risk score for LN-prRLN was calculated: risk score = 1.192 × (if age < 55 years) + 0.808 × (if multifocality) + 1.196 × (if microcalcification in nodule) + 0.918 × (if BRAFV600E mutation in nodule). The rates of the transient hypoparathyroidism and hoarseness were 1.2% (3/251) and 2.0% (5/251), respectively. Conclusion: The age < 55 years, multifocality, microcalcification, and BRAFV600E mutation are independent predictors of the LN-prRLN in cN0 PTC patients. An effective predictive model was established for predicting the LN-prRLN in cN0 PTC patients, with the aim to better guide the surgical treatment of PTC. A thorough inspection of the lateral compartment is recommended in PTC patients with risk factors. The multicenter research with long-term follow-up should be carried out to ascertain the optimal surgical approach for patients with PTC. [ABSTRACT FROM AUTHOR]

Surgical management of a diseased thyroid depends on sonological and pathological evaluation and thereby, planning of the surgery. The definite surgery has two objectives: removal of the diseased gland and preservation of the nerves, namely EBSLN (External Branch of Superior Laryngeal Nerve) and RLN (Recurrent Laryngeal Nerve) and the Parathyroid glands. The objectives of the study were: (1) To identify the course of the RLN and EBSLN of both sides, during Thyroidectomy. (2) To discern various anatomical landmarks, the relations of the two nerves with them and anatomical variations, if any. In this Prospective observational study, fifty selected goitre patients underwent various types of thyroidectomies based on sonological and cytological criteria. The course and anatomical variations of EBSLN and RLN were photo-documented and results were analysed. Most of the EBSLN were found as Cernea type 1 type (25 out of 50), followed by Cernea type 2a (comprising 36%). The least common was type 2b. It was found that 36 out of 50 (72%) of RLN passed posterior to Inferior Thyroid Artery (ITA). Moreover, before piercing cricothyroid joint, the RLN showed bifurcation in 13 out of 50 subjects (26%), 1 participant had trifurcation and the remaining 36 (72%) had a single trunk. The EBSLN shows relation to the horizontal plane passing through the upper pole of the thyroid gland and it is more prone to get damaged when it passes within less than 1 cm to the plane. The RLN has various relations to the distinct anatomical landmarks thereby helping in safe dissection of the nerve. The study also noted the RLN in relation to ITA and branching before entering into the cricothyroid joint. [ABSTRACT FROM AUTHOR]

Controversy exists on how to handle central lymph nodes in papillary thyroid carcinoma, particularly regarding indications for prophylactic central neck dissection (CND). Central node metastases are more difficult to diagnose preoperatively than lateral node metastases. We enrolled 493 patients with papillary thyroid carcinoma treated at our department in the past 22 years. Metastatic lymph nodes were diagnosed preoperatively mainly by ultrasonography. In principle, CND was performed for all cases; ipsilateral CND was performed for hemithyroidectomy, and bilateral CND was performed for total thyroidectomy. Lateral neck dissection (levels II to V; LND) was performed for metastases to lateral neck lymph nodes (clinical node (cN) 1b). The cN stage was cN0 in 365 patients, cN1a in 10, and cN1b in 118. Of the 357 patients with stage cN0 who underwent CND, 42.9 % had pathologically positive nodes (pN+) in level VI, and of the 118 with stage cN1b who underwent CND, 78.0 % had pN+ in level VI. Cases with advanced T stage were significantly more common with pN+ in level VI. Level VI metastases were significantly associated with pN+ in level IV. As the total number of pN+ at each level of the lateral neck increased, the rate of patients with pN+ in level VI increased, and in patients with 3 or more pN+, about 85 % had level VI metastases. Because about half of the patients with cN0 patients had pN+ in level VI, and the rate of pN+ in level VI in each clinical T stage was 46 to 65 %, prophylactic CND should be performed, considering the various clinical benefits. Central nodes will have metastases in about 80 % of cases with lateral node metastases, requiring more accurate dissection. In lateral node metastases, there is a significant association between metastases in levels IV and VI. [ABSTRACT FROM AUTHOR]

