International survey on the identification and neural monitoring of the EBSLN during thyroidectomy

Objectives/hypothesis: Surgical management of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy is complex. We hypothesized that there exist variations in surgical behaviors patterns in the management of the EBSLN during thyroidectomy.

Study design: A prospective Web-based anonymous survey (www.surveymonkey.com).

Methods: The survey, consisting of 22 questions including surgeon demographics, laryngeal examination before and after surgery, and utilization of intraoperative neuromonitoring (IONM) for the management of the recurrent laryngeal nerve (RLN) and the EBSLN, was sent to 673 surgeons worldwide with known interest in thyroid surgery.

Results: A total of 170/673 (25.3%) surgeons from five continents with low-volume (11.2%), moderate-volume (27.2%), and high-volume practices (61.5%) completed the survey. Laryngeal preoperative examination was performed by 94% of respondents. IONM was utilized in the RLN management by 95% of respondents. IONM was used for identification of the EBSLN by 26.3% of low-volume versus 68.4% of high-volume surgeons (P = .004), and 93% of respondents felt EBSLN identification with IONM as necessary in voice professionals. Staged thyroidectomy was performed for benign disease by 89.5% of low-volume versus 63.2% of high-volume surgeons (P = .031). Post-thyroid surgery laryngeal examination was performed by 36.8% of low-volume versus 64.9% of high-volume surgeons (P = .032).

Conclusions: Laryngeal examination and IONM is used frequently. However, the exact pattern of utilization varies notably with demographic information. Generally, high-volume surgeons, those with otolaryngology background, and younger surgeons more commonly utilize IONM according to existing international neural monitoring study group guidelines. Prospective multicenter studies are needed to guide an evidence-based management of the EBSLN during thyroidectomy.