Case report
Use of ultrasound in the evaluation of the vocal folds following thyroidectomy
Utilidad del ultrasonido en la valoración de cuerdas vocales posterior a tiroidectomía
Juan Pablo Aristizabal Linares
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Juanpablo.aristizabal@gmail.com
Correspondence to: Clinica Ces, Calle 58 No 50C-2 Prado Medellin, Antioquia, Colombia.
Correspondence to: Clinica Ces, Calle 58 No 50C-2 Prado Medellin, Antioquia, Colombia.
Anesthesiologist, Clinica Ces, Medellin, Colombia
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"figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1238 "Ancho" => 1650 "Tamanyo" => 235439 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Trachea and tracheal rings.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The use of ultrasound is becoming increasingly important in the daily practice of anesthesia, not only to assist in peripheral nerve blocks, but also in the ICU and ER environments. Some of the major advantages of this diagnostic and therapeutic tool are easy use at the patient's bedside, reproducible images and, above all, real time renderings.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The purpose of this case report – with prior approval by the institution's medical ethics committee – is to describe the benefits of ultrasound in airway evaluation, particularly for real time vocal-fold assessment to determine the integrity of the recurrent laryngeal nerve following thyroidectomy.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A systematic literature review was performed based on Ovid, Pubmed, and Cochrane database search; the terms used in the search included: “laryngeal nerve”, “ultrasonography”, and “thyroid”. The initial search was limited to human articles, meta-analyses, reviews and random articles.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The main search yielded 114 articles from which only the documents describing the thyroid ultrasound approach, studies to assess the vocal-fold paralysis and the evaluation of the recurrent laryngeal nerve were selected.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Case 1</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 47-year-old female patient scheduled for subtotal left thyroidectomy due to multinodular goiter and a history of primary high blood pressure, dyslipidemia and obesity; functional class I/IV. The patient was on metoprolol, amlodipine, furosemide, atorvastatin, and fluoxetine. The physical examination showed a body weight of 85<span class="elsevierStyleHsp" style=""></span>kg and a BMI of 36<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>. The airway evaluation resulted in Mallampati II, TMD less than 6<span class="elsevierStyleHsp" style=""></span>cm, and mouth opening 4<span class="elsevierStyleHsp" style=""></span>cm. A slightly oversized thyroid gland at the expense of the left lobe, no midline deviation, and no difficult airway predictors were observed. The rest of the physical workup did not show relevant findings.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The anesthetic induction was administered with propofol 160<span class="elsevierStyleHsp" style=""></span>mg, 4<span class="elsevierStyleHsp" style=""></span>ng/ml TCI remifentanil, neuromuscular relaxation with succinylcholine 150<span class="elsevierStyleHsp" style=""></span>mg; there were no complications during the orotracheal intubation. Maintenance of anesthesia was with desflurane or remifentanil. During the surgical procedure, the surgeon visualized the recurrent laryngeal nerve. The patient was extubated awake at the end of the procedure with no complications.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Prior to the induction of anesthesia, several structures including the tracheal rings, the carotid artery and the internal jugular artery (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) were identified under ultrasound vision with a lineal transducer (6–13<span class="elsevierStyleHsp" style=""></span>MHz, Sonosite Micromaxx) perpendicular to the trachea; the transducer slides into a cephalic position to identify the thyroid cartilage and the vocal folds. During phonation the vocal folds express bilateral movement (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">At the end of the procedure the patient was awake and an ultrasound evaluation was performed with a lineal transducer visualizing the trachea, the thyroid cartilage and the vocal folds, which are once again assessed for total bilateral mobility during phonation. The patient did not exhibit any clinical nerve injury and was then transferred to post-anesthesia care free of complications.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Case 2</span><p id="par0045" class="elsevierStylePara elsevierViewall">A 49-year-old female patient scheduled for subtotal thyroidectomy due to a thyroid nodule with a history of vertigo and ENT treatment, functional class I/IV. The patient had been receiving diphenhydramine, metoclopramide, and nimodipine. The physical examination indicated a body weight of 58<span class="elsevierStyleHsp" style=""></span>kg and a BMI of 24<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>. The airway examination resulted in Mallampati I, TMD 6<span class="elsevierStyleHsp" style=""></span>cm, and mouth opening 4<span class="elsevierStyleHsp" style=""></span>cm. Symmetric neck and absence of difficult airway predictors were observed on examination. The rest of the examination showed no alterations.