Identification of the External Branch of the

Superior Laryngeal Nerve (EBSLN) in

Large Goiters

Claudia R. Cernea, MD, Sunao Nishio, MD, and FlClvio C. Hojaij, MD

Background: lntraoperative injury to the external branch of the superior laryngeal nerve
(EBSLN) can result in significant postoperative voice problems. This injury can be avoided
by intraoperative nerve identification. The EBSLN has a close anatomic relationship with
the superior thyroid pedicle. According to a previous anatomic classification, the type 2b
nerve, which crosses the vessels below the superior thyroid pole and is considered high
risk, is found in 14% to 20% of persons with normal or slightly enlarged thyroid glands.
Objective: To analyze the frequency of this type 2b nerve in a population with large goiters
and to compare it with the previously mentioned proportions.
Design: Nonrandomized prospective study.
Patients and Methods: During a 15month period, patients with large uninodular or mul-
tinodular goiters were entered in the study. The EBSLN was searched with the help of a
nerve stimulator and the type was annotated. If the patient had to be submitted to a
bilateral thyroidectomy, each superior thyroid pole, with the correspondent nerve, was
considered as a separate unit.
Results: Nine patients, all women, underwent surgery. The average size of the goiters was
10.9 cm x 7.3 cm x 5.0 cm, and the average weight of the specimens was 431 g. There
were four bilateral procedures, totalling 13 nerves analyzed. Seven (54%) were type 2b.
Conclusion: The frequency of the type 2b EBSLN is considerably higher in large goiters.
This finding suggests that it is even more advisable to try to positively identify the nerve
in these situations, in order to prevent its injury, which is permanent and troublesome for
voice professionals.
Copyright 0 1995 by W.B. Saunders Company

The external branch of the superior laryn-
geal nerve (EBSLN), which is a branch of the X
cranial nerve, is the only motor supply to the
cricothyroid muscle (CTM).’ The contraction
of this muscle increases the tension of the ip-
silateral vocal fold during phonation in high
frequencies, particularly in women and in
voice professionals (speakers, singers, and so
on).’
Usually, there is a close anatomic relation-
ship between the EBSLN and the superior thy-
roid pedicle.3-6 Regarding the risk of iatrogen-
ic lesion during a thyroidectomy, from 14%~
to 20%* of these nerves are considered to be
“high risk,” because they cross the superior
thyroid vessels below the upper border of the
thyroid lobe. According to a previously pub-
From the Department of Head and Neck Surgery, Uni-
versity of SBo Paulo Medical School, Sao Paulo, Brazil.
Address reprint requests to Claudio R. Cernea, MD, Al.
Joaquim E. de Lima, 1094, Ap 152, CEP 01403-002, S?IO
Paulo, Brazil.
Copyright 0 1995 by W.B. Saunders Company
0196-0709/95/l 605-0004$5.00/O
lished classification,’ these are type 2b nerves
(Fig 1).
However, most of the thyroid glands ana-
lyzed in these papers were of average size or
just slightly enlarged. We speculated that this
incidence would change in cases in which the
thyroid growth would assume large propor-
tions and, hence, would markedly elevate the
superior thyroid pole. Theoretically, the pro-
portion of type 2b nerves would increase. Ver-
nettig found a more intimate attachment of the
EBSLN to the superior thyroid pedicle in
three cases of large goiters.
The purpose of this prospective nonran-
domized study was to verify the proportion of
high-risk nerves in a consecutive series of pa-
tients with large goiters and to compare these
results with those observed in a previous se-
ries including smaller thyroid enlargements.7
PATIENTS AND METHODS
During a 15-month period, patients with
large goiters were entered in this prospective

American Journal of Otolaryngology, Vol 16, No 5 (September-October), 1995: pp 307-311 307

308 CERNEA, NISHIO, AND HOJAIJ

ebsln

Type 2a Type 2b
Fig 1. Classification of the EBBLN, according to the potential risk of iatrogenic lesion during a hypothetical thyroidectomy. Type
1: the nerve crosses the superior thyroid vessels 1 or mora centimeters above a horizontal plane passing the upper border of the
superior thyroid pole. Type 2a: nerve crossing the vessels less than 1 cm above the plane. Type 2b: nerve crossing the vessels below
the plane. stv, superior thyroid vessels; stp, superior thyroid pole. Data from Cernee et al.*

