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Delayed recurrent laryngeal nerve palsy after anterior cervical discectomy and fusion C5-C7: Case report. Neurochirurgie 2021; 68:352-354. [PMID: 34186029 DOI: 10.1016/j.neuchi.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/09/2021] [Accepted: 06/20/2021] [Indexed: 11/22/2022]
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Ryu CH, Lee SJ, Cho JG, Choi IJ, Choi YS, Hong YT, Jung SY, Kim JW, Lee DY, Lee DK, Lee SJ, Lee YC, Lee YS, Nam IC, Park KN, Park YM, Sung ES, Son HY, Seo IH, Lee BJ, Lim JY. Care and Management of Voice Change for Thyroid Surgery: Korean Society of Laryngology, Phoniatrics and Logopedics Clinical Practice Guideline. Clin Exp Otorhinolaryngol 2021; 15:24-48. [PMID: 34098629 PMCID: PMC8901944 DOI: 10.21053/ceo.2021.00633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/31/2021] [Indexed: 11/22/2022] Open
Abstract
Voice change is a common complaint after thyroid surgery and has significant impacts on quality of life. The Korean Society of Laryngology, Phoniatrics, and Logopedics set up a task force team to establish guideline recommendations on education, care, and management related to thyroid surgery. The guideline recommendations include preoperative voice education, management of anticipated voice change during surgery, and comprehensive voice care after thyroid surgery, including in-depth information and up-to-date knowledge based on validated literature. The committee constructed 14 key questions (KQ) in three categories: preoperative (KQ1-2), intraoperative (KQ 3-8), and postoperative (KQ 9-14) management and developed 18 evidence-based recommendations. The Delphi survey reached an agreement on each recommendation. Detailed evidence profiles are presented for each recommendation. The level of evidence for each recommendation is classified into high, moderate, and low-quality. The recommendation's strengths are adjusted to consider the level of evidence resulting in the recommendation and are divided into strong and weak. The guidelines are primarily targeted toward physicians who treat thyroid surgery patients and speech-language pathologists participating in patient care. These guidelines will also help primary care physicians, nurses, healthcare policymakers, and patients improve their understanding of voice changes and voice care after thyroid surgery.
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Affiliation(s)
| | - Chang Hwan Ryu
- Department of Otorhinolaryngology Head and Neck Surgery, National Cancer Center, Goyang, Korea
| | - Seung Jin Lee
- Division of Speech Pathology and Audiology, Research Institute of Audiology and Speech Pathology, College of Natural Sciences, Hallym University, Chuncheon, Korea
| | - Jae-Gu Cho
- Department of Otorhinolaryngology Head and Neck Surgery, Korea University College of Medicine, Seoul, Korea
| | - Ik Joon Choi
- Department of Otorhinolaryngology Head and Neck Surgery, Korea Cancer Center Hospital, Korea Institute of Radiological Medical Sciences, Seoul, Korea
| | - Yoon Seok Choi
- Department of Otorhinolaryngology Head and Neck Surgery, Yeungnam University, College of Medicine, Daegu, Korea
| | - Yong Tae Hong
- Department of Otorhinolaryngology Head and Neck Surgery, College of Medicine, Jeonbuk National University Hospital, Jeonju, Korea
| | - Soo Yeon Jung
- Department of Otorhinolaryngology Head and Neck Surgery, Ewha Womans University, College of Medicine, Seoul, Korea
| | - Ji Won Kim
- Department of Otorhinolaryngology Head and Neck Surgery, Inha University, College of Medicine, Incheon, Korea
| | - Doh Young Lee
- Department of Otorhinolaryngology Head and Neck Surgery, Seoul National University, College of Medicine, Seoul, Korea
| | - Dong Kun Lee
- Department of Otorhinolaryngology Head and Neck Surgery, College of Medicine, Dong-A University, Busan, Korea
| | - Sang Joon Lee
- Department of Otorhinolaryngology Head and Neck Surgery, Dankook University, College of Medicine, Cheonan, Korea
| | - Young Chan Lee
- Department of Otorhinolaryngology Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Yong Sang Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Inn Chul Nam
- Department of Otorhinolaryngology Head and Neck Surgery, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Ki Nam Park
- Department of Otorhinolaryngology Head and Neck Surgery, Soonchunhyang University, College of Medicine, Bucheon, Korea
| | - Young Min Park
- Department of Otorhinolaryngology Head and Neck Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Eui-Suk Sung
- Department of Otorhinolaryngology Head and Neck Surgery, Pusan National University School of Medicine, Busan, Korea
| | - Hee Young Son
- Department of Otorhinolaryngology Head and Neck Surgery, Dongnam Institute Of Radiological & Medical Sciences, Busan, Korea
| | - In Hyo Seo
- Voice & Speech Clinic, College of Medicine, Dankook University, Cheonan, Korea
| | - Byung-Joo Lee
- Department of Otorhinolaryngology Head and Neck Surgery, Pusan National University School of Medicine, Busan, Korea
| | - Jae-Yol Lim