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The anesthetic induction was administered using lidocaine 40<span class="elsevierStyleHsp" style=""></span>mg, propofol 120<span class="elsevierStyleHsp" style=""></span>mg, and rocuronium 10<span class="elsevierStyleHsp" style=""></span>mg; there were no complications during the orotracheal intubation. The maintenance of anesthesia was accomplished with 0.2<span class="elsevierStyleHsp" style=""></span>μg/kg/min remifentanil and desflurane. During the surgical procedure, the surgeon visualized the recurrent laryngeal nerve. The patient was extubated awake at the end of the procedure with no complications.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Prior to the induction of anesthesia, several structures including the tracheal rings, the carotid artery and the internal jugular artery (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) were identified under ultrasound vision with a lineal transducer (6–13<span class="elsevierStyleHsp" style=""></span>MHz, Sonosite Micromaxx) perpendicular to the trachea; the transducer slides into a cephalic position to identify the thyroid cartilage and the vocal folds (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). During phonation the vocal folds expressed bilateral movement.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">At the end of the procedure the patient was awake and an ultrasound evaluation was performed with a lineal transducer visualizing the trachea, the thyroid cartilage and the vocal folds, which are once again assessed for total bilateral mobility during phonation (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The patient did not exhibit any clinical nerve injury and was then transferred to post-anesthesia care free of complications.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">For surgeries involving the thyroid gland, general anesthesia is preferable because of amnesia, immobility, and airway control.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In most cases the airway control is achieved using orotracheal intubation; however, since preserving the integrity of the recurrent laryngeal nerve is crucial to these surgical approaches,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> the use of the laryngeal mask has also been described for it provides advantages in terms of intraoperative visualization of vocal fold mobility under direct vision using the fibroscope. Hillermann et al., suggest the use of small diameter orotracheal tubes (5.0<span class="elsevierStyleHsp" style=""></span>mm inner diameter) together with a laryngeal mask to position the fibrobronchoscope. This mechanism allows for adequate airway control concurrent with direct monitoring of the recurrent laryngeal nerve.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The incidence of unilateral and temporary recurrent laryngeal nerve injury following thyroid surgery ranges from 1.4% to 5.1%.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The incidence of permanent lesions ranges from 0.4 to 0.9%. Some risk factors include thyroid carcinoma surgery, re-interventions, Graves’ disease or extensive lymphadenectomies; there have even been some cases of transient paralysis following infiltration of the surgical wound with local anesthesia in thyroidectomies.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Identifying the recurrent laryngeal nerve and documenting its integrity during surgery have been associated with a lower probability of transient postoperative injury.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> If the recurrent laryngeal nerve is injured, the complication usually arises during the immediate postoperative period as airway obstruction attributable to reduced diameter of the glottis, secondary to ipsilateral paralysis of the vocal folds. In the presence of unilateral injury, usually the respiratory involvement is not severe; however, if the lesion is bilateral, there may be total glottis closure and complete respiratory obstruction requiring orotracheal intubation.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Several methods have been described to monitor the recurrent laryngeal nerve and other nerves such as the upper lateral laryngeal nerve branch that controls the vocal folds and the cricothyroid muscles.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> Most techniques require direct stimulation or total visualization. Usually this function is determined by the following: (1) direct visualization under the fibro bronchoscope; (2) palpation of the larynx during stimulation of the recurrent laryngeal nerve; (3) laryngeal muscles electromyography; (4) electromyography with orotracheal tube inserted electrodes. Monitoring of the recurrent laryngeal nerve usually impacts the anesthetic technique used, particularly with regard to the airway management approach (orotracheal tube or laryngeal mask) and whether neuromuscular relaxants are used.