An Improved and Simplified Approach to Identify the Facial Nerve During Parotid Surgery.

Precise identification and preservation of the facial nerve is mandatory to avoid dysfunction of the facial nerve during parotidectomy. In this article, the authors are introducing a new landmark to identify the facial nerve for parotidectomy that is more protective for the facial nerve. The authors use a simple approach to predict the position of facial nerve main trunk intraoperatively without geometric calculations and a lot of landmarks. An imaginary almost 2 cm line is drawn between mastoid tip inferiorly and bony-cartilaginous junction of the external auditory canal superiorly. The main trunk of the facial nerve can be visualized at the midpoint of this line. The authors have been using this landmark successfully for the last 10 years, without any functional deficit of the parotid nerve. Identifying the facial nerve at the trunk level by this landmark renders following the branches forward in the glandular parenchyma less complicated.

The outcome of cochlear implantation among children with genetic syndromes.

OBJECTIVE: To assess the outcome and efficacy of cochlear implantation in children with genetic syndromes. METHOD: Study design: case-control study. SETTING: A cochlear implantation tertiary referral center. PATIENTS: All pediatric cochlear implantation recipients with Waardenburg syndrome, Usher syndrome, Dandy-Walker syndrome, or albinism. A control group was appropriately matched to the syndromic group with regard to age at implantation and duration of device use. INTERVENTION: Cochlear implantation. MAIN OUTCOME MEASURES: Subjects' auditory abilities, speech intelligibility, and pure tone thresholds were compared between the syndromic and non-syndromic group. RESULTS: A total of 25 subjects (13 syndromic and 12 non-syndromic) participated in the study. Neither auditory ability nor speech intelligibility scores differed significantly by group. The final PTA of both the groups showed normal-to-mild hearing loss: 26 dB HL in the syndromic group and 23 dB HL for the control group. CONCLUSIONS: Cochlear implant recipients with genetic syndromes achieved similar levels auditory perception and speech intelligibility as their peers with a genetic syndrome. The presence of any of the genetic syndromes described herein should not be a contraindication to cochlear implant provision, as it would have a positive impact on the patients' sensory perception and lifestyle.

Assessment of satisfaction based on age and gender in functional and aesthetic rhinoplasty.

The aim of this study was to assess patients' satisfaction based on gender and age using the Rhinoplasty Outcomes Evaluation (ROE) post-rhinoplasty from both functional and aesthetic outcomes. The study design was a prospective observational study. A total of 103 patients who underwent Rhinoplasty were prospectively investigated from January 2011 through December 2013 at King Abdulaziz University Hospital in Riyadh, Saudi Arabia. The sample included 61 males (59.2%) and 42 females (40.7%). The overall mean age was (25.2 ± 5.9) years (range 17-48 years). ROE was distributed pre- and post-surgery. The overall difference in satisfaction was significant (p < 0.0001). The mean satisfaction difference of function was increased by 21.5%, raising the satisfaction percentage from 57.1% initially to 78.5% post-surgery (mean -0.215, CI -0.269, -0.161). Satisfaction of shape post-rhinoplasty showed that the mean satisfaction increased by 31.3% (mean -0.313, CI -0.369, -0.256), which changed the satisfaction from a mean of 44.2% before surgery to 75.5% post-rhinoplasty (p = 0.000). There was no significant difference in satisfaction between males and females, nor was there a significant difference in satisfaction among different age groups (p > 0.05). There was a significant overall increase in patients' satisfaction from functional and aesthetic outcomes post-surgery based on ROE. Our study showed that age and gender did not significantly affect satisfaction. The ROE was a useful tool to implement for assessing the quality-of-life post-rhinoplasty.

Treatment of base of tongue cancer, stage III and stage IV with primary surgery: survival and functional outcomes.