Aim of the research: Assessment of intraoperative neuromonitoring in the prevention of damage to the recurrent laryngeal nerve during total thyroidectomy. Material and methods: A group of 367 patients qualified for the study, including 312 (85.01%) women and 55 (14.99%) men, aged 18--79 years, having undergone total thyroidectomy due to a neutral nodular goitre. The patients were operated on by one surgeon. The study group consisted of 205 patients, including 173 (84.39%) women and 32 (15.61%) men, aged 19-79 years, who were operated on with the use of intraoperative neuromonitoring. The control group consisted of 162 patients, including 139 (85.80%) women and 23 (14.20%) men, aged 18-77 years, who had undergone surgery only with macroscopic visualisation of the recurrent laryngeal nerve without the application of intraoperative neuromonitoring. Then, in the period from 2 to 10 years after the surgery, follow-up examinations were performed, which included 153 patients from the control group (74.6% [153/205]) and 122 patients from the study group (75.3% [122/162]). Results: The frequency of vocal fold palsy did not differ statistically significantly in the study group and the control group (study group: 4.9% [10/205], control group: 4.9% [8/162]; p = 0.979). In the follow-up study, the incidence of laryngeal fold palsy did not show statistically significant differences between the study and control groups. Most of the damage to the recurrent laryngeal nerves was persistent. Conclusions: Neuromonitoring did not reduce the number of recurrent laryngeal nerve injuries in relation to the nerve visualisation alone in noncapsular total thyroidectomy for benign nodular goitre, performed by the same experienced surgeon. [ABSTRACT FROM AUTHOR]

Background: Despite all the advances in thyroid surgery, thyroidectomy remains an operation open to complications due to the recurrent laryngeal nerve (RLN) which the thyroid gland is closely surrounded by. This study aims to investigate the anatomical relationship of the RLN with the surrounding structures and define the relationships between these structures. Methods: In this prospective study, the relationship of the RLN with the surrounding anatomical structures, which consist of Berry’s ligament, inferior thyroid artery, tracheoesophageal groove, and the inferior constrictor muscle, and the presence of extralaryngeal branching were evaluated during thyroid surgery performed on 91 patients. Results: A total of 151 thyroid lobectomies were performed, which included 75 right and 76 left lobectomies. One patient presented a nonRLN on the right side, and of the remaining 150 thyroid lobectomy materials, 40 (26.7%) demonstrated a nerve passing anterior to, 93 (62%) passing inside, and 17 (11.3%) passing posterior to the tracheoesophageal groove. Evaluation of the relationship between the nerve and Berry’s ligament revealed that the nerve was located on the lateral side of Berry’s ligament in 114 lobectomies (76%). The nerve passed anterior to the inferior thyroid artery in 29 lobectomies (19.3%), between its branches in 17 (11.3%), and posterior to the artery in 104 (69.4%). The nerve was found to penetrate the crico-pharyngeal part of the inferior pharyngeal constrictor muscle in 8 lobectomies (5.3%), while it entered the larynx immediately under the muscle fibers in 142 (94.7%). The RLN demonstrated branching before entering the larynx in a total of 9 cases (6%). It was determined that the relationship of the nerve and the associated anatomical structures did not cause a significant difference in either side. Conclusion: None of the anatomical parameters investigated in this study demonstrated a constant pathway associated with the anatomical course of the nerve [ABSTRACT FROM AUTHOR]