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Conventional ultrasound allows for visualization of the airway from the most superior region to the pleura. Special techniques enable a more specific functional airway evaluation and may be applicable to anesthesia. Ultrasound delivers multiple advantages inter alia: it is safe, fast, reproducible, portable and renders of real time images.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Due to the superficial localization of the larynx, the ultrasound lineal transducer provides for an adequate definition of the structures and precise identification. The component parts of the laryngeal skeleton elicit different ultrasound images.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The trachea for instance is characterized by alternating hypo- and hyper-echoic bands representing the cartilaginous rings and the annular ligaments, respectively. The thyroid cartilage and the cricoid in adults exhibit progressive calcification and hence slight changes in the ultrasound images, particularly in males, which make the vocal-fold visualization in men even more difficult. The epiglottis on the other hand remains constantly hypoechoic. Thus, at 60 years of age, everyone shows signs of partial calcification; 40% of the cartilages at the level of the vocal folds are calcified and show a strong echo with posterior acoustic shadow; the thyroid cartilage provides the best window to observe the vocal folds in the form of an isosceles triangle with a central tracheal shadow; the vocal folds are medially aligned by the vocal ligaments that are hyperechoic.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The vocal folds may be seen as lineal hyperechoic images that move during phonation. The thyrohyoid membrane that runs from the posterior margin of the hyoid bone to the cephalic margin of the thyroid provides an acoustic membrane through which the epiglottis may be visualized. However this is usually done with the lineal transducer placed parallel to the trachea with a slight cephalic angulation. Under the parasagittal view, the epiglottis looks like a curved hypoechoic structure and in the transverse view it looks like an inverted “C” anteriorly next to a triangular hyperechoic space, pre-epiglottic space and posteriorly against the mucous-air interphase.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The vocal folds may easily be seen through the thyroid cartilage in people with no thyroid cartilage calcifications<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>; on the other hand, when calcifications are present, the vocal folds and the arytenoid cartilages may still be visualized, but some times the transducer has to be angulated at approximately 30° in the cephalic direction from the cricothyroid membrane. Singh et al., in a trial with 24 volunteers with an average age of 30 years, found that the best window to visualize the vocal folds is through the thyroid cartilage, moving the transducer slightly into a cephalic angle in the cephalocaudal direction.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The true vocal folds are seen as hypoechoic images surrounded by lineal hyperechoic images corresponding to the vocal ligament that moves medially during phonation. Hu and cols in a trial with 229 patients, 2 to 81 years old, found that the vocal folds were visible in 100% of female participants; the visualization was 100% in males under 18 years of age and gradually dropped up to 40% in the 60-year-old patients.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">These results are consistent with that of a trial by Wang et al.,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> between august 2008 and march 2010, including 705 patients of whom 33 had some type of vocal fold paralysis. The purpose of the trial was to evaluate the use of ultrasound for vocal fold mobility. The average age of the participants in the trial was 48 years. The vocal fold movement seen under ultrasound was 87% in total, with 98% discrimination for females and 51% for males. Based on previous studies reported in the literature, ultrasound has the ability to document vocal fold mobility dysfunction in the pediatric population, as well as phonation disorders.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The article concludes that ultrasound is an option for the assessment of vocal fold mobility in over 90% of the female population and approximately 50% of males. Flexible nasolanryngoscopy has been considered the method of choice to establish the paralysis of the vocal folds in the pediatric population; however, it does pose some limitations, particularly in children under 10 yeas of age because they tend to be uncooperative. Although CT scan and MRI are extremely useful, these methods do not allow for real time evaluation of the vocal fold movements, in addition to the risk of radiation and contrast media exposure. Wang et al.,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> in a trial with pediatric patients, analyzed the maximum angle of the glottis (determined by a line between the anterior commissure and the medial margin of the arytenoid with the vocal folds in total abduction) and the maximum arytenoid angle (formed by the medial and anterior margin of the commissure and the medial and lateral margin of the vocal folds) as a quantitative measure to evaluate the extent of vocal fold paralysis. They found that most patients presented with a maximum angle of the glottis of 61.