This study examines functional outcome (speech and swallowing), survival, and disease control in patients receiving an intensified treatment regimen with primary aggressive surgery, and postoperative radiotherapy or postoperative concomitant chemoradiotherapy, for previously untreated, resectable, stage III and IV squamous cell carcinoma (SCC) of the tongue base. Sixty-six consecutive patients treated from June 1997 to June 2006 were followed prospectively through the Multidisciplinary Head and Neck Surgery Reconstruction Clinic. Speech and swallowing data were gathered at four evaluation times during the first year. Speech assessment was conducted by PERCI, Nasometer, and C-AIDS and swallowing assessment by Modified barium swallow, Diet survey and G-tube. Also, the overall survival, disease-specific survival and loco regional control were measured. The average age of the patients was 56.8, 85 % male and 15 % female. All patients had primary surgical resection and 83 % received postoperative radiotherapy and 17 % chemoradiation therapy. Overall survival at 3 years was 80.3 % and 5 years 52.2 %. Disease-specific survival at 3 years was 86.7 % and 5 years was 77.5 %. Local control was 94 %. Distal metastasis and second primary were found to be 7.5 % each. Primary surgical treatment of advanced BOT cancer offers excellent functional outcome, local control and disease-specific survival.

Potential barriers to the daily use of hearing aids in children.

OBJECTIVES: To identify factors affecting hearing aid usage in children. METHODS: This retrospective study examined 59 hearing-impaired children fitted with hearing aids for at least 6 months. Patients with moderate to profound sensorineural hearing loss with complete data-logging information stored in the hearing aid programming file from January 2020 until June 2021 were included. Children with concomitant disabilities were excluded. Data for audiological assessments included hearing assessment, aided hearing thresholds, and aided speech tests. RESULTS: The children's age ranged from 6 months to 6 years. Average daily hearing aid usage was 5.5 hour (h) after 3 months, 7 h after 6 months; and 8.7± 4.7 h as reported by parents. Patient age was positively correlated with data logging at 3 months (r=0.414, p=0.01) and 6 months (r=0.406, p=0.01). CONCLUSION: We found that children's age, gender, severity of hearing loss, residential location, and parents' educational level had a significant effect on daily hearing aid usage. Whereas, family size and a family history of hearing loss or use of amplification devices had no discernible influence.

Comparing Thyroidectomy Techniques, Surgical Loupe and Neuromonitoring Between ENT and Endocrine Surgeons-an Observational Study.

Thyroid surgery is performed by ENT head and neck (ENT-HNS), endocrine (ES) and general surgeons (GS). Each modality adopts different surgical techniques causing difference in outcome, operative time and postoperative complication. A retrospective chart review of thyroid surgeries performed by two ENT-HNS, three ES of a single tertiary center was conducted. We compared the use of neuromonitoring and surgical loupe and subsequent patient outcomes between surgeries performed by ENT-HNS versus ES, focusing on parathyroid gland identification, operative duration, vocal cord paralysis and length of hospital stay. A total of 167 patients underwent thyroid surgery. Surgical loupes were used in all the surgeries performed by ENT-HNS vs. 85% by the ES. Parathyroid glands were identified in all the surgeries performed by ENT-HNS versus 95% by ES. Neuromonitoring was used in all the surgeries performed by ENT-HNS, and none by the ES. Vocal cord paralysis developed in two patients of ES versus none in the ENT-HNS. Mean operative duration for total thyroidectomy in ENT-HN surgeries, 183.7 min vs. 151 min in the ES. The mean hospital stay of patients was 3.6 ± 1.6 days for ENT-HNS, and 5.45 ± 3 days for ES. Identification of parathyroid gland and recurrent laryngeal nerve by neuromonitoring and surgical loupes may increase operative time but decrease the rate of vocal cord paralysis and increases the chance of parathyroid gland identification.

Long-Term Quality of Life (5-15 Years Post-Thyroidectomy) of Thyroid Carcinoma Patients in Two Tertiary Care Hospitals.

Purpose Early detection of thyroid cancer has reduced mortality and improved survival of patients. Increased detection has raised the incidence of early stage disease. Some physicians underestimate the suffering of these patients due to the concept of "good cancer." The unmet needs of the survivors still need to be addressed. The objective of this paper was to evaluate the long-term quality of life (QOL) of thyroid cancer survivors. Methods A cross-sectional telephone survey of 211 thyroid cancer survivors who underwent thyroidectomy performed between 2006 and 2016 in two academic tertiary care hospitals was conducted using a validated Arabic version of the European Organization for Research and Treatment of Cancer head and neck cancer specific quality of life questionnaire (EROTC QLQ) - H&N43 questionnaire using a scale of 1-4, with 4 being most severe. Results On almost half (48.5%) of patients, thyroidectomy was performed in 2013 or earlier. Patients' perceptions of problems were very low, with a mean score of 1.56 ± 0.7). Worry about the test results (2.37 ± 1.19), future health (2.36 ± 1.22), tingling or numbness in hands or feet (2.32 ± 1.22), pain in the shoulder (2.04 ± 1.18), and dry, itchy skin (2.04 ± 1.18) were the only items that received a mean score of more than 2. No statistically significant differences in patients' problems were observed according to either tumor histopathology or type of thyroidectomy. Conclusion The overall QOL score for the patients was very good. The persistent problems identified need to be addressed in the long-term follow-up. Survivorship care plans need to be developed incorporating proper interventions.