Objectives: Ultrasound-guided superior laryngeal nerve (SLN) block is a practical and painless approach to avoid the hemodynamic stress response during endotracheal intubation and relieve sore throat after laryngeal surgery. The main purpose of this study was to establish an optimal dosage of local anesthetic when performing SLN block to help anesthetists balance analgesia and side effects. Methods: Twenty fresh larynx specimens were obtained immediately after resection and then injected with 2-, 3-, 4-, or 5- mL of a lidocaine-blue dye mixture at bilateral SLN puncture sites. Superficial areas of deposited blue dye were measured. Dye leakage and surrounding dyed tissue were recorded. Another 40 patients were included in the ultrasound investigation. Distances between the internal branch of the SLN (iSLN) and adjacent structures were calculated. Results: The dye spread area was greater with the administration of larger doses, especially to the visceral space. A 2- or 3-mL injection of local anesthetic was sufficient to infiltrate the SLN gap. A higher incidence of dye leaking out of the thyrohyoid membrane and anterior epiglottis space was observed; furthermore, there was substantially more dyed hyoid/thyroid cartilage with 4 and 5 mL of injected dye mixture than 2 mL. There was no significant difference between the specimen and ultrasound measurements of for length of iSLN-adjacent structures. Conclusions: In the Chinese population, 2- or 3- mL of local anesthetic is a safe dose during SLN block. A larger volume could overflow from the cavity to cause complications. The thyrohyoid membrane combined with the superior laryngeal artery is a reliable target for positioning the iSLN during ultrasound-guided regional anesthesia. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this systematic review and meta-analysis was to systematically review and perform a meta-analysis on the anatomical variations of the RLN. Methods: We performed online research for studies that addressed anatomical variations of the RLN and laterality, published between 2015 and 2021. We found 230 articles, and nine were included. Results: Eight variations were found, with Type I prevailing (41.17%; 95% CI 19.44–64.88), extra laryngeal divergence of the RLN. The other types were: II—fan shape; III—distance greater than 5 mm to the cricothyroid joint; IV—thickening and adipopexy in the elderly; V—non-recurrent laryngeal nerve; VI—intracranial branch; VII—tortuous ascending RLN; and VIII—combination between the inferior branch of the NV and the ascending trunk of the RLN. Types I (p = 0) and III (p < 0.01) prevailed on the left and types II (p < 0.01) and V (p < 0.01) on the right. Conclusions: It was observed that variations occurred due to the path of the RLN to the entrance to the larynx, its shape, and the age of the evaluated individual. The most frequent variation and side were, respectively, Type I, extra laryngeal divergence and left. [ABSTRACT FROM AUTHOR]

Intravenous (systemic) bolus injection of fentanyl (FNT) reportedly induces an immediate vagal-mediated apnea; however, the precise origin of vagal afferents responsible for this apnea remains unknown. We tested whether intralaryngeal (local) application of FNT would also trigger an apnea and whether the apneic response to both local and systemic administration of FNT was laryngeal afferentmediated. Cardiorespiratory responses to FNT were recorded in anesthetized male adult rats with and without bilateral sectioning of the superior laryngeal nerve (SLNx) or peri-SLN capsaicin treatment (SLNcap) to block local C-fiber signal conduction. Opioid mu-receptor (MOR)-immunoreactivity was detected in laryngeal C- and myelinated neurons. We found that local and systemic administration of FNT elicited an immediate apnea. SLNx, rather than SLNcap, abolished the apneic response to local FNT application though MORs were abundantly expressed in both laryngeal C- and myelinated neurons. Importantly, SLNx failed to affect the apneic response to systemic FNT administration. These results lead to the conclusion that laryngeal afferents' MORs are responsible for the apneic response to local, but not systemic, administration of FNT. [ABSTRACT FROM AUTHOR]

The ansa cervicalis (AC) is a neural loop within the carotid triangle of the anterior neck. The loop is traditionally formed by nerve roots C1–C3 of the cervical plexus and extends multiple motor branches. The current case was discovered during a routine dissection as an anatomical variation of the right AC in an 86-year-old Caucasian male cadaver. In this variation, the C1 nerve root did not form the typical loop with the C2 and C3 nerve roots, but instead, remained independent, traveling deep to the superior belly of the omohyoid muscle to supply the sternothyroid muscle. Because no loop was formed, the anatomy of the current case was not an ansa according to the Latin origin of the word, meaning handle or loop. The AC is an important anatomical landmark within the neck and is implicated in laryngeal reinnervation and respiratory nerve stimulation for patients with sleep apnea. The current anatomical variant contributes to a relatively limited catalog of identified anomalies. Knowledge of new AC variations can guide future surgical interventions and further develop the current base of knowledge surrounding the neuromuscular structures of the head and neck. [ABSTRACT FROM AUTHOR]