nonrandomized study. The patients had uni- cal tests, T,, T,, and thyroid simulating hor-
nodular or multinodular goiters, usually ex- mone, chest radiograph, electrocardiogram
ceeding 10 cm in the largest diameter (Fig 2). and, in some cases, fine-needle aspiration bi-
In most cases, the indication of the operation opsy. The patients were submitted to a surgi-
were symptoms and/or signs of respiratory cal procedure using a technique that is de-
compression. scribed in detail elsewhere.7 In brief, a large
After a routine preoperative work-up, collar incision was performed. After section-
which included hematological and biochemi- ing the strap muscles and exposing the larynx,
a careful search for the EBSLN was under-
taken, using a nerve stimulator (Vari-Stim III;
Xomed, Jacksonville, FL). With a positive
identification (when an unequivocal contrac-
tion of the ipsilateral CTM was obtained after
electrically stimulating the nerve), the dissec-
tion of the superior thyroid pole was com-
pleted, always keeping the EBSLN under di-
rect vision. The remaining steps of the
thyroidectomy were performed in a routine
way.7 The surgical specimens were weighed
and measured. Some patients underwent bi-
lateral procedures. In these situations, each
superior thyroid pole, with the corresponding
Fig 2. One of the large goiters of the present study. EBSLN, was considered as a separate unit.
SUPERIOR LARYNGEAL NERVE IN LARGE GOITERS 309

TABLE 1. Clinical Features and Types of EBSLN

Specimen Type
Patient Age Goiter Size (cm) Weight (g) Operation EBSLN

1 43 LL: 11.5 x 8.0 x 6.0 265 LTL 2b

2 52 RL: 11.0 x 8.0 x 5.0 240 RTL 2b
3 38 LL: 10.2 x 5.0 x 3.8 420 LSTL
RL: 9.0 x 5.3 x 3.5 RSTL 2b
4 63 LL: 8.0 x 5.3 x 4.0 324 LSTL 2b
RL: 10.0 x 6.8 x 5.1 RTL Not found
5 68 RL: 13.0 x 7.6 x 5.0 359 RTL 1
6 51 LL: 10.5 x 7.8 x 4.2 242 LTL 2a
7 74 LL: 11.4 x 5.2 x 4.4 670 LTL 2a
RL: 10.2 x 6.8 x 3.7 RTL 2b
a 23 RL: 10.0 x 8.5 x 4.7 285 RTL 1
9 52 LL: 18.0 x 12.0 x 10 1080 LTL 2b
RL: 12.0 x 7.9 x 7.0 RSTL 2b

Abbreviations: LL, left thyroid lobe; RL, right thyroid lobe; LTL, left total lobectomy; RTL, right total lobectomy; LSTL,
left subtotal lobectomy; RSTL, right subtotal lobectomy.

RESULTS lator at the end of the operations and showed

no deficit.
Nine patients, all women, underwent sur-
gery (Table 1). In 4 patients, a bilateral thyroi- DISCUSSION
dectomy was performed: 3 patients had sub-
total thyroidectomies, and 1 had a total The possibility of iatrogenic lesion of the
thyroidectomy. The approaches to both supe- EBSLN during operations involving the supe-
rior thyroid poles were identical in all these rior thyroid pole has been recognized since
patients. The weight of the surgical specimens the beginning of the century. In 1931,
ranged from 240 g to 1,080 g, with an average Roeder” mentioned this risk, based on a per-
of 431 g. The dimensions of the specimens sonal experience of more than 1,600 thyroi-
varied between 8.0 cm x 5.3 cm x 4.0 cm and dectomies. However, very little attention has
18.0 cm X 12.0 cm X 10.0 cm, with an average been directed either to the real frequency of
of 10.9 cm x 7.3 cm x 5.0 cm. Eight patients injury or to its prevention. Moreover, how
had adenomatous goiters and 1 (patient 7) had great would this theoretical risk be if a large
a follicular carcinoma. All patients experi- goiter would have to be operated on? In 1935,
enced an uneventful recovery and were dis- one of the most famous sopranos of that time,
charged from the hospital between the second Amelita Galli-Curci, underwent such an oper-
and the fifth postoperative days. ation under local anesthesia. A 170-g goiter
Thirteen EBSLNs were investigated (Fig was excised. After the surgery, her vocal range
3A). Seven (54%) were type 2b, ie, were con- experienced a marked lowering, in spite of
sidered high risk (Fig 4). Comparing the pre-
vious series with small goiters,7 a marked in-
crease in the number of these type 2b nerves
was noted (Fig 3B). One nerve was not iden-
tified (case no. 4, right side). In patient no. 6,
the nerve, which was type 2a, was located
within the fibers of the inferior constrictor
muscle. In the patients submitted to bilateral
operations, the type of the EBSLN was similar 11% 14%

in both sides in one patient (25%) and differ-

Fig 3. Percentage of high-risk sxtemal branches of the su-
ent in three (75%). All identified nerves had perior laryngeal nervw; (A) large goiters (present series); (B)
their function verified with the nerve stimu- small goiters (previous series’). Data from Cernea et al.’
310 CERNEA, NISHIO, AND HOJAIJ