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9°, while patients with paralysis exhibited flaccidity and immobility during phonation and their maximum angle of the glottis dropped to 42.25°. Likewise, the maximum angle of the glottis decreased, as did the maximum angle of the arytenoid, so the authors suggest these ultrasound measurements as valuable parameters in the evaluation of the vocal fold paralysis.</p><p id="par0105" class="elsevierStylePara elsevierViewall">It is then clear that ultrasound has multiple clinical applications, particularly in terms of real time images that can be used dynamically to enhance the evaluation and to develop airway management protocols, not only for the OR, but also for the ER and the ICU.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The purpose of this case report is to underline the use of ultrasound in surgeries involving the thyroid gland and potentially the recurrent laryngeal nerve. The literature supports the use of ultrasound for the evaluation of the vocal folds and through phonation it is possible to assess the integrity of the recurrent laryngeal nerve, before and after surgery. This examination is easy, reproducible and on real time and can be done at the patient's bedside.</p><p id="par0115" class="elsevierStylePara elsevierViewall">This article discusses 2 patients undergoing thyroidectomy for various surgical reasons and in both cases a previous evaluation was done to verify the bilateral and posterior integrity of the vocal folds bilateral mobility, using ultrasound with a lineal transducer, and evaluate the integrity of the recurrent laryngeal nerve.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The use of ultrasound is thus considered an option for the evaluation of the integrity of the recurrent laryngeal nerve following thyroidectomy.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Funding</span><p id="par0125" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres354034" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Objective" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec335373" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres354033" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Objetivo" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec335372" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 1" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 2" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-07-10" "fechaAceptado" => "2014-03-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec335373" "palabras" => array:5 [ 0 => "Ultrasonics" 1 => "Vocal cords" 2 => "Thyroidectomy" 3 => "Recurrente laryngeal nerve" 4 => "Nerve block" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec335372" "palabras" => array:5 [ 0 => "Ultrasonido" 1 => "Cuerdas vocales" 2 => "Tiroidectomia" 3 => "Nervio laríngeo recurrente" 4 => "Bloqueo nervioso" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Recurrent laryngeal nerve injury ranges from 1.4 to 5.1% following surgery involving the thyroid gland. Some associated risk factors include extensive lymphadenectomy, thyroid carcinoma, Graves’ disease and re-intervention. The introduction of ultrasound in daily practice offers advantages such as safe examination, easy reproducibility, and rendering real time imaging, inter alia. This article describes the use of ultrasound in the evaluation of the recurrent laryngeal nerve via the visualization of the vocal folds.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the use of ultrasound in thyroidectomy for evaluation of the recurrent laryngeal nerve via the vocal-fold movement.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The article discusses 2 female patients undergoing thyroidectomy due to different gland pathologies. Before the start of the surgical procedure, vocal fold mobility was evaluated in real time using ultrasound. The recurrent laryngeal nerve was identified during surgery and the integrity of the vocal fold mobility was again assessed during phonation under ultrasound visualization.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ultrasound may be a tool for the evaluation of the recurrent laryngeal nerve in surgical procedures involving the thyroid gland.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La lesión del nervio laríngeo recurrente va desde el 1,4 al 5,1% tras cirugías que comprometen la glándula tiroides. Existen factores de riesgo como cirugías asociadas a linfadenectomía extensas, carcinoma tiroideo, enfermedad de Graves y reintervenciones. La llegada del ultrasonido a la práctica diaria ofrece ventajas como ser un examen seguro, de fácil reproducción y brindar imágenes en tiempo real entre otras. En este trabajo se hace la descripción de su uso para la valoración del nervio laríngeo recurrente mediante la visualización de las cuerdas vocales.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Describir la utilidad del ultrasonido en tiroidectomía para la evaluación del nervio laríngeo recurrente mediante la movilidad de las cuerdas vocales.