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Objectives/hypothesis Anatomical variations of the recurrent laryngeal nerve (RLN), such as extralaryngeal branching, are a well-known risk factor for RLN injury during thyroid surgery. This study aimed to analyze the surgical anatomy and to investigate the existence of posterior branch motor fibers of extralaryngeal RLNs. Study design Prospective consecutive observational study. Methods This was a prospective cohort study of 366 patients between January 2014 and February 2016. Operative data included the type of operation, incidence of nerve bifurcation, the distances among anatomical landmarks. The motor fibers were evaluated using neurostimulation with laryngeal palpation. Results A total of 667 RLNs at risk were analyzed in this study, and of these 103 (14.5%) nerves were bifurcated or trifurcated before the laryngeal entry point (LEP). More extralaryngeal branched RLNs were observed on the right side than on the left (17.5% vs. 13.3%, P = .294). The mean distance of the LEP point of division was longer on the left side (16.2 ± 6.7 mm) than on the right (14.7 ± 5.9 mm, P = .132). All branched RLNs had a palpable laryngeal twitch when stimulating anterior branches. When stimulating posterior branches, 28.2%(29/103) of branched RLNs showed palpable laryngeal twitch. Overall incidence of posterior motor branch in total RLNs was 4.3% (29/667). Conclusions The motor fibers of the RLN are all located in the anterior branch, whereas some posterior branches have motor function. Identification of all of the branches of the RLN may be mandatory to decrease the risk of postoperative nerve injury. Level of evidence 4. Laryngoscope, 127:2678-2685, 2017.

Objectives/Hypothesis Office-based biopsy (OBB) is widely used to diagnose suspicious laryngeal lesions. However, its routine use is still controversial and the algorithm for clinical strategy is not concrete. We tried to evaluate the accuracy of OBB as a diagnostic tool for laryngeal malignancy. Methods Medical data of 581 patients undergoing OBB were reviewed. Diagnostic values of OBB were analyzed for malignancy and malignancy/premalignancy. False negative rates (FNRs) were analyzed according to subsites, lesion sizes, and morphology. Results The collection rate of adequate specimens was 99.1%, and there were no complications during OBB. The false omission rates for malignancy of benign lesion; mild, moderate, and severe dysplasia; and carcinoma in situ (CIS) were 5.1%, 11.9%, 14.3%, 50.0%, and 100.0%, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value for malignancy in OBB were 78.2%, 100.0%, 100.0%, and 87.3%, respectively. Those for malignancy/premalignancy in OBB were 88.2%, 86.7%, 85.7%, and 89.1%, respectively. The high FNRs were reported in glottis lesions (27.0%) and small lesions below 1 cm (27.5%). Morphologically fungating lesions showed low FNR (9.1%) compared to nonfungating ones. Conclusion Office-based biopsy could be used as an initial diagnostic tool for laryngeal malignancy for early detection and avoidance of general anesthesia. However, operative re-biopsy should be considered when severe dysplasia or CIS were reported in OBB, or when the lesions are clinically suspicious for malignancy. Level of Evidence 4. Laryngoscope, 2016

Objectives/Hypothesis Recurrent laryngeal nerve (RLN) injury during thyroidectomy or parathyroidectomy is a challenging issue and causes significant morbidity. We adopted the supramaximal stimulation protocol for neurostimulation with laryngeal palpation (NSLP) and tried to evaluate the predictive values of supramaximal NSLP for immediate postoperative vocal fold (VF) mobility. Study Design Prospective cohort study. Methods Prospectively, 293 patients who underwent thyroid and parathyroid surgery and 542 RLNs at risk were enrolled in this study. During NSLP, the current was escalated to 3 mA until definite laryngeal twitch was observed. Immediate postoperative VF mobility was evaluated using flexible laryngoscopy. Results Diagnostic accuracy of NSLP is calculated according to cutoff values of minimal current intensity (1 mA, 1.5 mA, and 2 mA). At 2mA, sensitivity was 81.82%, specificity 100%, positive predictive value 100%, and negative predictive value 99.62%. Conclusions Supramaximal NSLP might be a simple and reliable method to predict immediate postoperative VF mobility in open thyroid and parathyroid surgeries when intraoperative neuromonitoring is unavailable. Level of Evidence 4. Laryngoscope, 2016