The Evaluation of the Sensitivity and Specificity of a New Endoscopic Diagnostic Sign of Allergic Fungal Rhinosinusitis: Intrapolypoidal White Particles.

PURPOSE: The diagnostic criteria of allergic fungal rhinosinusitis focus on characteristic clinical, radiographic, histopathologic findings and immunologic characteristics of the disease. None of these are useful for a prompt outpatient diagnosis of the condition. No clear endoscopic signs (pathognomonic) of polyps in allergic fungal rhinosinusitis are mentioned in the literature. OBJECTIVE: The objective of this study is to describe and evaluate the sensitivity and specificity of an endoscopic sign the intrapolypoidal white particles for the diagnosis of allergic fungal rhinosinusitis in outpatient setting. METHODOLOGY: In a descriptive, cross-sectional study, 46 chronic rhinosinusitis patients were examined by endoscope in the outpatient clinic. The endoscopic images of the nasal polypi were captured preoperatively. During endoscopic surgery, a sample of nasal polypi was taken for fungal staining and culture. Results of histopathology were compared to the impression of rhinologist on the images of nasal polypi captured preoperatively. RESULTS: The most common endoscopic features were the expansion of sinus (24, 52.2%) and intrapolypoidal white particles (50%). Intrapolypoidal white particles were calculated to have 85.71% sensitivity, 65.63% specificity, 52.17% positive predictive value, 91.3% negative predictive value and 71.74% diagnostic accuracy. CONCLUSION: This study offers a new endoscopic sign, intrapolypoidal white particles for diagnosing allergic fungal rhinosinusitis.

Mapping COVID-19 related research from Saudi Arabia, a scoping review. Between reality and dreams.

OBJECTIVES: To map research production by Saudi-affiliated investigators in order to identify areas of strength and weakness. Method: We followed the Arksey and O'Malley (2005) framework. Medline and Cochrane databases were searched with a focus on identifying articles related to COVID-19 and Saudi Arabia following the PRISMA protocol. The study was conducted at King Saud University, Riyadh, Saudi Arabia between March and May 2020. Results: A total of 53 articles were ultimately included. Most of the research production from Saudi Arabia was opinion and narrative reviews related to the clinicopathological features of COVID-19 as well as control and prevention of virus spread.  Conclusion: The results of this scoping review identify a relative deficiency in original research, which requires further investigation.

A new landmark for the identification of the facial nerve during parotid surgery: A cadaver study.

OBJECTIVE: Precise knowledge of facial nerve anatomy is crucial for parotid surgery. Although several surgical landmarks to identify the facial nerve have been described in literature, their position is variable, inconsistent, and difficult to follow in some cases. The purpose of this study was to prove that the facial nerve trunk (FNT) is located midway between the mastoid tip (MT) and osteocartilaginous junction of the external auditory canal (EAC). METHODS: A prospective study of 7 frozen cadaver specimens, of which 13 facial sides were dissected. The distances between the osteocartilaginous junction and the MT, between the FNT and the MT, and between the FNT and the osteocartilaginous junction were recorded, respectively. RESULTS: The distance between the osteocartilaginous junction and the MT ranged from 17 to 21 mm, with a mean of 19.5 mm (SD = ±1.19). The mean distances between the osteocartilaginous junction and the FNT and between the MT and the FNT were 9.2 mm (±1.58) and 10.3 mm (±1.79), respectively. CONCLUSION: The FNT was consistently located close to the midpoint between mastoid tip inferiorly and bony-cartilaginous junction of the EAC superiorly. LEVEL OF EVIDENCE: NA.

Predictors for Salivary Gland Cancer Recurrence at Two Tertiary Hospitals in Saudi Arabia.