- Department of Otorhinolaryngology Head and Neck Surgery, Yonsei University College of Medicine, Seoul, Korea
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Propst EJ, Gorodensky J, Wasserman JD, Glazman EF, Tilis LA, Wolter NE. Recurrent laryngeal nerve monitoring with surface electrodes in pediatric thyroid surgery. Laryngoscope 2019; 130:1583-1589. [PMID: 31454091 DOI: 10.1002/lary.28250] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/22/2019] [Accepted: 08/06/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To prospectively evaluate 1) use of endotracheal tube (ETT) surface electrodes for recurrent laryngeal nerve (RLN) monitoring in thyroid surgery in children, and 2) effects of thyroid surgery on the RLN in children. METHODS Patients <18 years old undergoing thyroidectomy were included. Vocal cord mobility was assessed pre- and postoperatively. RLNs were monitored using adhesive or integrated electrodes. Recordings were made before and after dissection, and area under the curve and latency were compared using mixed models. RESULTS Twenty-five children (44 nerves at risk), mean (standard deviation) age 13.1 (3.4) years (range 4.5-17.4 years), underwent thyroidectomy. Twelve (46%) monitors were adhesive. One nerve had unobtainable responses. Nerveäna Power Index (NPI) (Neurovision Medical Products, Ventura, CA) decreased, and latency increased pre- versus postdissection at all amplitudes (P < 0.0001), with change in slope of NPI affected by tumor size (P < 0.05). Postdissection, the NPI was lower, and the latency was longer when stimulating low in the neck versus near the cricothyroid joint at all stimulating amplitudes (P < 0.0001), with change in NPI related to tumor size (P < 0.0001). Changes were not associated with decreased vocal cord mobility, aspiration, or voice change. One patient had a temporary unilateral paresis that resolved by 7 weeks, and another had normal movement 3 weeks postoperatively and developed a paresis 2 months postoperatively. CONCLUSION ETT surface electrodes are reliable for RLN monitoring in thyroid surgery in children. Thyroid surgery is associated with a decrease in RLN stimulability that is related to tumor size. The site of RLN stimulation matters when evaluating the nerve. LEVEL OF EVIDENCE 4 Laryngoscope, 130:1583-1589, 2020.
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Affiliation(s)
- Evan Jon Propst
- Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jonah Gorodensky
- Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Daniel Wasserman
- Division of Endocrinology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ethan Forde Glazman
- Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Leona Ariel Tilis
- Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus Ernst Wolter
- Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Schneider M, Dahm V, Passler C, Sterrer E, Mancusi G, Repasi R, Gschwandtner E, Fertl E, Handgriff L, Hermann M. Complete and incomplete recurrent laryngeal nerve injury after thyroid and parathyroid surgery: Characterizing paralysis and paresis. Surgery 2019; 166:369-374. [PMID: 31262569 DOI: 10.1016/j.surg.2019.05.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 04/25/2019] [Accepted: 05/21/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Injury of the recurrent laryngeal nerve and consequent disorder of vocal fold movement is a typical complication in thyroid and parathyroid surgery. During postoperative laryngoscopy we observed not only a complete standstill (vocal fold paralysis), but also a hypomobility (paresis). In this prospective study, we investigated the difference in incidence and prognosis as well as risk-factors, intraoperative neuromonitoring, and symptoms between vocal fold paralysis and vocal fold paresis. METHODS Data were prospectively collected and analyzed in a single high-volume thyroid center between 2012 and 2016. Vocal fold paresis was defined as hypomobility in abduction or adduction, a reduction in range and speed of vocal fold movement. Vocal fold paralysis was defined as asymmetry and missing purposeful vocal fold movement. RESULTS The study included 4,707 surgeries and 7,992 at-risk nerves at risk. Vocal fold paralysis was diagnosed in 374 patients (4.68% of 7,992 nerves at risk) and vocal fold paresis in 114 patients (1.43%). Exclusively in the paralysis group, 36 patients (0.45%) developed permanent loss of vocal fold function (P < .001). In follow-up, vocal fold paresis patients regain normal vocal fold function significantly earlier than vocal fold paralysis (mean duration: 6.96 ± 6.506 vs 10.77 ± 7,827 weeks) and presented with significantly less symptoms like hoarseness, diplophonia, dysphagia, and dyspnea (68.8% vs 95.9 %). In intraoperative neuromonitoring, vocal fold paresis showed a significantly higher postresectional N. vagus amplitude than vocal fold paralysis patients (0.349 mV vs 0.114 mV, P < .001). CONCLUSION After thyroidectomy, vocal fold paresis must be distinguished from vocal fold paralysis and should be implemented as a separate outcome parameter in the postoperative quality assessment.
