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Smaxwil CA, Zielke A. [Modern thyroid surgery : Efficient and safe thyroidectomy technique]. CHIRURGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00104-024-02100-2. [PMID: 38862785 DOI: 10.1007/s00104-024-02100-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 06/13/2024]
Abstract
After decades of bilateral "subtotal" and later "total" thyroidectomy, the extent of resection is now determined individually depending on the dominant thyroid condition. The leading indication by far in the study, documentation and quality center (StuDoQ) register of the Surgical Working Group Endocrinology (CAEK) is currently the suspicion of malignancy, which is followed by benign symptomatic nodular goiter, functional disorders and confirmed malignancy. The decision for an intervention as well as the extent of resection must be rigorously established. Aids for intraoperative nerve monitoring, vessel-sealing and parathyroid autofluorescence increase the safety of thyroid resections but also the complexity. The surgical technique of lobectomy using modern devices for vessel sealing is an intricate process in which the positioning, access to the neck and a modified sequence of dissection steps are equally important. While the usefulness of neuromonitoring is nowadays no longer in doubt, this is not yet so clear for other technologies. Above all, however, modern thyroid surgery is characterized by the knowledge of one's own results and a clear positioning to follow-ups. The selection of any surgical aid should be based on this knowledge.
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Affiliation(s)
- Constantin Aurel Smaxwil
- Endokrine Chirurgie, Diakonie-Klinikum Stuttgart, Rosenbergstraße 38, 70176, Stuttgart, Deutschland
| | - Andreas Zielke
- Endokrine Chirurgie, Diakonie-Klinikum Stuttgart, Rosenbergstraße 38, 70176, Stuttgart, Deutschland.
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Setså E, Svendsen ØS, Henriksen B, Stangeland L, Husby P, Brauckhoff K. Accelerometry May be Superior to EMG for Early Evaluation of Vocal Cord Function After Nerve Injury in a Pig Model. Laryngoscope 2024; 134:1485-1491. [PMID: 37658747 DOI: 10.1002/lary.31020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/01/2023] [Accepted: 08/15/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE Vocal cord (VC) movement has been demonstrated by the use of accelerometry (ACC) to decrease in parallel with the electromyographic amplitude (EMG) during ongoing traction injury to the recurrent laryngeal nerve (RLN). When RLN function recovers, discrepancies between EMG and VC movement have been reported in clinical and experimental studies. The present study was conducted to clarify the actual relationship between EMG and VC movement measured by ACC during nerve recovery. METHODS EMG obtained by continuous nerve monitoring (C-IONM) was compared with ACC during traction injury to the RLN, and throughout 40-min nerve recovery. A three-axis linear accelerometer probe was attached to the VC, and ACC data were registered as described. Traction damage was applied to the RLN until there was a 70% amplitude decrease from baseline EMG, or until loss of signal (LOS), that is, EMG values ≤100 μV. RESULTS Thirty-two RLN from 16 immature pigs were studied. Correlation between EMG and ACC were calculated during nerve injury and nerve recovery. The mean correlations were for the 70% and LOS group from start to end of traction: 0.82 (±0.17) and 0.87 (±0.17), respectively. Corresponding correlation coefficients during 40-min recovery was 0.50 (±0.48) in the 70% group and 0.53 (±0.33) in the LOS group. CONCLUSION There is a high correlation between EMG and VC movement during nerve injury, and a moderate correlation during early nerve recovery. EMG recovery after RLN injury ensures sufficient VC function as assessed by ACC. LEVEL OF EVIDENCE N/A Laryngoscope, 134:1485-1491, 2024.
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Affiliation(s)
- E Setså
- Department of Breast and Endocrine Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Ø S Svendsen
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - B Henriksen
- Norwegian research institute (NORCE), Bergen, Norway
| | - L Stangeland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - P Husby
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - K Brauckhoff
- Department of Breast and Endocrine Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Sciences, University of Bergen, Bergen, Norway
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Barczyński M, Konturek A. Clinical validation of NerveTrend versus conventional i-IONM mode of NIM Vital in prevention of recurrent laryngeal nerve events during bilateral thyroid surgery: A randomized controlled trial. Head Neck 2024; 46:492-502. [PMID: 38095022 DOI: 10.1002/hed.27601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/04/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND The aim of this study was to test the hypothesis that use of NerveTrend™ mode of intermittent neuromonitoring (i-IONM) during thyroidectomy may identify and prevent impending recurrent laryngeal nerve (RLN) injury. METHODS A randomized clinical trial. The primary outcome was prevalence of RLN injury on postoperative day 1. In NerveTrend™ group the i-IONM stimulator was used for trending of amplitude and latency changes from initial vagal electromyographic baseline to tailor surgical strategy. RESULTS Some 264 patients were randomized into the intervention versus the control group, 132 patients each. RLN injury was found on postoperative day 1 in 5/264 (1.89%) nerves at risk (NAR) versus 12/258 (4.65%) NAR whereas staged thyroidectomy was used in 0/132 (0.00%) versus 6/132 (4.54%) patients (p = 0.067 and p = 0.029, respectively). CONCLUSION The use of NerveTrend™ mode resulted in tendency towards reduced RLN injury on postoperative day 1 and significant decrease of need for a staged thyroidectomy.