Background Tumors of salivary glands are enlarged as a low-risk mass and mostly benign in nature. The treatment of salivary gland malignancy remains quite challenging because of its relative infrequency, unreliable biological manners, and risk of re-emergence. For effective treatment planning, prediction of factors associated with the recurrence of salivary gland malignancy is essential. Aim The objective of this study was to identify the factors associated with recurrence of salivary gland malignancy at two tertiary hospitals in Saudi Arabia. Material and methods A cross-sectional study was conducted at two tertiary hospitals in Saudi Arabia, where data of patients were recorded from the medical records of hospitals from 2012 to 2018. 63 patients who were diagnosed with salivary gland malignancy, whether originated from parotid, submandibular, sublingual, and minor salivary glands were included in the study. Descriptive statistics are shown in mean, frequency, and percentages, while comparative analysis was done using the Chi-square test, where p < 0.05 is considered significant. Results This study included 63 participants. The majority of malignant salivary gland cancers arise from the parotid gland (47.6%), and mucoepidermoid carcinoma was the commonest form of malignancy in 36.5% of the studied population. Out of 63 patients, 17 had a recurrence of cancer, and the initial advanced stage of the disease is apparently associated with the re-emergence of salivary gland cancer. Conclusion The initial advanced stage of cancer has a significant role in the recurrence of salivary gland malignancy. As salivary gland malignancy is rare and has unreliable behavior, establishing an adequate treatment plan prediction for recurrence is essential.

Comparative study on nutrient contents in the different parts of indigenous and hybrid varieties of pumpkin (Cucurbita maxima Linn.).

Two varieties (indigenous and hybrid) of pumpkin (Cucurbita maxima) are cultivated and widely used as food sources in Bangladesh. The aim of this study is to compare nutrient contents in different parts of two varieties of pumpkin. The nutritional compositions were analyzed by standard methods. Fatty acids and amino acids were analyzed by GC/MS and amino acid analyzer. The proximate compositions analysis data indicate that a higher amount of moisture (p < 0.001) and fat (p < 0.01) were observed in the seed of indigenous but the seed of hybrid were rich in crude fiber (p < 0.01) and carbohydrate (p < 0.001). On the contrary carbohydrate content was predominant in the flesh (p < 0.05) and peel (p < 0.01) of indigenous. The energy content was high in the peel, seed and flesh of indigenous (p < 0.001, 0.001 and 0.05 respectively). A significant amount of reducing sugar was found in the peel, flesh (p < 0.05) and seed (p < 0.001) of hybrid. Vitamin C content was high in peel (p < 0.001) and seed (p < 0.01) of indigenous and only in the flesh (p < 0.001) of the hybrid. A remarkable amount of Na, K, Fe and Zn were present in peel (p < 0.001) of hybrid. The notable amount of P and Cu (p < 0.01) were present in the seed and K, Fe and Ca (p < 0.001) were in the flesh of indigenous. The seed of hybrid was enriched with saturated fatty acid (capric acid, p < 0.001; myristic acid, p < 0.01 and stearic acid, p < 0.05), whereas unsaturated fatty acids (oleic, linoleic and linolenic acid, p < 0.05) were rich in the seed of indigenous. A significant amount of threonine, serine, methionine, isoleucine and tyrosine were present in the seed of indigenous (p < 0.01) but only alanine in the seed of hybrid (p < 0.01). These results suggested that a considerable amount of nutrients were present in all three parts of the two varieties, thus both varieties could be the potential source of nutraceuticals.

Effect of thyroidectomy with totally preserved recurrent laryngeal nerve on the objective vocal functions.

OBJECTIVE: To study the effect of thyroidectomy with totally preserved recurrent laryngeal nerve (RLN) on the objective vocal functions. METHODOLOGY: It is a prospective pilot study of 10 patients undergoing thyroid surgery on whom to study the effect of thyroidectomy with totally preserved RLN on the objective vocal functions. Patient history and demographic data were collected at the time of admission and in each period of assessment average fundamental frequency; absolute jitter, shimmer, and others were measured. Furthermore, one-way analysis of variance (ANOVA) repeated measurements statistical technique was used to test the difference among the 3 time period of measurements and P < 0.05 was considered significant (α = 0.05). RESULTS: The mean age was 39.5 ± 3.31 years. There were two males and eight females. Total thyroidectomy was performed on eight patients while one had left hemithyroidectomy and one completion thyroidectomy. Histopathology revealed papillary thyroid carcinoma in 50%. 34 acoustic voice analysis parameters were measured using the multidimensional voice program, which showed no significant differences at the end of 1st and 3rd month post-operative as compared to the pre-operative measurements. There was no significant difference in measurement for each factor over the time (P > 0.05). CONCLUSIONS: All the acoustic analysis parameters for 10 patients showed no significant differences in 1st and 3rd month postoperatively as compared to the pre-operative values. However, due to small sample size, our study may have failed to detect any significant difference.