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se describen los casos de 2 pacientes de sexo femenino sometidas a tiroidectomía por diferentes patologías glandulares. Antes de iniciar el procedimiento quirúrgico se realiza valoración de la movilidad de las cuerdas vocales en tiempo real bajo visión ecográfica. Durante la cirugía se identifica el nervio laríngeo recurrente y al finalizar el procedimiento nuevamente se revisa la integridad de cuerdas vocales mediante movilidad durante la fonación bajo visión ecográfica.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El ultrasonido puede ser una herramienta en la valoración del nervio laríngeo recurrente en cirugías que comprometen la glándula tiroides.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Linares JPA. Utilidad del ultrasonido en la valoración de cuerdas vocales posterior a tiroidectomia. Rev Colomb Anestesiol. 2014;42:238–242.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Author." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1238 "Ancho" => 1650 "Tamanyo" => 235439 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Trachea and tracheal rings.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Author." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1233 "Ancho" => 1650 "Tamanyo" => 271670 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Vocal folds and arytenoid cartilages.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Author." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1230 "Ancho" => 1650 "Tamanyo" => 230333 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The trachea and the carotid artery.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Author." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 18 | 1 | 19 |
| 2024 October | 36 | 6 | 42 |
| 2024 September | 35 | 1 | 36 |
| 2024 August | 21 | 3 | 24 |
| 2024 July | 24 | 0 | 24 |
| 2024 June | 46 | 2 | 48 |
| 2024 May | 44 | 5 | 49 |
| 2024 April | 24 | 8 | 32 |
| 2024 March | 38 | 10 | 48 |
| 2024 February | 73 | 5 | 78 |
| 2024 January | 50 | 8 | 58 |
| 2023 December | 39 | 4 | 43 |
| 2023 November | 44 | 9 | 53 |
| 2023 October | 61 | 10 | 71 |
| 2023 September | 28 | 1 | 29 |
| 2023 August | 45 | 6 | 51 |
| 2023 July | 30 | 3 | 33 |
| 2023 June | 45 | 18 | 63 |
| 2023 May | 76 | 5 | 81 |
| 2023 April | 62 | 3 | 65 |
| 2023 March | 31 | 2 | 33 |
| 2023 February | 29 | 5 | 34 |
| 2023 January | 27 | 10 | 37 |
| 2022 December | 36 | 12 | 48 |
| 2022 November | 31 | 12 | 43 |
| 2022 October | 22 | 8 | 30 |
| 2022 September | 27 | 11 | 38 |
| 2022 August | 23 | 8 | 31 |
| 2022 July | 26 | 9 | 35 |
| 2022 June | 31 | 8 | 39 |
| 2022 May | 22 | 5 | 27 |
| 2022 April | 18 | 7 | 25 |
| 2022 March | 64 | 7 | 71 |
| 2022 February | 37 | 6 | 43 |
| 2022 January | 60 | 9 | 69 |
| 2021 December | 37 | 7 | 44 |
| 2021 November | 26 | 7 | 33 |
| 2021 October | 46 | 7 | 53 |
| 2021 September | 37 | 8 | 45 |
| 2021 August | 23 | 6 | 29 |
| 2021 July | 9 | 3 | 12 |
| 2021 June | 10 | 5 | 15 |
| 2021 May | 13 | 5 | 18 |
| 2021 April | 93 | 26 | 119 |
| 2021 March | 29 | 4 | 33 |
| 2021 February | 13 | 5 | 18 |
| 2021 January | 20 | 8 | 28 |
| 2020 December | 19 | 2 | 21 |
| 2020 November | 19 | 4 | 23 |
| 2020 October | 20 | 1 | 21 |
| 2020 September | 13 | 7 | 20 |
| 2020 August | 24 | 11 | 35 |
| 2020 July | 10 | 6 | 16 |
| 2020 June | 4 | 2 | 6 |
| 2020 May | 12 | 6 | 18 |
| 2020 April | 4 | 2 | 6 |
| 2020 March | 9 | 3 | 12 |
| 2020 February | 9 | 3 | 12 |
| 2020 January | 8 | 2 | 10 |
| 2019 December | 10 | 4 | 14 |
| 2019 November | 5 | 1 | 6 |
| 2019 October | 14 | 3 | 17 |
| 2019 September | 9 | 0 | 9 |
| 2019 August | 2 | 0 | 2 |
| 2019 July | 4 | 9 | 13 |
| 2019 June | 0 | 1 | 1 |
| 2019 May | 2 | 10 | 12 |
| 2019 April | 1 | 0 | 1 |
| 2019 January | 1 | 0 | 1 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 7 | 1 | 8 |
| 2018 May | 45 | 12 | 57 |
| 2018 April | 51 | 8 | 59 |
| 2018 March | 88 | 11 | 99 |
| 2018 February | 38 | 15 | 53 |
| 2018 January | 49 | 11 | 60 |
| 2017 December | 52 | 8 | 60 |
| 2017 November | 42 | 7 | 49 |
| 2017 October | 48 | 12 | 60 |
| 2017 September | 61 | 12 | 73 |
| 2017 August | 79 | 11 | 90 |
| 2017 July | 57 | 9 | 66 |
| 2017 June | 80 | 12 | 92 |
| 2017 May | 88 | 10 | 98 |
| 2017 April | 63 | 19 | 82 |
| 2017 March | 63 | 13 | 76 |
| 2017 February | 46 | 7 | 53 |
| 2017 January | 54 | 12 | 66 |
| 2016 December | 56 | 16 | 72 |
| 2016 November | 109 | 12 | 121 |
| 2016 October | 93 | 10 | 103 |
| 2016 September | 128 | 8 | 136 |
| 2016 August | 105 | 12 | 117 |
| 2016 July | 42 | 14 | 56 |
| 2016 June | 0 | 20 | 20 |
| 2016 May | 3 | 26 | 29 |
| 2016 April | 1 | 28 | 29 |
| 2016 March | 2 | 27 | 29 |
| 2016 February | 1 | 0 | 1 |
| 2016 January | 1 | 19 | 20 |
| 2015 December | 41 | 9 | 50 |
| 2015 November | 88 | 12 | 100 |
| 2015 October | 87 | 20 | 107 |
| 2015 September | 95 | 10 | 105 |
| 2015 August | 76 | 9 | 85 |
| 2015 July | 92 | 16 | 108 |
| 2015 June | 65 | 7 | 72 |
| 2015 May | 72 | 17 | 89 |
| 2015 April | 69 | 9 | 78 |
| 2015 March | 60 | 14 | 74 |
| 2015 February | 65 | 7 | 72 |
| 2015 January | 82 | 14 | 96 |
| 2014 December | 59 | 15 | 74 |
| 2014 November | 57 | 7 | 64 |
| 2014 October | 57 | 15 | 72 |
| 2014 September | 63 | 16 | 79 |
| 2014 August | 38 | 8 | 46 |
| 2014 July | 114 | 17 | 131 |
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