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Affiliation(s)
- Marcin Barczyński
- Department of Endocrine Surgery, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Aleksander Konturek
- Department of Endocrine Surgery, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
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Najah H, Donatini G, Van Slycke S, Bizard JP, Triponez F, Sebag F. Place of laryngoscopy and neuromonitoring in thyroid surgery. Recommendations of the AFCE (Association francophone de chirurgie endocrinienne) with the SFE (Société française d'endocrinologie) and the SFMN (Société française de médecine nucléaire). J Visc Surg 2023:S1878-7886(23)00069-3. [PMID: 37210345 DOI: 10.1016/j.jviscsurg.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Preoperative laryngoscopy is mandatory when there is a history of cervical or thoracic surgery, dysphonia, posteriorly developed thyroid carcinoma, or significant lymph node involvement in the central compartment. Postoperative laryngoscopy should be performed for any postoperative dysphonia, swallowing difficulties, respiratory symptoms, or loss of signal during neuromonitoring of the recurrent and/or vagus nerve. Neuromonitoring can be useful in thyroid surgery because it lowers the rate of transient recurrent palsy (RP), although no impact on permanent RP has been demonstrated. It facilitates location of the recurrent nerve. Continuous neuromonitoring of the vagus nerve can, in some situations, allow early detection of a signal drop during dissection near the recurrent nerve.
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Affiliation(s)
- Haythem Najah
- Department of Digestive and Endocrine Surgery, Haut Lévêque Hospital, University Hospital Center of Bordeaux, Bordeaux France.
| | - Gianluca Donatini
- Digestive and endocrine surgery department, University Hospital Center of Poitiers, Poitiers, France
| | - Sam Van Slycke
- Digestive and endocrine surgery department, OLV Alost, Alost, Belgium
| | | | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery, University Hospital of Genève and Faculty of Medicine, Genève, Switzerland
| | - Frédéric Sebag
- General and Endocrine Surgery Department, University Hospital of Marseille Conception, Marseille, France
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Mathieson T, Jimaja W, Triponez F, Licker M, Karenovics W, Makovac P, Muradbegovic M, Belfontali V, Bédat B, Demarchi MS. Safety of continuous intraoperative vagus nerve neuromonitoring during thyroid surgery. BJS Open 2023; 7:zrad039. [PMID: 37289251 PMCID: PMC10249491 DOI: 10.1093/bjsopen/zrad039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 02/02/2023] [Accepted: 03/08/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Continuous intraoperative neuromonitoring has successfully demonstrated to predict impending damage to the recurrent laryngeal nerve, by detecting changes in electromyographic recordings. Despite the apparent benefits associated with continuous intraoperative neuromonitoring, its safety is still a debate. The aim of this study was to investigate the electrophysiological impact of continuous intraoperative neuromonitoring on the vagus nerve. METHODS In this prospective study, the amplitude of the electromyographic wave of the vagus nerve-recurrent laryngeal nerve axis was measured both proximally and distally to the stimulation electrode placed upon the vagus nerve. Electromyographic signal amplitudes were collected at three distinct events during the operation: during the dissection of the vagus nerve, before application of the continuous stimulation electrode onto the vagus nerve and after its removal. RESULTS In total, 169 vagus nerves were analysed, among 108 included patients undergoing continuous intraoperative neuromonitoring-enhanced endocrine neck surgeries. Electrode application resulted in a significant overall decrease in measured proximo-distal amplitudes of -10.94 µV (95 per cent c.i. -17.06 to -4.82 µV) (P < 0.005), corresponding to a mean(s.d.) decrease of -1.4(5.4) per cent. Before the removal of the electrode, the measured proximo-distal difference in amplitudes was -18.58 µV (95 per cent c.i. -28.31 to -8.86 µV) (P < 0.005), corresponding to a mean(s.d.) decrease of -2.50(9.59) per cent. Seven nerves suffered a loss of amplitude greater than 20 per cent of the baseline measurement. CONCLUSION In addition to supporting claims that continuous intraoperative neuromonitoring exposes the vagus nerve to injury, this study shows a mild electrophysiological impact of continuous intraoperative neuromonitoring electrode placement on the vagus nerve-recurrent laryngeal nerve axis. However, the small observed differences are negligible and were not associated with a clinically relevant outcome, making continuous intraoperative neuromonitoring a safe adjunct in selected thyroid surgeries.