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Affiliation(s)
- Max Schneider
- Surgical Department, Rudolfstiftung, Wien Kliniken, Rudolfstiftung, Vienna, Austria
| | - Valerie Dahm
- Department of Otorhinolaryngology, Medical University of Vienna, Vienna, Austria.
| | - Christian Passler
- Surgical Department, Rudolfstiftung, Wien Kliniken, Rudolfstiftung, Vienna, Austria
| | - Elisabeth Sterrer
- Department of Otorhinolaryngology, Wien Kliniken, Rudolfstiftung, Vienna, Austria
| | - Gudrun Mancusi
- Department of Otorhinolaryngology, Wien Kliniken, Rudolfstiftung, Vienna, Austria
| | - Robert Repasi
- Department of Otorhinolaryngology, Wien Kliniken, Rudolfstiftung, Vienna, Austria
| | | | - Elisabeth Fertl
- Department of Neurology, Wien Kliniken, Rudolfstiftung, Vienna, Austria
| | - Laura Handgriff
- Surgical Department, Rudolfstiftung, Wien Kliniken, Rudolfstiftung, Vienna, Austria
| | - Michael Hermann
- Surgical Department, Rudolfstiftung, Wien Kliniken, Rudolfstiftung, Vienna, Austria
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Wijerathne S, Goh X, Parameswaran R. Ipsilateral nonrecurrent laryngeal nerve palsy and delayed palsy of the contralateral recurrent laryngeal nerve in a case of third-time reoperative thyroid surgery. Ann R Coll Surg Engl 2019; 101:e55-e58. [PMID: 30371103 PMCID: PMC6351873 DOI: 10.1308/rcsann.2018.0191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2018] [Indexed: 01/26/2023] Open
Abstract
The occurrence of nonrecurrent laryngeal nerve and delayed nerve palsy of the contralateral nerve occurring simultaneously has never been described. A 67-year-old woman underwent reoperative completion thyroidectomy for enlarging thyroid nodules with recurrent hyperthyroidism and obstructive symptoms. Preoperative computed tomography of the neck showed a large compressive goitre with an aberrant right subclavian artery. At surgery, a type 1 nonrecurrent laryngeal nerve was found and inadvertently transected due to dense adhesions. It was repaired with ansa cervicalis graft. A fully preserved and functional recurrent laryngeal nerve was seen on the contralateral side at the end of surgery. However, the patient developed a delayed palsy on day 4 of the recurrent laryngeal nerve requiring a tracheostomy. Following successful speech and swallowing therapy, the patient was decannulated with good phonation and recovery of the left cord. Patients are at risk of bilateral nerve injury and late onset palsy in reoperative thyroid surgery. Management can be challenging and should be recognised to ensure appropriate therapy.