Thyroid surgery rates have tripled over the past three decades, making it one of the most frequently performed procedures within general surgery. Thyroid surgery is associated with the possibility of serious postoperative complications which have a significant impact on the patient's quality of life. Recurrent laryngeal nerve (RLN) palsy and external branch of the superior laryngeal nerve (EBSLN) palsy are, next to hypoparathyroidism and postoperative bleeding, some of the most common complications. The introduction of neuromonitoring into thyroid surgery, which enabled both the confirmation of anatomical integrity and the assessment of laryngeal nerve function, was a milestone that began a new era in thyroid surgery. The International Neural Monitoring Study Group has produced a standardization of the technique of RLN and EBSLN monitoring during thyroid and parathyroid surgery, which in turn increased the prevalence of neural monitoring during thyroidectomy. The current status of IONM and the benefits of its use have been presented in this publication. [ABSTRACT FROM AUTHOR]

The ansa cervicalis (AC) is a neural loop within the carotid triangle of the anterior neck. The loop is traditionally formed by nerve roots C1–C3 of the cervical plexus and extends multiple motor branches. The current case was discovered during a routine dissection as an anatomical variation of the right AC in an 86-year-old Caucasian male cadaver. In this variation, the C1 nerve root did not form the typical loop with the C2 and C3 nerve roots, but instead, remained independent, traveling deep to the superior belly of the omohyoid muscle to supply the sternothyroid muscle. Because no loop was formed, the anatomy of the current case was not an ansa according to the Latin origin of the word, meaning handle or loop. The AC is an important anatomical landmark within the neck and is implicated in laryngeal reinnervation and respiratory nerve stimulation for patients with sleep apnea. The current anatomical variant contributes to a relatively limited catalog of identified anomalies. Knowledge of new AC variations can guide future surgical interventions and further develop the current base of knowledge surrounding the neuromuscular structures of the head and neck.

We describe a rare occurrence of unilateral vocal fold paralysis associated with a cervical osteophyte abutting the course of the recurrent laryngeal nerve. Trans-nasal laryngoscopy is vital in diagnosing vocal fold paralysis, but often does not provide insight into etiology. This case highlights the importance of radiographic imaging in newly diagnosed vocal fold paralysis, and underscores the principle that a diagnosis is not idiopathic until all sources have been ruled out. [ABSTRACT FROM AUTHOR]

This article discusses a case study involving the use of bilateral internal laryngeal nerve block and lignocaine nebulization to prevent airway spasm in a child after the removal of a tracheobronchial foreign body. The study found that the nerve block and nebulization effectively prevented coughing and spasm in the patient. Traditionally, intravenous steroids and β‑2 agonist sprays have been used for the treatment of airway spasms, but this case study suggests that the nerve block and nebulization may be a viable alternative. The authors obtained informed consent from the parent before publishing the case study. [Extracted from the article]

Background: Robotic assistance in thyroidectomy is a developing field that promises enhanced surgical precision and improved patient outcomes. This study investigates the impact of the da Vinci Surgical System on operative efficiency, learning curve, and postoperative outcomes in thyroid surgery. Methods: We conducted a retrospective cohort study of 104 patients who underwent robotic thyroidectomy between March 2018 and January 2022. We evaluated the learning curve using the Cumulative Sum (CUSUM) analysis and analyzed operative times, complication rates, and postoperative recovery metrics. Results: The cohort had a mean age of 36 years, predominantly female (68.3%). The average body mass index (BMI) was within the normal range. A significant reduction in operative times was observed as the series progressed, with no permanent hypoparathyroidism or recurrent laryngeal nerve injuries reported. The learning curve plateaued after the 37th case. Postoperative recovery was consistent, with no significant difference in hospital stay duration. Complications were minimal, with a noted decrease in transient vocal cord palsy as experience with the robotic system increased. Conclusion: Robotic thyroidectomy using the da Vinci system has demonstrated a significant improvement in operative efficiency without compromising safety. The learning curve is steep but manageable, and once overcome, it leads to improved surgical outcomes and high patient satisfaction. Further research with larger datasets and longer follow-up is necessary to establish the long-term benefits of robotic thyroidectomy. [ABSTRACT FROM AUTHOR]