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Affiliation(s)
- Timothy Mathieson
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Wedali Jimaja
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Marc Licker
- Department of Anaesthesiology and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Wolfram Karenovics
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Petra Makovac
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Mirza Muradbegovic
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Valentina Belfontali
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Benoît Bédat
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Marco Stefano Demarchi
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
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Eltelety AM, Terris DJ. Minimally invasive thyroid and parathyroid surgery: modifications for low-resource environments. THE EGYPTIAN JOURNAL OF OTOLARYNGOLOGY 2022. [DOI: 10.1186/s43163-022-00341-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
AbstractMinimally invasive thyroidectomy (MIT) and parathyroidectomy (MIP) are gaining popularity in the current surgical practice. The need for specific equipment and technology is an obstacle in the low-resource environment. This article provides simple and practical guidance for surgeons practicing in low-resource environments to help them attain quality surgical practice, maintain patient safety, preserve available resources, and achieve the best outcomes.
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Iscan Y, Aygun N, Sormaz IC, Tunca F, Uludag M, Senyurek YG. Is craniocaudal dissection of recurrent laryngeal nerve safer than lateral approach: a prospective randomized study comparing both techniques by using continuous intraoperative nerve monitoring. Ann Surg Treat Res 2022; 103:205-216. [PMID: 36304193 PMCID: PMC9582614 DOI: 10.4174/astr.2022.103.4.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/10/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose This study was performed to compare the real-time electromyographic (EMG) changes and the rate of recurrent laryngeal nerve (RLN) injury in craniocaudal and lateral approaches for RLN during thyroidectomy. Methods One hundred twelve and 86 patients were prospectively randomized to receive lateral (group 1) or craniocaudal (group 2) approach to RLN, respectively, under continuous intraoperative nerve monitoring. Results Loss of signal (LOS) occurred in 7 (2.0%) of 356 nerves at risk (NAR). LOS was significantly associated with repeated adverse EMG changes and presence of RLN entrapment at the ligament of Berry (LOB), which was accompanied by other clinicopathological or anatomical features, such as tubercle of Zuckerkandl (TZ), extralaryngeal branching, hyperthyroidism, autoimmune thyroid disease (ATD), or thyroid lobe volume of >29 cm3 (P = 0.001 and P = 0.030, respectively). The rate of repeated adverse EMG changes and LOS in the NARs with LOB entrapment accompanied by other clinicopathological and anatomical features was higher in group 1 vs. group 2 (11.1% vs. 2.2%, respectively and 9.7% vs. 0%, respectively; P = 0.070). The total rate of vocal cord palsy (VCP) was significantly higher in group 1 than in group 2 (P = 0.005). The rate of permanent VCP showed no significant difference between the 2 groups. Conclusion The craniocaudal approach to the RLN is safer than the lateral approach in the RLNs with entrapment at the LOB accompanied by other features, such as TZ, extralaryngeal branching, hyperthyroidism, ATD, or high thyroid lobe volume.
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Affiliation(s)
- Yalin Iscan
- Division of Endocrine Surgery, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nurcihan Aygun
- Division of Endocrine Surgery, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences Turkey, Istanbul, Turkey
| | - Ismail Cem Sormaz
- Division of Endocrine Surgery, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Fatih Tunca
- Division of Endocrine Surgery, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Uludag
- Division of Endocrine Surgery, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences Turkey, Istanbul, Turkey
| | - Yasemin Giles Senyurek
- Division of Endocrine Surgery, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Tension-free thyroidectomy (TFT): initial report. Updates Surg 2022; 74:1953-1960. [PMID: 35913529 DOI: 10.1007/s13304-022-01338-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/15/2022] [Indexed: 10/16/2022]
Abstract
The safety of thyroid surgery in terms of recurrent laryngeal nerve palsy and hypoparathyroidism has increased over the last decade. In this study, we present a new method of tension-free thyroidectomy (TFT), which could be used to further decrease the complication rate after a thyroidectomy. The procedure is based on the medial approach to the recurrent laryngeal nerve and the parathyroid glands after the division of the isthmus and successive complete dissection of Berry's ligament. In total, 92 patients (127 nerves at risk) underwent "tension-free thyroidectomy" (TFT) between August and November 2021. All the procedures were performed by a single surgeon at Saint Petersburg State University Hospital. There were 74 females and 18 male patients (ratio 4.1:1) with a mean age of 46.9 (range from 17 to 74). A lobectomy was carried out in 57 (62%) patients and a total thyroidectomy in 35 (38%). In 27 cases, patients additionally underwent central and/or lateral neck dissection. Indications for surgery were papillary carcinoma (N = 34), medullary cancer (N = 2), follicular neoplasia (N = 43), Grave's disease (N = 9), multinodular toxic goiter (N = 3), and multinodular nontoxic goiter (N = 1). Mean thyroid volume was 24.6 ml (ranged 12-70 ml). Intraoperative neuromonitoring was used in all the cases (5 mA). Translaryngeal ultrasound (TLUS) or direct laryngoscopy were routinely used prior and after surgery to evaluate vocal cords mobility. Calcium and parathormone levels were measured in patients after thyroidectomy on the first, 14th and 30th postoperative days. No recurrent laryngeal nerve palsy was observed. One patient exhibited hypoparathyroidism which was resolved in 2 weeks using substitution therapy with calcium and alfacalcidol. The mean operating time for lobectomy was 54 ± 14 min (range: 30-95 min) and for total thyroidectomy 99 ± 28 min (range: 55-158 min). There was no conversion to the conventional lateral-to-medial approach. TFT can be considered a safe and feasible operation. Comparative (randomized studies) with conventional dissection technique should be performed to investigate the hypothesis that this approach can provide a lower complication rate.