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Affiliation(s)
- S Wijerathne
- Department of Endocrine Surgery, National University Hospital, Singapore
| | - X Goh
- Department of Otolaryngology and Head and Neck Surgery, National University Hospital, Singapore
| | - R Parameswaran
- Department of Endocrine Surgery, National University Hospital, Singapore
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Yerneni K, Burke JF, Nichols N, Tan LA. Delayed Recurrent Laryngeal Nerve Palsy Following Anterior Cervical Discectomy and Fusion. World Neurosurg 2018; 122:380-383. [PMID: 30465958 DOI: 10.1016/j.wneu.2018.11.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 11/06/2018] [Accepted: 11/08/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Vocal cord dysfunction resulting from recurrent laryngeal nerve palsy (RLNP) is a known complication following anterior cervical discectomy and fusion. RLNP occurs typically secondary to neurapraxia caused by intraoperative compression or traction on the nerve and less commonly from direct nerve injury intraoperatively in the setting of anterior cervical spine surgery. Patients with RLNP typically present with hoarseness immediately after surgery owing to unilateral vocal cord paralysis. In rare cases, there is late-onset, progressive development of RLNP that may potentially lead to permanent vocal cord paralysis or respiratory failure. CASE DESCRIPTION A 75-year-old woman presented with myeloradiculopathy and chronic urinary incontinence. Imaging showed severe foraminal and central stenosis with T2 cord signal change. A C4-7 anterior cervical discectomy and fusion was successfully performed without immediate complications following surgery. The patient had a normal voice and was tolerating a regular diet well. On postoperative day 3, the patient developed new hoarseness and dysphagia. An otolaryngologist was consulted, and flexible nasolaryngoscopy showed left vocal cord paralysis consistent with left RLNP. The patient was treated with a course of steroids, and her hoarseness and dysphagia had resolved at the 6-month follow-up visit. CONCLUSIONS To our knowledge, this is the first report of delayed RLNP in patients undergoing anterior cervical discectomy and fusion. This rare complication should be discussed during preoperative patient counseling. Previous literature indicates the underlying pathophysiology for delayed onset of RLNP may be small vessel ischemia, vasospasm, or viral resurgence that leads to recurrent laryngeal nerve dysfunction.
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Affiliation(s)
- Ketan Yerneni
- Department of Neurological Surgery, UCSF Medical Center, University of California, San Francisco, San Francisco, California, USA
| | - John F Burke
- Department of Neurological Surgery, UCSF Medical Center, University of California, San Francisco, San Francisco, California, USA
| | - Noah Nichols
- Department of Neurological Surgery, UCSF Medical Center, University of California, San Francisco, San Francisco, California, USA
| | - Lee A Tan
- Department of Neurological Surgery, UCSF Medical Center, University of California, San Francisco, San Francisco, California, USA.
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Sun W, Liu J, Zhang H, Zhang P, Wang Z, Dong W, He L, Zhang T. A meta-analysis of intraoperative neuromonitoring of recurrent laryngeal nerve palsy during thyroid reoperations. Clin Endocrinol (Oxf) 2017; 87:572-580. [PMID: 28585717 DOI: 10.1111/cen.13379] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/19/2017] [Accepted: 05/05/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND The rate of recurrent laryngeal nerve (RLN) palsy, a common complication of thyroid surgery, is especially high in thyroid reoperations. The present meta-analysis assesses whether intraoperative neuromonitoring (IONM) reduces the prevalence of RLN palsy in thyroid reoperations. DESIGN AND METHODS A systematic literature search was conducted in the PubMed, SCIE and Wan Fang databases for studies published up to 31 August 2016. All data were analysed using STATA (version 11) software. Publication bias was assessed using Begg's funnel plot and Egger's test, and sensitivity analysis was performed. RESULTS Nine studies including 2436 at-risk nerves met the inclusion criteria. The results were presented as pooled relative risks (RRs) with 95% confidence intervals (CI). The overall RLN palsy rate was significantly lower in reoperations conducted with IONM than in those conducted without IONM (RR=0.434, 95% CI=0.206-0.916, P=.029). High heterogeneity was found (I2 =70.2%, P=.001). The rates of transient RLN palsy with and without IONM did not differ significantly (RR=0.607, 95% CI=0.270-1.366, P=.227). The heterogeneity was high (I2 =67.4%, P=.005). However, IONM was significantly associated with a reduction in permanent RLN palsy (RR=0.426, 95% CI=0.196-0.925, P=.031). No significant heterogeneity was found (I2 =13.7%, P=.325). Funnel plots for overall and transient RLN palsy showed a possible publication bias. CONCLUSIONS Intraoperative neuromonitoring (IONM) is associated with a reduction in overall and permanent RLN palsy in thyroid reoperations. However, given the limited sample size and heterogeneity in this meta-analysis, further studies are required to confirm our preliminary findings.