Background: The hyolaryngeal apparatus generates biosonar pulses in the laryngeally echolocating bats. The cartilage and muscles comprising the hyolarynx of laryngeally echolocating bats are morphologically modified compared to those of non-bat mammals, as represented by the hypertrophied intrinsic laryngeal muscle. Despite its crucial contribution to laryngeal echolocation, how the development of the hyolarynx in bats differs from that of other mammals is poorly documented. The genus Rhinolophus is one of the most sophisticated laryngeal echolocators, with the highest pulse frequency in bats. The present study provides the first detailed description of the three-dimensional anatomy and development of the skeleton, cartilage, muscle, and innervation patterns of the hyolaryngeal apparatus in two species of rhinolophid bats using micro-computed tomography images and serial tissue sections and compares them with those of laboratory mice. Furthermore, we measured the peak frequency of the echolocation pulse in active juvenile and adult individuals to correspond to echolocation pulses with hyolaryngeal morphology at each postnatal stage. Results: We found that the sagittal crests of the cricoid cartilage separated the dorsal cricoarytenoid muscle in horseshoe bats, indicating that this unique morphology may be required to reinforce the repeated closure movement of the glottis during biosonar pulse emission. We also found that the cricothyroid muscle is ventrally hypertrophied throughout ontogeny, and that the cranial laryngeal nerve has a novel branch supplying the hypertrophied region of this muscle. Our bioacoustic analyses revealed that the peak frequency shows negative allometry against skull growth, and that the volumetric growth of all laryngeal cartilages is correlated with the pulse peak frequency. Conclusions: The unique patterns of muscle and innervation revealed in this study appear to have been obtained concomitantly with the acquisition of tracheal chambers in rhinolophids and hipposiderids, improving sound intensity during laryngeal echolocation. In addition, significant protrusion of the sagittal crest of the cricoid cartilage and the separated dorsal cricoarytenoid muscle may contribute to the sophisticated biosonar in this laryngeally echolocating lineage. Furthermore, our bioacoustic data suggested that the mineralization of these cartilages underpins the ontogeny of echolocation pulse generation. The results of the present study provide crucial insights into how the anatomy and development of the hyolaryngeal apparatus shape the acoustic diversity in bats. [ABSTRACT FROM AUTHOR]

Background: Compared to the recurrent laryngeal nerve, the EBSLN (or external laryngeal nerve) is less studied in terms of its course and relationship with the thyroid gland. This is a prospective intraoperative study designed to identify the anatomical variations of the EBSLN in relation to the IPC, the superior thyroid pedicle, and the point where the nerve crosses the STA. Additionally, the study aims to propose a technical procedure for its preservation. Methods: We conducted a prospective study of 50 patients (total of 100 nerves) undergoing total thyroidectomy at the Department of Surgery 'B' in Ibn Sina Hospital, Rabat. Intraoperatively, the EBSLN was visually identified and preserved before ligating the superior thyroid vessels. Each nerve was categorized using established classification systems. Results: The overall pooled EBSLN identification rate was 82%. Cernea type IIa (nerves crossing the STA less than 1 cm above the upper edge of the superior thyroid pole) and Friedman type II (nerves piercing the lower fibers of the IPC) were the most prevalent (64% and 44%, respectively). Kierner type IV (nerves crossing the branches of the STA immediately above the upper pole of the thyroid gland) was represented in 27% of cases. Conclusion: A better understanding of surgical anatomy of the neck allows for better results of thyroidectomy by preserving the external and recurrent laryngeal nerves. [ABSTRACT FROM AUTHOR]