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Surgical Significance of Berry’s Posterolateral Ligament and Frequency of Recurrent Laryngeal Nerve Injury into the Last 2 cm of Its Caudal Extralaryngeal Part(P1) during Thyroidectomy. Medicina (B Aires) 2022; 58:medicina58060755. [PMID: 35744018 PMCID: PMC9228495 DOI: 10.3390/medicina58060755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/23/2022] [Accepted: 05/27/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Objectives: Recurrent laryngeal nerve injury is one of the major complications of thyroidectomy, with the lateral thyroid ligament (Berry’s ligament) being the most frequent site of nerve injury. Neuromonitoring during thyroidectomy revealed three possible anatomical regions of the recurrent laryngeal nerve P1, P2, and P3. P1 represents the recurrent laryngeal nerve’s caudal extralaryngeal part and is primarily associated with Berry’s ligament. The aim of this systematic review is to identify the anatomical region with the highest risk of injury of the recurrent laryngeal nerve (detected via neuromonitoring) during thyroidectomy and to demonstrate the significance of Berry’s ligament as an anatomical structure for the perioperative recognition and protection of the nerve. Materials and Methods: This study conducts a systematic review of the literature and adheres to all PRISMA system criteria as well as recommendations for systematic anatomical reviews. Three search engines (PubMed, Scopus, Cochrane) were used, and 18 out of 464 studies from 2003–2018 were finally included in this meta-analysis. All statistical data analyses were performed via SPSS 25 and Microsoft Office XL software. Results: 9191 nerves at risk were identified. In 75% of cases, the recurrent laryngeal nerve is located superficially to the ligament. In 71% of reported cases, the injury occurred in the P1 area, while the P3 zone (below the location where the nerve crosses the inferior thyroid artery) had the lowest risk of injury. Data from P1, P2, and P3 do not present significant heterogeneity. Conclusions: Berry’s ligament constitutes a reliable anatomical structure for recognizing and preserving recurrent laryngeal nerves. P1 is the anatomical area with the greatest risk of recurrent laryngeal nerve damage during thyroidectomy, compared to P2 and P3.
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Rao KN, Satpute S, Nagarkar NM, Singh A. Revision Thyroid Surgery. Indian J Surg Oncol 2022; 13:199-207. [PMID: 35462649 PMCID: PMC8986899 DOI: 10.1007/s13193-021-01467-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/19/2021] [Indexed: 11/28/2022] Open
Abstract
The incidence of recurrence in well-differentiated thyroid malignancies range from 10 to 30%. It is estimated that about 31-46% of patients with differentiated thyroid cancer will have the persistent disease and 1.2-6.8% will have structural recurrences during post-operative monitoring, depending on the initial therapy and prognostic variables. It is challenging to decide on treatment versus active monitoring following repeated or persistent tumour detection. The biological factors of the tumour and the patient guide us in the overall decision-making. Revision thyroid surgery is technically challenging. The morbidity encountered during the revision surgery is related to the anatomy of the region undergoing dissection, the degree of fibrosis and scarring from prior surgery and the operating surgeon's experience. Successful comprehensive management of revision thyroid surgery needs a multi-disciplinary approach. This review article highlights the definition, indications for revision surgery, identification of recurrent disease, management of parathyroid and recurrent laryngeal nerves with neuromonitoring.
