The Cernea Classification in Thyroid Surgery

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The Cernea classification:
    • Is used during thyroid surgery to predict the risk of injury to the external branch of the superior laryngeal nerve (EBSLN):
      • Based on its anatomical relation to the superior thyroid artery and the upper pole of the thyroid
    • It includes three types:
      • Type I:
        • The EBSLN crosses more than 1 cm above the upper edge of the thyroid superior pole:
          • The artery-nerve intersection is > 1 cm above the gland
        • Minimal risk during ligation of the superior thyroid vessels
      • Type IIa:
        • The nerve crosses within 1 cm above the superior pole:
          • Distance < 1 cm but above the pole
        • Moderate risk, as it’s close to vascular pedicle
      • Type IIb:
        • The EBSLN crosses below the upper edge of the superior pole:
          • Under the pole
        • Highest risk:
          • Nerve lies within the ligation field
  • Clinical Significance:
    • Intraoperative studies show Type IIa + IIb:
      • Account for ~ 65% of cases:
        • Emphasizing the high chance of encountering the nerve near or below the vascular pedicle
    • Type IIb alone:
      • Occurs in up to 48% of cases in some series 
    • Risk of EBSLN injury rises with more inferior nerve trajectories (IIa / IIb):
      • Injuries lead to altered voice quality:
        • Reduced pitch, vocal fatigue, and weakened projection
  • Surgical Implications:
    • Routine identification:
      • Especially for Type II subtypes:
        • Is key during superior pole dissection
    • Intraoperative neuromonitoring (IONM) helps detect and preserve the EBSLN:
      • Reducing morbidity
    • Transection of overlying muscles (e.g., sternothyroid):
      • Can improve visualization of the nerve
Unknown's avatar

Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

Leave a comment