Impact of body mass index on survival outcome in patients with differentiated thyroid cancer.

INTRODUCTION: Increased body mass index is known to be associated with the high prevalence of differentiated thyroid cancers; however data on its impact on survival outcome after thyroidectomy and adjuvant therapy is scanty. OBJECTIVE: We aimed to evaluate the impact of body mass index on overall survival and disease free survival rates in patients with differentiated thyroid cancers. METHODS: Between 2000 and 2011, 209 patients with differentiated thyroid cancers (papillary, follicular, hurthle cell) were treated with thyroidectomy followed by adjuvant radioactive iodine-131 therapy and thyroid-stimulating hormone suppression. Based on body mass index, patients were divided into five groups; (a) <18.5kg/m2 (underweight); (b) 18.5-25kg/m2 (normal weight); (c) 26-30kg/m2 (overweight); (d) 31-40kg/m2 (obese) and (e) >40kg/m2 (morbid obese). Various demographic, clinical and treatment characteristics and related toxicity and outcomes (overall survival, and disease free survival) were analyzed and compared. RESULTS: Median follow up period was 5.2years (0.6-10). Mean body mass index was 31.3kg/m2 (17-72); body mass index 31-40kg/m2 was predominant (89 patients, 42.6%) followed by 26-30kg/m2 seen in 58 patients (27.8%). A total of 18 locoregional recurrences (8.6%) and 12 distant metastasis (5.7%) were seen. The 10 year disease free survival and overall survival rates were 83.1% and 58.0% respectively. No significant impact of body mass index on overall survival or disease free survival rates was found (p=0.081). Similarly, multivariate analysis showed that body mass index was not an independent prognostic factor for overall survival and disease free survival. CONCLUSION: Although body mass index can increase the risk of thyroid cancer, it has no impact on treatment outcome; however, further trials are warranted.

Myxoma of the nasal bone.

Myxoma is a benign tumor that arises from mesenchymal tissue, and found in the soft tissue and less commonly in the bone. The majority of bony myxomas of the head and neck occur in the jaws and maxilla. We report an extremely rare case of nasal bone myxoma in a 52-year-old man. The diagnosis was confirmed by biopsy. Due to the aggressive nature of the lesion the nasal bone was eroded by the disease. The patient underwent resection of the mass with reconstruction of the defect by septal cartilage. The patient remains tumor free after 5 years.

Burnout Among Otolaryngology Residents in Saudi Arabia: A Multicenter Study.

OBJECTIVE: Determine the prevalence of, and associated risk factors for, burnout among otolaryngologist residents in Saudi Arabia. DESIGN AND SETTING: A cross-section study of multicenter hospitals in Saudi Arabia conducted in March 2013. PARTICIPANTS: Registered residents in Saudi Otolaryngology Board Program. MAIN OUTCOMES MEASURES: The Maslach Burnout Inventory was used to measure burnout status. Questions supplementary to the Maslach Burnout Inventory were also included to identify associated potential risk factors such as demographic data, resident satisfaction, and work conditions. RESULTS: Of the initial 123 questionnaires that were distributed, 85 yielded responses, a rate of 69%. The mean age (standard deviation [SD]) of respondents was 29 (2.3) years. Of those, 67% (57/85) were men and 66% (55/85) were married. Resident levels were delineated: level 2, 19%; level 3, 33%; level 4, 29%; and level 5, 19%. The mean number of on-call days/month (SD) was 7 (2), clinics/week (SD) was 3 (1), sleep hours/day (SD) was 6 (1), and operations/week (SD) was 2 (1). The mean emotional exhaustion (EE) and depersonalization scores were high at 29.5 (SD = 9.6) and 10.7 (SD = 6), respectively. The mean personal accomplishment was low at 32.33 (SD = 6). The mean of all subscales did not differ by sex (EE p = 0.5; depersonalization p = 0.09; personal accomplishment p = 0.4). Mean EE differed by marital status, which was 31.2, 31.3, and 25.6 for married, divorced, and single, respectively, analysis of variance test p = 0.045. CONCLUSION: Burnout prevalence was found to be high among otolaryngologist residents in Saudi Arabia. The associated variables examined in this study should be addressed to decrease this level of burnout and provide residents with a less stressful work environment.