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Affiliation(s)
- Karthik Nagaraja Rao
- Department of Head and Neck Oncology, All India Institute of Medical Sciences, Raipur, India
| | - Satish Satpute
- Department of Otolaryngology and Head Neck Surgery, All India Institute of Medical Sciences, Raipur, India
| | | | - Ambesh Singh
- Department of Head and Neck Oncology, All India Institute of Medical Sciences, Raipur, India
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Mohammad R, Huh G, Cha W, Jeong WJ. Recurrent Laryngeal Nerve Paralysis Following Thyroidectomy: Analysis of Factors Affecting Nerve Recovery. Laryngoscope 2022; 132:1692-1696. [PMID: 35043983 DOI: 10.1002/lary.30024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 12/19/2021] [Accepted: 01/04/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Paralysis of the recurrent laryngeal nerves (RLNs), albeit decreased over the years, leaves the surgeon helpless as there is not much that can be done once it occurs. Nimodipine has been suggested as a remedy that could accelerate the recovery of the nerve. Our study aimed to examine the factors that affect the recovery rate (RR) and time to recovery (TTR) of post-thyroidectomy RLN paralysis, with an emphasis on the use of nimodipine. METHODS A total of 197 patients who had undergone thyroid and parathyroid surgeries were retrospectively reviewed from October 2016 to August 2019. Patients who had RLN paralysis following surgery were assessed. The medical records were retrospectively analyzed to look for possible factors that may influence RLN recovery. RESULTS A total of 289 nerves were at risk. Temporary RLN paralysis rate was 7.9% while 1.7% was permanent. Age (odds ratio [OR] = 4.8) and intra-operative extra-thyroid extension (OR = 9.0) were independent risk factors for RLN paralysis. The rate of recovery was 82.1%. Loss of signal (LOS; P = .066) was a factor trending for an impact on RR but not nimodipine (P > .05). The mean TTR was 32 days. LOS, nimodipine, and steroid use, among others, were factors trending for an impact on the TTR. CONCLUSION Although not reaching statistical significance, nimodipine and steroids might influence TTR but not the RR. Larger studies are warranted to address the effect of nimodipine on the outcome of RLN paralysis. LEVEL OF EVIDENCE 4 Laryngoscope, 2022.
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Affiliation(s)
- Ramla Mohammad
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Otolaryngology and Head and Neck Surgery, Jaber Al-Ahmad Hospital, Ministry of Health, South Surra, Kuwait
| | - Gene Huh
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Wonjae Cha
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Woo-Jin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
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Sinclair CF, Buczek E, Cottril E, Angelos P, Barczynski M, Ho AS, Makarin V, Musholt T, Scharpf J, Schneider R, Stack BC, Tellez MJ, Tolley N, Woodson G, Wu CW, Randolph G. Clarifying optimal outcome measures in intermittent and continuous laryngeal neuromonitoring. Head Neck 2021; 44:460-471. [PMID: 34850992 DOI: 10.1002/hed.26946] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/15/2021] [Accepted: 11/18/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Intraoperative neuromonitoring (IONM) techniques have evolved over the past decade into intermittent IONM (I-IONM) and continuous IONM (C-IONM) modes of application. Despite many prior publications on both types of IONM, there remains uncertainty about what outcomes should be measured for each form of IONM. The primary objective of this paper is to define categories of benefit for I-IONM/C-IONM and to clarify and standardize their reporting outcomes. METHODS Expert review consensus statement utilizing modified Delphi methodology. RESULTS I-IONM provides diagnosis, classification, and prevention of nerve injury through accurate and early nerve identification. C-IONM provides real-time information on nerve functional integrity and thus may prevent some types of nerve injury but cannot assist in nerve localization. Sudden mechanisms of nerve injury cannot be predicted or prevented by either technique. CONCLUSIONS I-IONM and C-IONM are complementary techniques. Future studies evaluating the utility of IONM should focus on outcomes that are appropriate to the type of IONM being utilized.
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Affiliation(s)
- Catherine F Sinclair
- Department of Otolaryngology Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erin Buczek
- Department of Otolaryngology Head and Neck Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth Cottril
- Department of Otolaryngology Head and Neck Surgery, Jefferson University, Philadelphia, Pennsylvania, USA
| | - Peter Angelos
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Marcin Barczynski
- Department of Endocrine Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Allen S Ho
- Department of Otolaryngology Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Viktor Makarin
- Saint Petersburg State University Hospital, Saint Petersburg, Russian Federation
| | - Thomas Musholt
- Department of Endocrine Surgery, Gutenberg University Mainz, Mainz, Germany
| | - Joseph Scharpf
- Department of Otolaryngology Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rick Schneider
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Brendan C Stack
- Department of Otolaryngology Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Maria J Tellez
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Neil Tolley
- Department of Otolaryngology Head and Neck Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Gayle Woodson
- Department of Otolaryngology Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Che Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Greg Randolph
- Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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Graceffa G, Vieni S, Mannino V, Gennari V, Genova P, Cipolla C. Effectiveness of early administration of a single dose of steroids and escin after loss of signal on electromyographic signal recovery during neuromonitored thyroidectomy. Am J Surg 2021; 223:923-926. [PMID: 34663501 DOI: 10.1016/j.amjsurg.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/08/2021] [Accepted: 10/11/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the effect of a single early administration of dexamethasone and escin after loss of signal (LOS) during a neuromonitored total thyroidectomy. METHODS A retrospective analysis of results concerning consecutive patients undergoing total thyroidectomy was performed. Patients included in the study were divided into two groups: Group 1 for which a "wait and see" strategy was used; Group 2, receiving dexamethasone and escin immediately after LOS detection. RESULTS Overall 37 patients were included in Group 1 and 35 in Group 2. LOS recovery occurring in 29.7% of cases (n. 11) versus 65.7% (n. 23) respectively (p < 0.001). Postoperative fibrolayngoscopy for patients without LOS recovery showed normal cord function in 4 out of 26 cases (15.4%) in Group 1 and in 7 out of 12 (58.3%) in Group 2 (p < 0.001). CONCLUSIONS The early administration of dexamethasone and escin after LOS detection may achieve greater EMG signal recovery than a "wait and see" strategy.