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Affiliation(s)
- Wei Sun
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Jinhao Liu
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Hao Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ping Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Zhihong Wang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Wenwu Dong
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Liang He
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ting Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
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Abstract
INTRODUCTION Surgical site infections after thyroid surgery are mostly superficial and can be well treated. Streptococcal mediastinitis in contrast is a rare but life-threatening complication. CASE REPORT A 57-year-old female patient experienced septic fever, increase of inflammation parameters and erythema 2 days after thyroid surgery for Graves' disease. This process was triggered by a three-compartment infection by group A Streptococcus (GAS) with involvement of the mediastinum. Therapy over 6 weeks including seven wound revisions with the patient under general anesthesia, pathogen-adapted antibiotic treatment and cervical negative pressure treatment managed to control the infection. A total of 21 cases have been published on this phenomenon, 11 of which had a fatal outcome. CONCLUSION High fever and surgical site erythema in the early postoperative period after thyroid surgery can be signs of a GAS infection, which might lead to necrotizing, descending, life-threatening mediastinitis. Early diagnosis with support of computed tomography (CT) scans, immediate therapy including wound opening, lavage, intravenous antibiotic treatment with penicillin and clindamycin are vital. If treatment resistance occurs, cervical negative pressure treatment should be considered.
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Wojtczak B, Sutkowski K, Kaliszewski K, Głód M, Barczyński M. Experience with intraoperative neuromonitoring of the recurrent laryngeal nerve improves surgical skills and outcomes of non-monitored thyroidectomy. Langenbecks Arch Surg 2016; 402:709-717. [PMID: 27209315 PMCID: PMC5437184 DOI: 10.1007/s00423-016-1449-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 05/11/2016] [Indexed: 01/03/2023]
Abstract
Purpose Intraoperative neuromonitoring (IONM) can serve as a tool to increase skills in recurrent laryngeal nerve (RLN) identification and complete removal of thyroid tissue. The aim of this study was to validate this hypothesis. Methods This prospective study involved 632 patients (1161 RLNs at risk) who underwent thyroid surgery in 2011–2014. Although IONM was not used until 2012, this prospective study started on 1 January 2011. The three participating surgeons knew about the study before that date and that the rate of RLN identification would be carefully measured in total and near-total surgery. Solely, visual identification of the RLN was used throughout 2011. IONM was introduced as a training tool in 2012–2014 for the first 3 months of each year. In the remaining months, thyroid operations were performed without IONM. Outcomes of non-monitored thyroid operations were compared before (01-12/2011) vs. after (04-12/2012–2014) 3 months of exposure to IONM yearly (01-03/2012–2014). The rate of RLN identification was assessed in total and near-total thyroidectomies and in totally resected lobes in Dunhill’s operation. The prevalence of RLN injury and the utilization of total thyroidectomy were evaluated. Results In 2011, the rate of successful RLN visual identification in total and near-total thyroidectomies and in totally resected lobes in Dunhill’s operation was 45.71 %. After the introduction of IONM in 2012–2014, in the procedures performed without IONM, the rate was 86.66, 90.81, and 91.3 %. The prevalence of RLN injury in 2011 was 6.8 %, while in the years following the introduction of IONM, it was 3.61, 2.65, and 1.45 %. Utilization of total thyroidectomy increased from 47.9 % in 2011 to 100 % in 2014. Conclusions Experience with IONM led to an increase in RLN identification (p < 0.0001), a decrease of RLN injury (p < 0.05), and an increase in the safe utilization of total thyroidectomy (p < 0.0001) in non-monitored thyroid operations. IONM is a valuable tool for surgical training.
