Superior Laryngeal Nerve Signal Attenuation Influences Voice Outcomes in Thyroid Surgery

Ayaka J. Iwata, Whitney Liddy, Marcin Barczyński, Che Wei Wu, Tzu Yen Huang, Sam Van Slycke, Rick Schneider, Gianlorenzo Dionigi, Henning Dralle, Claudio R. Cernea, Dipti Kamani, Amr H. Ahmed, Okenwa C. Okose, Bo Wang, Gregory W. Randolph*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

14 Scopus citations


Objectives/Hypothesis: The objective was to identify whether injury of the external branch of the superior laryngeal nerve (EBSLN) or changes in EBSLN parameters after dissection during thyroidectomies correlate with changes in voice quality postoperatively. Study Design: Prospective multicenter case series. Methods: A prospective multicenter study was conducted on patients undergoing thyroidectomies with intraoperative nerve monitoring. Electromyography waveforms of EBSLN stimulation before (S1) and after superior pole dissection (S2) were evaluated using endotracheal tube (ETT) and cricothyroid intramuscular (CTM) electrodes. Voice outcomes were assessed using Voice-Related Quality of Life Surveys and Voice Handicap Index. Results: A total of 131 at-risk EBSLNs were evaluated in 80 patients. Two nerves showed loss of CTM twitch coupled with an absent S2 signal response. Complete EBSLN loss of signal was more likely with: 1) Cernea EBSLN anatomic classification Type 2B; 2) with a longer distance from the sternothyroid muscle insertion site; and 3) with larger lobar volumes (P <.05). Patients who experienced a more than 50% decrement in CTM amplitudes of S2 (n = 7) by CTM electrodes had a statistically significant decline in their voice outcomes compared to those who did not (n = 69) (P <.05). Conclusions: Patients experienced worse voice outcomes when at least one EBSLN response amplitude decreased by more than 50% after dissection when measured by CTM needle electrodes. CTM needle electrodes have an ability to measure finer amplitude changes compared to ETT electrodes, may represent a safe method to deduce subtle EBSLN injuries, and may serve to optimize voice outcomes during thyroidectomy. CTM needle electrodes are safe and tolerated well. Level of Evidence: 4 Laryngoscope, 131:1436–1442, 2021.

Original languageEnglish (US)
Pages (from-to)1436-1442
Number of pages7
Issue number6
StatePublished - Jun 2021


  • External branch of superior laryngeal nerve
  • cricothyroid muscle twitch
  • neural monitoring
  • thyroid surgery
  • voice outcomes

ASJC Scopus subject areas

  • Otorhinolaryngology


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