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Affiliation(s)
- Giuseppa Graceffa
- Department of Surgical Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Salvatore Vieni
- Department of Surgical Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Valeria Mannino
- Department of Surgical Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Valeria Gennari
- Department of Surgical Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Pietro Genova
- Department of Surgical Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Calogero Cipolla
- Department of Surgical Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.
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Ku D, Hui M, Cheung P, Chow O, Smith M, Riffat F, Sritharan N, Kamani D, Randolph G. Meta-analysis on continuous nerve monitoring in thyroidectomies. Head Neck 2021; 43:3966-3978. [PMID: 34342380 DOI: 10.1002/hed.26828] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/15/2021] [Accepted: 07/22/2021] [Indexed: 11/05/2022] Open
Abstract
In the last decade, the introduction of continuous intraoperative recurrent laryngeal nerve (RLN) monitoring (C-IONM) has enabled the operator to verify the functional integrity of the vagus nerve-recurrent laryngeal nerve (VN-RLN) axis in real-time. We aim to present the current evidence on C-IONM utility for thyroid surgery by conducting the first meta-analysis on this technique. A systematic review of literature was conducted by two independent reviewers via Ovid in the Medline, EMBASE, and Cochrane reviews databases. The search was limited to human subject research in peer-reviewed articles of all languages published between Jan 1946 and April 2020. Medical subject headings (MeSH) terms utilized were thyroid surgery, thyroidectomies, recurrent laryngeal nerve, vagal nerve, monitor, and stimulation. Thirty-eight papers were identified from Ovid, another six papers were identified by hand-search. A random effect meta-analysis was performed with assessment of heterogeneity using the I2 value. A total of 23 papers that investigated the use of continuous vagal nerve monitoring during thyroid surgery were identified. The proportion of nerves at risk (NAR) with temporary RLN paralysis postoperation was 2.26% (95% CI: 1.6-2.9, I2 = 37). The proportion of NAR with permanent RLN palsy postoperation was 0.05% (95% CI: 0.08-0.2, I2 = 0). In this meta-analysis, there is one case of temporary vagal nerve paralysis secondary to VN electrode dislodgement, and a case of hemodynamic instability manifested in bradycardia and hypotension in the initial phase of surgery shortly after calibration. C-IONM is a safe and effective means by which RLN paralyses in thyroid surgery can be reduced.
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Affiliation(s)
- Dominic Ku
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michelle Hui
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Phylannie Cheung
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Oliver Chow
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mark Smith
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Otolaryngology - Head & Neck Surgery, Nepean Hospital, Sydney, New South Wales, Australia
| | - Faruque Riffat
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Otolaryngology - Head & Neck Surgery, Nepean Hospital, Sydney, New South Wales, Australia
| | - Niranjan Sritharan
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Otolaryngology - Head & Neck Surgery, Nepean Hospital, Sydney, New South Wales, Australia
| | - Dipti Kamani
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Gregory Randolph
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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15
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Aygun N, Isgor A, Uludag M. Intraoperative Posterior Cricoarytenoid Muscle Electromyography May Predict Vocal Cord Function Prognosis after Loss of Signal during Thyroidectomy. J INVEST SURG 2021; 35:768-775. [PMID: 34232108 DOI: 10.1080/08941939.2021.1942338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Intraoperative posterior cricoarytenoid muscle (PCAM) electromyography (EMG) may be useful for predicting postoperative vocal cord function (VCF) and prognosis of vocal cord palsy (VCP) in patients with intraoperative loss of signal (LOS). MATERIALS AND METHODS Thirty out of 395 patients having LOS detected by intraoperative neural monitoring (IONM), were applied intraoperative PCAM EMG. RESULTS VCP was present in all Type 1 injury RLNs (16) (100%) and in 8 (57%) of 14 RLNs with Type 2 injury (p = 0.005). 14 out of 30 LOS patients (47%) had positive PCAM EMG amplitudes. The sensitivity, specificity, positive and negative predictive values and accuracy rates for predicting postoperative VCP via PCAM EMG, were calculated as 66.7%, 100%,100%, 42.86% and 73.33%. The negative PCAM EMG was related to VCP in both Type 1 and Type 2 LOS. VCP recovery time of Type 1 LOS patients was significantly longer than that of Type 2 LOS patients (p = 0.009). In Type 2 LOS, VCP recovery time was significantly longer in negative PCAM EMG patients compared to positive PCAM EMG patients (p = 0.046). CONCLUSION Negative PCAM EMG is associated with the postoperative VCP. Type 1 injury results in VCP regardless of PCAM EMG results, and VCF recovers after a longer period compared to Type 2 LOS.In Type 2 LOS, positive PCAM EMG may result in VCP by 40%. However, the presence of negative PCAM EMG is related to the postoperative VCP in all patients and the recovery time is longer compared to positive PCAM EMG patients.