Objectives/Hypothesis Vocal fold injection is a minimally invasive technique for various vocal fold pathologies. The shortcomings of the cricothyroid (CT) membrane approach are mainly related to invisibility of the injection needle. If localization of the needle tip can be improved during vocal fold injection with the CT approach, the current problems of the technique can be overcome. We have conceptualized real-time light-guided vocal fold injection that enables simultaneous injection under precise localization. In this study, we developed a device for real-time light-guided vocal fold injection and applied it in excised canine larynx. Study Design Animal model. Methods A single optic fiber was inserted in an unmodified 25-gauge needle. A designated connector for the device was attached to the needle, the optic fiber, and the syringe. A laser diode module was used as the light source. An ex vivo canine larynx model was used to validate the device. Results The location of the needle tip was accurately indicated, and the depth from the mucosa could be estimated according to the brightness and size of the red light. The needle was inserted and could be localized in the canine vocal fold by the light of the device. Precise injection at the intended location was easily performed with no manipulation of the device or the needle. Conclusions Real-time light-guided vocal fold injection might be a feasible and promising technique for treatment of vocal fold pathology. It is expected that this technique can improve the precision of vocal fold injection and expand its indication in laryngology. Level of Evidence NA Laryngoscope, 2015

Objectives/Hypothesis To evaluate the prognostic and predictive value of electroneuronography (ENoG) in acute severe inflammatory facial paralysis, including Bell's palsy and Ramsay Hunt syndrome (RHS). Study Design Prospective observational study. Methods Patients with acute severe facial paralysis of House-Brackmann (H-B) grade IV or worse and diagnosed with Bell's palsy or RHS were enrolled from August 2007 to July 2011. After treatment with oral corticosteroid, antiviral agent, and protective eye care, patients were followed up until recovery or 12 months from onset. Results Sixty-six patients with Bell's palsy and 22 with RHS were included. Multiple logistic regression analysis showed significant effect of ENoG value on recovery in both Bell's palsy and RHS. Values of ENoG were significantly worse in RHS than Bell's palsy. Chance of early recovery within 6 weeks after correction of ENoG effect was still significantly worse in RHS. Logistic regression analysis showed 90% chance of recovery within 6 months, expected with ENoG values of 69.2% degeneration (Bell's palsy) and 59.3% (RHS). The receiver operating characteristics (ROC) curves showed ENoG values of 82.5% (Bell's palsy) and 78.0% (RHS) as a critical cutoff value of nonrecovery until 1 year, with the best sensitivity and specificity. Conclusions A higher chance of recovery was expected with better ENoG in Bell's palsy and RHS. Based on our data, nonrecovery is predicted in patients with ENoG value greater than 82.5% in Bell's palsy, and 78% in RHS. Level of Evidence 4. Laryngoscope, 123:2526–2532, 2013

Anatomical variations of the recurrent laryngeal nerve (RLN), such as extralaryngeal branching, are a well-known risk factor for RLN injury during thyroid surgery. This study aimed to analyze the surgical anatomy and to investigate the existence of posterior branch motor fibers of extralaryngeal RLNs.Prospective consecutive observational study.This was a prospective cohort study of 366 patients between January 2014 and February 2016. Operative data included the type of operation, incidence of nerve bifurcation, the distances among anatomical landmarks. The motor fibers were evaluated using neurostimulation with laryngeal palpation.A total of 667 RLNs at risk were analyzed in this study, and of these 103 (14.5%) nerves were bifurcated or trifurcated before the laryngeal entry point (LEP). More extralaryngeal branched RLNs were observed on the right side than on the left (17.5% vs. 13.3%, P = .294). The mean distance of the LEP point of division was longer on the left side (16.2 ± 6.7 mm) than on the right (14.7 ± 5.9 mm, P = .132). All branched RLNs had a palpable laryngeal twitch when stimulating anterior branches. When stimulating posterior branches, 28.2%(29/103) of branched RLNs showed palpable laryngeal twitch. Overall incidence of posterior motor branch in total RLNs was 4.3% (29/667).The motor fibers of the RLN are all located in the anterior branch, whereas some posterior branches have motor function. Identification of all of the branches of the RLN may be mandatory to decrease the risk of postoperative nerve injury.4. Laryngoscope, 127:2678-2685, 2017.

