ArticleFrontiers in surgery2026
Intraoperative neuromonitoring for preservation of the external branch of the superior laryngeal nerve in transoral endoscopic thyroidectomy: initial experience from Vietnam.
Article in Frontiers in surgery, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Objectives: To evaluate the feasibility of intraoperative neuromonitoring (IONM) in identifying the external branch of the superior laryngeal nerve (EBSLN), classifying its anatomical variations, and to evaluate short-term vocal function in patients undergoing transoral endoscopic thyroidectomy vestibular approach (TOETVA). Methods: A prospective descriptive study was conducted on 30 patients with thyroid nodules who underwent TOETVA with IONM using the NIM 3.0 system (Medtronic) at Hanoi Medical University Hospital from September 2021 to September 2024. EBSLNs were identified using a standardized intermittent stimulation protocol (1 mA) during superior pole dissection and classified according to the Cernea system. Voice outcomes were assessed using the Voice Handicap Index-10 (VHI-10) and laryngoscopy preoperatively and at 3 months post-surgery. Results: A total of 31 EBSLNs were assessed (1 total thyroidectomy). IONM facilitated a 100% identification rate. The anatomical distribution according to Cernea classification was: Type 1: 11/31 (35.5%, 95% CI: 19.2-54.6%), Type 2a: 18/31 (58.1%, 95% CI: 39.1-75.5%), and Type 2b (high-risk variant): 2/31 (6.5%, 95% CI: 0.8-21.4%). No loss of EBSLN signal was recorded before the end of surgery. Mean VHI-10 scores showed no clinically significant change from baseline (2.1 ± 1.5) to 3 months postoperatively (3.4 ± 2.2; mean difference 1.3, 95% CI: -0.2 to 2.8, Conclusions: IONM-assisted EBSLN mapping during TOETVA is technically feasible and allows consistent intraoperative identification. In this preliminary series, no clinically apparent deterioration in voice function was observed. However, given the descriptive design and limited functional assessment tools, comparative studies incorporating objective acoustic measures are required to determine the incremental benefit of routine IONM use for EBSLN preservation.
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