Fig 4. A type 2b nerve (ar-

row). stp, superior thyroid pole.

normal bilateral vocal cord mobility, and she fore clamping and sectioning any structure in
had to interrupt a brilliant career.” this area; otherwise, a theoretical chance of
In 1992, an anatomic classification of the more than 50% of iatrogenic lesion may be
EBSLN was proposed.8 The type 2b nerve, ie, faced.
crossing the superior thyroid pedicle below Four patients had both EBSLNs dissected
the upper border of the superior thyroid pole, because of bilateral operations. Interestingly
was considered “high risk.” In these situa- enough, only one (25%) showed the same type
tions, even the placement of a tie right on the of nerve on both sides. This feature should
thyroid pole could put the nerve under jeop- alert the surgeon that, during bilateral thyroi-
ardy. The frequency of this hazardous rela- dectomies, very often he or she will find two
tionship varied from 14%’ to 20%,8 but most different types of nerve on each superior pole.
of the thyroid lobes in both studies were only The damage to the EBSLN is usually perma-
slightly enlarged. Vernettig noticed a closer at- nent and may present serious consequences to
tachment between the EBSLN and the supe- a voice professional. Clearly, the only way to
rior thyroid vessels in three cases of huge thy- effectively deal with this complication is to
roid growths. What would have happened in prevent it through a careful identification of
these incidences if a population of large goi- the nerve, especially when operating on very
ters could have been analyzed? enlarged thyroid glands.
In fact, we could show in the present study
a significant increase in the proportion of type REFERENCES
2b nerves among patients with very large thy-
roid glands. The frequency of these nerves in- 1. Regules E: Nervio laringeo superior y motilidad lar-
creased from 14% in the previous study to ingea. Ann Otol Rhino1 Laringol Uruguay 5:139-170,1935
2. Hirano M: Vocal mechanisms in singing: Laryn-
54%. Even if the small number of superior
gological and phoniatric aspects. J Voice 2:51-69, 1988
thyroid poles analyzed in this series pre- 3. Nordland, M: The larynx as related to surgery of the
cludes the application of statistical tests, it thyroid based on an anatomical study. Surg Gynecol Ob-
stet 51:449-459, 1930
seems that the elevation of the pole creates a
4. Clader DN, Luter PW, Daniels BT: A photographic
more intimate contact between the EBSLN study of the superior and inferior laryngeal nerves and the
and the superior thyroid pedicle. Therefore, it superior and inferior laryngeal arteries. Am Surg 23:609-
is even more advisable to try to perform a pos- 618,1957
5. Durham CF, Harrison TS: The surgical anatomy of
itive identification of the nerve when dealing the superior laryngeal nerve. Surg Gynecol Obstet 118:38-
with these large goiters. This search should be 44,1964
done preferably with a nerve stimulator,l’ be- 6. Moosman DA, DeWeese MS: The external laryngeal
SUPERIOR LARYNGEAL NERVE IN LARGE GOITERS 311

nerve as related to thyroidectomy. Surg Gynecol Obstet pedunculo vascolare superiore della tireoide Minerva
129:1011-1016, 1968 Chir 2:427-432, 1947
7. Cernea CR, Ferraz AR, Furlani J et al: Identification 10. Roeder CA: Operations on the superior pole of the
of the external branch of the superior laryngeal nerve dur- thyroid Arch Surg 41:448-459, 1931
ing thyroidectomy. Am J Surg 164:634-639, 1992 11. Kark AR, Kissin MW, Auerbach R, Meikle M: Voice
8. Cernea CR, Ferraz AR, Nishio S. et al: Surgical anat- changes after thyroidectomy: role of the external laryn-
omy of the external branch of the superior laryngeal geal nerve. Br Med J 289:1412-1415, 1984
nerve. Head & Neck 14:380-383, 1992 12. Friedman M, Toriumi DM: Functional identifica-
9. Vernetti L: Studio anatomo-chirurgico sui raporti tion of the external laryngeal nerve during thyroidec-
della banca esterna de1 nervo laringeo superiore con il tomy. Laryngoscope 96:87-90, 1986