Is intraoperative neural monitoring necessary for exploration of the superior laryngeal nerve? Mehmet Uludag, MD, a Nurcihan Aygun, MD, a Kinyas Kartal, MD, a Evren Besler, MD, a and Adnan Isgor, MD, b Istanbul, Turkey Background. We aimed to evaluate the contribution of intraoperative neuromonitoring to the visual and functional identification of the external branch of the superior laryngeal nerve and the effect on postoperative voice changes. Methods. The prospective data of 221 patients (183 women, 38 men) who underwent thyroid operation with intraoperative neuromonitoring for exploration of the external branch of the superior laryngeal nerve were evaluated retrospectively. The surface endotracheal tube–based Medtronic NIM3 (Medtronic, Jacksonville, FL) intraoperative neuromonitoring device was used. The function of the external branch of the superior laryngeal nerve was evaluated by cricothyroid muscle twitch. Additionally, the contribution of the external branch of the superior laryngeal nerve to vocal cord adduction was evaluated using electromyographic records. Results. A total of 374 (95.2%) of 393 external branch of the superior laryngeal nerves were identified; 145 (36.9%) external branch of the superior laryngeal nerves were identified visually before being stimulated with a probe, and 130 (33.1%) external branch of the superior laryngeal nerves were identified visually after being identified with a probe. Although 99 (25.2%) external branch of the superior laryngeal nerves were identified with a probe, they were not visualized. Intraoperative neuromonitoring provided meaningful contributions to visual (P = .001) and functional (P = .001) identification of the external branch of the superior laryngeal nerve. Positive electromyographic responses were recorded from 257 external branch of the superior laryngeal nerves (68.7%). After the patients with recurrent laryngeal nerve palsy were excluded, voice changes were detected in 6 (3.3%) of 184 patients with identified external branch of the superior laryngeal nerves and 3 (20%) of 15 patients in whom at least 1 external branch of the superior laryngeal nerve could not be identified with intraoperative neuromonitoring. Conclusion. Intraoperative neuromonitoring provided an important contribution to the visual and functional identification of the external branch of the superior laryngeal nerve. Intraoperative neuromonitoring is a helpful adjunct for identifying the external branch of the superior laryngeal nerve. (Surgery 2016;j:j-j.) From the Department of General Surgery, a Sisli Hamidiye Etfal Training and Research Hospital, and the Department of General Surgery, b Bahcesehir University Medical Faculty, Istanbul, Turkey The authors declare that this study has received no financial support. There were no financial or professional associations between the authors and the commercial company that sup- plied the nerve-monitoring product. All authors have agreed to the manuscript’s content. All authors warrant that the submitted article is original and has not been submitted to another journal for publication, has not been pub- lished elsewhere, or if published in whole or in part, all permis- sions were granted for publication in Surgery. Presented at the First World Congress of Neural Monitoring in Thyroid and Parathyroid Surgery, September 17–19, 2015, Krakow, Poland. Accepted for publication October 6, 2016. Reprint requests: Mehmet Uludag, MD, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital Si- sli Hamidiye Etfal E gitim ve Arastirma Hastanesi, Genel Cerrahi Klini gi, Kat: 4, C Blok, Halaskargazi Cad. Etfal Sk., Sisli, Istanbul 34371, Turkey. E-mail: drmuludag@hotmail.com. 0039-6060/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2016.10.026 SURGERY 1 ARTICLE IN PRESS