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Affiliation(s)
- Beata Wojtczak
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, M.C. Sklodowskiej 66, 50-369, Wrocław, Poland.
| | - Krzysztof Sutkowski
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, M.C. Sklodowskiej 66, 50-369, Wrocław, Poland
| | - Krzysztof Kaliszewski
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, M.C. Sklodowskiej 66, 50-369, Wrocław, Poland
| | - Mateusz Głód
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, M.C. Sklodowskiej 66, 50-369, Wrocław, Poland
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Kraków, Poland
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Lamadé W, Béchu M, Lauzana E, Köhler P, Klein S, Tuncer T, Rashid NIH, Kahle E, Erdmann B, Meyding-Lamadé U. The weepy nerve-different sensitivity of left and right recurrent laryngeal nerves under tensile stress in a porcine model. Langenbecks Arch Surg 2016; 401:983-990. [PMID: 27209314 DOI: 10.1007/s00423-016-1439-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 04/19/2016] [Indexed: 01/23/2023]
Abstract
PURPOSE Recurrent laryngeal nerve palsy in thyroid surgery is still a threatening complication. Our aim was to analyze the impact of prolonged tensile stress on the recurrent laryngeal nerve (RLN) in an animal model using continuous intraoperative neuromonitoring (C-IONM). METHODS Constant tensile stress was applied to left and right RLNs in 20 pigs (40 RLN). In a pilot study, five animals were subjected to a tensile force of 0.34 ± 0.07 N for 10 min and changes in amplitude were documented using C-IONM. In the main study, a force of 1.2 N was applied until the signal amplitude was reduced by 85 %, in 15 pigs. Nerve conductivity was analyzed by threshold current measurements. RESULTS Good correlation was found between stress and amplitude decrease in the pilot study as well as between signal decrease and duration of trauma in the main study. Great variations were found inter- and intra-individually. These variations were most prominent at 85 % signal reduction (median 36 min, range 0.3-171 min). There was no side specificity (left 0.3-171 min, right 0.3-168 min, respectively, p = 0.19). However, in each individual animal, there was a sensitive (0.3-98.9 min) and less sensitive nerve (26.8-171 min). These differences became highly significant at 85 % of signal reduction (p = 0.008), where the vulnerability is 1.4 to 146.4 times higher on one side (mean 4.3). CONCLUSIONS Our study demonstrates the presence of a sensitive RLN that was 4.3 times more vulnerable than the contralateral nerve (range 1.4-146.4 times, p = 0.008). Thus, the right and the left nerves cannot be assumed to be of equal sensitivity to trauma. In our data, the more sensitive nerve does not occur predominantly on one side and was named the "weepy nerve."
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Affiliation(s)
- Wolfram Lamadé
- Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany.
| | - Maren Béchu
- Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany.,Klinik für Neurologie, Krankenhaus Nordwest, Frankfurt am Main, Germany
| | - Ester Lauzana
- Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany
| | - Peter Köhler
- Friedrich-Loeffler-Institut, Bundesforschungsinstitut für Tiergesundheit, Neustadt, Germany
| | - Sabine Klein
- Friedrich-Loeffler-Institut, Bundesforschungsinstitut für Tiergesundheit, Neustadt, Germany
| | - Tuncay Tuncer
- Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany
| | | | - Erich Kahle
- Friedrich-Loeffler-Institut, Bundesforschungsinstitut für Tiergesundheit, Neustadt, Germany
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Simon D, Boucher M, Schmidt-Wilcke P. [Intraoperative avoidance and recognition of recurrent laryngeal nerve palsy in thyroid surgery]. Chirurg 2014; 86:6-12. [PMID: 25502321 DOI: 10.1007/s00104-014-2816-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Recurrent laryngeal nerve palsy is an intrinsic complication of thyroid surgery. Prevention of nerve palsy is considered to be a feature of quality in this very frequently performed operation. Risk factors and prevention strategies are demonstrated and discussed with reference to the current literature. Exact knowledge of the anatomy and possible variants of the track of the recurrent laryngeal nerve as well as its visualization and careful dissection are the cornerstones for nerve preservation. The use of intraoperative neuromonitoring allows preservation of the anatomical structure and functional integrity of the nerve and lesions which are not visible can be detected. Preconditions for correct interpretation are a standardized application and preoperative and postoperative laryngoscopy.
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Affiliation(s)
- D Simon
- Klink für Allgemein- und Viszeralchirurgie, Thoraxchirurgie und Endokrine Chirurgie, Ev. Krankenhaus Bethesda Duisburg GmbH, Heerstr. 219, 47053, Duisburg, Deutschland,
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