title: The thyrohyoid membrane as a target for ultrasonography-guided block of the internal branch of the superior laryngeal nerve.
abstract: OBJECTIVE
  The objective was to present a proof of concept for a simple and consistently successful ultrasonograpy (US)-guided technique to block the internal branch of the superior laryngeal nerve (iSLN).
  
  
  METHODS
  This was a volunteer and cadaver anatomy study.
  
  
  METHODS
  The setting was an anesthesiology department and an anatomy laboratory at a medical school
  
  
  METHODS
  H13-6 MHz US scans were performed in 40 healthy volunteers positioned supine and with extended necks. The goals were to identify the thyrohyoid membrane, measure its depth (in centimeters) using the shortest vertical distance from the skin, and record the scanning time (in seconds) needed to obtain the optimal image. Anatomical dissection was performed with an operating microscope bilaterally on 5 adult cadaver heads, fixed in formalin, to expose the point of iSLN penetration through the thyrohyoid membrane. The distance between the greater horn of the hyoid bone and the nerve entry point into the thyrohyoid membrane was measured. Ultrasonography-guided in-plane injections were performed unilaterally with 22-gauge 50-mm nerve block needles in 3 fresh cadavers with 2-mL lidocaine/methylene blue mixture deposited under direct vision just superficial to the thyrohyoid membrane to evaluate technical feasibility and injectate spread.
  
  
  RESULTS
  Anatomically, the iSLN was identified in all formalin-preserved cadavers, with hyoid bone greater horn to nerve-membrane interface distances measuring 1.0-2.4 cm (mean, 2.0 cm; SD, 0.5). Sonographically, the iSLN was not visualized, whereas the hyoid bone and the thyrohyoid membrane were visualized in all volunteers. The mean distance from skin to thyrohyoid membrane was 1.69 cm (SD, 0.38). The mean time needed to scan was 15 seconds (SD, 2.3). After US-guided injection, the dye deposition was observed around the iSLN in all cadaver specimens.
  
  
  CONCLUSIONS
  A simpler and consistently reproducible US-guided iSLN block is feasible using the thyrohyoid membrane as target plane for local anesthetic injection. Clinical trials are needed to determine its effectiveness and safety, needle entry point, trajectory, and local anesthetic volume.
authors: Clinical Department of Anesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Zaloška 7, 1000 Ljubljana, Slovenia. Electronic address: tatjanas@gmail.com.
authors: Tatjana
authors: T
authors: Stopar-Pintaric
authors: Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School/Brigham and Women's Hospital, Boston, MA, USA.
authors: Kamen
authors: K
authors: Vlassakov
authors: Department of Anesthesiology and ICU, Rijeka University Hospital, Rijeka, Croatia.
authors: Josip
authors: J
authors: Azman
authors: Institute of Anatomy, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia.
authors: Erika
authors: E
authors: Cvetko
mesh_terms: D000328:Adult; D000368:Aged; D000779:Anesthetics, Local / Q000008:administration & dosage*; D002102:Cadaver; D005260:Female; D006801:Humans; D006928:Hyoid Bone / Q000033:anatomy & histology; D007823:Laryngeal Nerves / Q000033:anatomy & histology*; D008012:Lidocaine / Q000008:administration & dosage*; D008297:Male; D008751:Methylene Blue / Q000008:administration & dosage; D008875:Middle Aged; D009407:Nerve Block / Q000379:methods*; D011446:Prospective Studies; D016683:Supine Position; D018084:Ultrasonography, Interventional / Q000379:methods; D055815:Young Adult
chemical_list: D000779:Anesthetics, Local; D008012:Lidocaine; D008751:Methylene Blue
keywords: Airway management; Difficult airway; Nerve block; Superior laryngeal nerve; Ultrasonography