Objective: Superior laryngeal nerve (SLN) block consists of injection of steroid and anesthetic at the internal branch of the SLN entry site. Prior case series have demonstrated beneficial effects on neurogenic cough. SLN blocks have also recently shown benefit for paralaryngeal pain. We describe short-term outcomes for multiple symptoms of irritable larynx syndrome (ILS) including neurogenic cough, dysphonia related to laryngeal hypersensitivity, inducible laryngeal obstruction (ILO), paralaryngeal pain, and isolated globus. Methods: Retrospective review from 2 institutions of patients undergoing a single SLN block for the indications listed. Variables include age, sex, indication(s), known vagus neuropathy, and patient-reported outcomes at short-term follow-up. Results: A total of 209 patients were included (59 males, 150 females; age: 58 ± 13 years). Twenty-six patients (12%) had a history of a vagus nerve injury. Indications included neurogenic cough (n = 149), dysphonia related to laryngeal hypersensitivity (n = 66), paralaryngeal pain (n = 50), ILO (n = 23), and isolated globus (n = 3). Some patients had multiple indications. Significant improvements in patient-reported measures occurred after a single SLN block within 2 to 4 weeks for neurogenic cough (cough severity index; 25.2 ± 11.2 to 19.0 ± 12.8; P <.001), dysphonia (voice handicap index-10; 22.1 ± 12.2-18.0 ± 13.3; P =.005), and ILO (dyspnea index; 21.0 ± 14.9-14.7 ± 15.7; P =.017). Subjective pain improved in 23 of 39 patients with paralaryngeal pain. There was no observed improvement for isolated globus. Presence of known vagal neuropathy or therapy around the time of SLN block did not affect outcome. Conclusion: SLN block can be an effective component of treatment for a variety of ILS symptoms. Patients may experience some improvement after 1 injection. Lay Summary: Symptoms of irritable larynx syndrome, such as neurogenic cough, paralaryngeal pain, inducible laryngeal obstruction, and dysphonia related to laryngeal hypersensitivity can be challenging to manage. In-office Superior Laryngeal Nerve blocks can serve as a quick, well tolerated, adjunctive treatment with positive short-term outcomes. Level of evidence: 4 [ABSTRACT FROM AUTHOR]

Objective Etiology of vocal cord paralysis (VCP) and laryngeal dysfunction may be congenital or surgical trauma of recurrent and superior laryngeal nerves. We assessed the incidence, risk factors, and morbidity of VCP after repair of esophageal atresia (EA). Methods Medical records of 201 EA patients from 2000 to 2022 were reviewed for this retrospective study. Postrepair vocal cord examination (VCE) included awake nasolaryngeal fiberoscopy by otolaryngologist or laryngoscopy under spontaneous breathing anesthesia. Before 2017, postoperative VCE was performed in symptomatic patients only and routinely after 2017. Main Results Overall, VCE was performed on 79 (38%) patients (52 asymptomatic), whereas 122 asymptomatic patients underwent no VCE. VCP was diagnosed in 32 of 79 patients (right 12, left 10, and bilateral 10; symptomatic 25 and asymptomatic unilateral 7) corresponding with extrapolated overall VCP incidence of 16 to 24% among 201 patients including asymptomatic ones. Ten patients (bilateral VCP 8 and left VCP 2) required tracheostomy. Of 10 patients with bilateral VCP, three underwent laryngotracheal expansion surgery (left VC lateralization in one and laryngoplasty in two with acquired subglottic stenosis), three remained tracheostomy dependent, three were off tracheostomy, and one died of complications after redo esophageal reconstruction. All patients with unilateral VCP managed without tracheostomy. Cervical dissection or ostomy formation was a major risk factor of VCP. Conclusion Repair of EA is associated with a considerable risk of VCP and associated morbidity. Cervical EA surgery significantly increased the risk of VCP. Bilateral VCP may eventually require laryngotracheal expansion surgery. [ABSTRACT FROM AUTHOR]