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Affiliation(s)
- Nurcihan Aygun
- Department of General Surgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Adnan Isgor
- Faculty of Medicine, Department of General Surgery, Bahcesehir University, Istanbul, Turkey
| | - Mehmet Uludag
- Department of General Surgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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16
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Anatomical, Functional, and Dynamic Evidences Obtained by Intraoperative Neuromonitoring Improving the Standards of Thyroidectomy. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2021; 55:146-155. [PMID: 34349588 PMCID: PMC8298074 DOI: 10.14744/semb.2021.45548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022]
Abstract
The use of intraoperative neuromonitoring (IONM) is getting more common in thyroidectomy. The data obtained by the usage of IONM regarding the laryngeal nerves’ anatomy and function have provided important contributions for improving the standards of the thyroidectomy. These evidences obtained through IONM increase the rate of detection and visual identification of recurrent laryngeal nerve (RLN) as well as the detection rate of extralaryngeal branches which are the most common anatomic variations of RLN. IONM helps early identification and preservation of the non-recurrent laryngeal nerve. Crucial knowledge has been acquired regarding the complex innervation pattern of the larynx. Extralaryngeal branches of the RLN may contribute to the motor innervation of the cricothyroid muscle (CTM). Anterior branch of the extralaryngeal branching RLN has always motor function and gives motor branches both to the abductor and adductor muscles. In addition, up to 18% of posterior branches may have adductor and/or abductor motor fibers. In 70–80% of cases, external branch of superior laryngeal nerve (EBSLN) provides motor innervation to the anterior 1/3 of the thyroarytenoid muscle which is the main adductor of the vocal cord through the human communicating nerve. Furthermore, approximately 1/3 of the cases, EBSLN may contribute to the innervation of posterior cricoarytenoid muscle which is the main abductor of ipsilateral vocal cord. RLN and/or EBSLN together with pharyngeal plexus usually contribute to the motor innervation of cricopharyngeal muscle that is the main component of upper esophageal sphincter. Traction trauma is the most common reason of RLN injuries and constitutes of 67–93% of cases. More than 50% of EBSLN injuries are caused by nerve transection. A specific point of injury on RLN can be detected in Type 1 (segmental) injury, however, Type 2 (global) injury is the loss of signal (LOS) throughout ipsilateral vagus-RLN axis and there is no electrophysiologically detectable point of injury. Vocal cord paralysis (VCP) develops in 70–80% of cases when LOS persists or incomplete recovery of signal occurs after waiting for 20 min. In case of complete recovery of signal, VCP is not expected. VCP is temporary in patients with incomplete recovery of signal and permanent VCP is not anticipated. Visual changes may be seen in only 15% of RLN injuries, on the other hand, IONM detects 100% of RLN injuries. IONM can prevent bilateral VCP. Continuous IONM (C-IONM) is a method in which functional integrity of vagus-RLN axis is evaluated in real time and C-IONM is superior to intermittent IONM (I-IONM). During upper pole dissection, IONM makes significant contributions to the visual and functional identification of EBSLN. Routine use of IONM may minimalize the risk of nerve injury. Reduction of amplitude more than 50% on CTM is related with poor voice outcome.
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17
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Continuous Intraoperative Recurrent Laryngeal Nerve Monitoring: Techniques, Applications, and Controversies. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00353-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Abstract
Purpose of Review
Purpose of the present review is to illustrate the current state of the art concerning continuous intraoperative recurrent laryngeal nerve monitoring (cIONM) for thyroid surgery.
Recent Findings
cIONM potentially leads to an improved postoperative vocal cord palsy rate, compared to the intermittent technique. There are currently two main approaches for cIONM: either conventional cIONM based on vagal nerve stimulation or experimental methods, which do not require the positioning of a vagal nerve electrode. One of these methods is the recently described technique “LAR-cIONM,” which utilizes the laryngeal adductor reflex.
Summary
cIONM represents an advancement of intermittent nerve monitoring, which allows for an immediate reaction to signal changes. Threshold values and guidelines to prevent recurrent laryngeal nerve palsy were validated for the direct stimulation of the vagal nerve and require verification for alterative cIONM methods, including LAR-cIONM.
