A 32-year-old professional vocalist undergoes total thyroidectomy for Graves disease. Voice is normal at rest, but three months later she cannot sustain high-pitched notes and her voice tires rapidly with projection. Screening laryngoscopy shows normal vocal cord mobility. Which nerve was most likely injured?

• A External branch of the superior laryngeal nerve ✓
• B Internal branch of the superior laryngeal nerve
• C Recurrent laryngeal nerve
• D Glossopharyngeal nerve

Explanation

The external branch of the superior laryngeal nerve supplies cricothyroid, the muscle that tenses the vocal cords and raises pitch. Its injury leaves cord movement grossly normal on laryngoscopy, so routine screening misses it; patients complain of loss of high register and early voice fatigue, which is devastating for singers. The internal branch is purely sensory to the supraglottic larynx, while recurrent laryngeal nerve injury causes visible cord palsy and hoarseness.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

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Written and medically reviewed by the StethoPrep medical team.