Ultra percutaneous dilation tracheotomy vs mini open tracheotomy. A comparison of tracheal damage in fresh cadaver specimens.

BACKGROUND: To compare the ultra percutaneous dilation tracheostomy (PDT) and mini open techniques (MOT) in randomized fixed and fresh cadavers. Assess degrees of damage to tracheal cartilage and mucosa via tracheal lumen and external dissection. METHOD: Comparative cadaver study was performed, tracheostomy was placed in 36 cadavers (16 fixed, 20 fresh) from July 2004 to December 2004, in University of Alberta, Canada. PDT (size 7) were placed by intensivist and MOT (size 7) otolaryngologist. Both fixed and fresh cadavers were randomized. Evaluation was done according to gender, ease of landmark, mucosal and cartilage injuries. RESULTS: Significant differences in mucosal injury (7 of 9 in UPDT VS 0 of 7 in MOT, p value 0.008), and cartilage injury (8 of 9 in UPDT VS 1 of 7 in MOT p value 0.012) were seen in fixed cadavers; and in fresh cadavers, mucosal injury (5 of 10 in UPDT VS 0 of 10 in MOT, p value 0.043), and cartilage injury (5 of 10 in UPDT VS 0 of 10 in MOT, p value 0.043). CONCLUSIONS: PDT resulted in severe damage to mucosa and cartilage, that might contribute to subglottic stenosis preventing decannulation. Considering the injury, MOT has better outcome than UPDT.

Intraoperative localization of the marginal mandibular nerve: a landmark study.

BACKGROUND: Identification and preservation of the marginal mandibular nerve (MMN) remains an important step in otolaryngology procedures. Current publications place the MMN at least 1 cm below the mandible. This study will evaluate the accuracy of the method of determining the surgical location of this branch of the facial nerve in vivo. METHODS: MMN were examined in 52 consecutive otolaryngology patients. Using a validated landmarking scheme, distances were measured from the inferior edge of the mandible and the lowest point of the nerve. A comparison of 33 nerves pairs was undertaken. Effect of patient's age was analysed. RESULTS: Eighty five nerves were landmarked. The mean position of the nerve was 0.2-3.4 mm higher than the margin of the mandible. There were no significant difference in position with respect to age and left versus right comparisons. CONCLUSION: The marginal mandibular nerve (MMN) is significantly higher than previously published. The location of the nerve on the right does not correlate with the left. Location of the nerve does not correlate with patient's age.

Impact of neuromonitoring of recurrent laryngeal nerve and surgical loupes on the outcome of thyroidectomy. A retrospective chart review.

OBJECTIVE: To determine whether the post-operative complication rate of thyroidectomy can be reduced using surgical loupes to identify parathyroid gland and recurrent laryngeal nerve (RLN) with simultaneous intraoperative neuromonitoring of RLN. METHODS: This retrospective chart review was conducted from December 2012 to March 2013 at the Ear, Nose, Throat, and Head-Neck Department of King Saud Hospital, Riyadh, Kingdom of Saudi Arabia. The study group included patients who underwent primary thyroid surgeries performed from July 2007 to September 2011, older than 16 years old, without history of vocal cord palsy, hypocalcemia, and sternotomy. Patient outcomes were analyzed with emphasis on complication rates related to the procedure, operative duration, use of drain, and length of hospital stay. RESULTS: Eighty-eight patients underwent thyroid surgeries during our study period. Sixty-one underwent total thyroidectomy. Temporary hypocalcemia accounted for 14 (15.9%), and permanent hypocalcemia accounted for 5 (5.7%) of the patients. None of the patients showed vocal cord paralysis, wound infections, or thyroid crisis post-operatively. The length of hospital stay was 2-7 days. CONCLUSION: Careful neuromonitoring of the RLN nerve using surgical loupes will minimize post-surgical complications, decrease hospital stay, and eventually improve surgery outcomes.