Recurrent laryngeal nerve (RLN) injury during thyroidectomy or parathyroidectomy is a challenging issue and causes significant morbidity. We adopted the supramaximal stimulation protocol for neurostimulation with laryngeal palpation (NSLP) and tried to evaluate the predictive values of supramaximal NSLP for immediate postoperative vocal fold (VF) mobility.Prospective cohort study.Prospectively, 293 patients who underwent thyroid and parathyroid surgery and 542 RLNs at risk were enrolled in this study. During NSLP, the current was escalated to 3 mA until definite laryngeal twitch was observed. Immediate postoperative VF mobility was evaluated using flexible laryngoscopy.Diagnostic accuracy of NSLP is calculated according to cutoff values of minimal current intensity (1 mA, 1.5 mA, and 2 mA). At 2mA, sensitivity was 81.82%, specificity 100%, positive predictive value 100%, and negative predictive value 99.62%.Supramaximal NSLP might be a simple and reliable method to predict immediate postoperative VF mobility in open thyroid and parathyroid surgeries when intraoperative neuromonitoring is unavailable.4. Laryngoscope, 126:2863-2868, 2016.

Vocal fold injection is a minimally invasive technique for various vocal fold pathologies. The shortcomings of the cricothyroid (CT) membrane approach are mainly related to invisibility of the injection needle. If localization of the needle tip can be improved during vocal fold injection with the CT approach, the current problems of the technique can be overcome. We have conceptualized real-time light-guided vocal fold injection that enables simultaneous injection under precise localization. In this study, we developed a device for real-time light-guided vocal fold injection and applied it in excised canine larynx.Animal model.A single optic fiber was inserted in an unmodified 25-gauge needle. A designated connector for the device was attached to the needle, the optic fiber, and the syringe. A laser diode module was used as the light source. An ex vivo canine larynx model was used to validate the device.The location of the needle tip was accurately indicated, and the depth from the mucosa could be estimated according to the brightness and size of the red light. The needle was inserted and could be localized in the canine vocal fold by the light of the device. Precise injection at the intended location was easily performed with no manipulation of the device or the needle.Real-time light-guided vocal fold injection might be a feasible and promising technique for treatment of vocal fold pathology. It is expected that this technique can improve the precision of vocal fold injection and expand its indication in laryngology.NA.

Objectives: To investigate the long-term outcomes of intraoral submandibular stone removal in children as compared with those in adult patients. Study Design: Retrospective clinical review. Methods: We retrospectively analyzed the medical records of 17 children and 48 adult patients who had undergone intraoral stone removal for submandibular sialolithiasis and followed up for more than 24 months. The mean durations of follow-up were 43.4 months and 49.4 months for children and adults, respectively. The long-term outcomes were compared between the two age groups. Results: Intraoral submandibular stone removal achieved the status of “symptom-free” in 82.4% of child and 83.3% of adult patients. Recurrence in the affected gland was not found in any children but was found in two adult patients (4.2%). In pediatric patients with calculi around the hilum, a higher incidence (50%) of having long-term complaints was noted as compared with cases with calculi in the proximal and distal duct (P = .029). However, this difference was not evident in adult patients. Conclusions: Intraoral removal of submandibular stones is an effective treatment option with an acceptable long-term outcome for children. Nevertheless, in cases with calculi around the hilum, a careful surgical approach is required. Laryngoscope, 119:116–120, 2009