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18
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Noda T, Ishisaka T, Okano K, Kobayashi Y, Shimode Y, Tsuji H. Experience with the use of intraoperative continuous nerve monitoring in video-assisted neck surgery and external cervical incisions. Laryngoscope Investig Otolaryngol 2021; 6:346-353. [PMID: 33869768 PMCID: PMC8035944 DOI: 10.1002/lio2.540] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/01/2021] [Accepted: 02/08/2021] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Recurrent laryngeal nerve (RLN) injury is one of the severe complications in thyroid surgery. Therefore, intraoperative nerve monitoring (IONM) has been widely used to identify the RLN and confirm its integrity. Recently, the usefulness of continuous IONM (CIONM) with automatic, periodic stimulation to the vagus nerve during thyroid surgery was reported. This study aimed to report our experience with minimally invasive video-assisted endoscopic endocrine neck surgery (VANS), during which, CIONM was successfully applied for the first time. METHODS Consecutive patients who underwent thyroid surgery with CIONM, performed in our department using either external neck incision surgery or VANS between July 2017 and June 2019, were retrospectively analyzed. RESULTS A total of 22 patients who underwent thyroid surgery with neck incision (14 cases; 7 men and 7 women; age, 21-75 years [mean, 52 years]) or VANS (8 cases; 8 women, age, 20-61 years [mean, 41 years]) were enrolled in this study. The addition of CIONM in VANS prolonged the operation's duration by approximately 30 minutes as the endoscopic surgery was technically more difficult. No intra- and postoperative incidence of transient or permanent RLN palsy was observed in any patient, except for three patients who underwent external neck incision surgery in whom combined resection was unavoidable due to tumor invasion of the RLN. CONCLUSION We reported the first successful application of CIONM during thyroidectomy using VANS. Future clinical trials should clarify the benefits of CIONM when compared to intermittent IONM in VANS. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Takuya Noda
- Department of Head and Neck SurgeryKanazawa Medical UniversityKahokuIshikawaJapan
| | - Tomo Ishisaka
- Department of Head and Neck SurgeryKanazawa Medical UniversityKahokuIshikawaJapan
| | - Keiichiro Okano
- Department of Head and Neck SurgeryKanazawa Medical UniversityKahokuIshikawaJapan
| | - Yoshiaki Kobayashi
- Department of Head and Neck SurgeryKanazawa Medical UniversityKahokuIshikawaJapan
| | - Yuzo Shimode
- Department of Head and Neck SurgeryKanazawa Medical UniversityKahokuIshikawaJapan
| | - Hiroyuki Tsuji
- Department of Head and Neck SurgeryKanazawa Medical UniversityKahokuIshikawaJapan
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19
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Setså EJ, Svendsen ØS, Husby PJ, Heimdal J, Stangeland L, Dahle GO, Brauckhoff K. An experimental study on intraoperative recovery of recurrent laryngeal nerve function. Laryngoscope Investig Otolaryngol 2020; 5:954-960. [PMID: 33134545 PMCID: PMC7585241 DOI: 10.1002/lio2.456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/08/2020] [Accepted: 08/28/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE If bilateral thyroid surgery is planned and staged thyroidectomy considered in case of loss of neuromonitoring signal (LOS), a waiting time of 20 minutes is suggested for evaluation of early nerve recovery. This recommendation is based on clinical observations and has not been thoroughly validated experimentally. METHODS Sixteen pigs were randomly studied, and electromyogram (EMG) was continuously recorded during traction injury until an amplitude decrease of 70% from baseline (BL) (16 nerves) or LOS (16 nerves), and further during 40-minute recovery time. At the end of the experiments, vocal cord twitch was evaluated by video-laryngoscopy. RESULTS In the 70% group, 8 of 16 nerves recovered to or above an amplitude of 50% of baseline after 20 minutes and finally one more after 40 minutes. In the LOS group, only one nerve showed recovery after 20 minutes and one more after 40 minutes. Video-laryngoscopy revealed good or strong vocal cord twitches, in 10 of 14 nerves in the 70% group and in only 2 of 14 nerves in the LOS group. CONCLUSIONS The overall intraoperative recovery was low after LOS. Even after 70% amplitude depression, only half of the nerves showed recovery to amplitudes ≥50% of BL. Nerve recovery is dynamic, and a waiting time of 20 minutes seems appropriate for the identification of early nerve recovery before decisions are taken to continue or terminate surgery. The final EMG amplitude was not always well correlated with estimated vocal cord twitch, evaluated by video-laryngoscopy. This observation needs further investigation.
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Affiliation(s)
- Erling J. Setså
- Department of Breast and Endocrine SurgeryHaukeland University HospitalBergenNorway
| | - Øyvind S. Svendsen
- Department of Anesthesia and Intensive CareHaukeland University HospitalBergenNorway
| | - Paul J. Husby
- Department of Anesthesia and Intensive CareHaukeland University HospitalBergenNorway
| | - John‐Helge Heimdal
- Department of SurgeryHaukeland University HospitalBergenNorway
- Department of Clinical SciencesUniversity of BergenBergenNorway
| | | | - Geir O. Dahle
- Department of Anesthesia and Intensive CareHaukeland University HospitalBergenNorway
| | - Katrin Brauckhoff
- Department of Breast and Endocrine SurgeryHaukeland University HospitalBergenNorway
- Department of Clinical SciencesUniversity of BergenBergenNorway
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20
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Moreira A, Forrest E, Lee JC, Paul E, Yeung M, Grodski S, Serpell JW. Investigation of recurrent laryngeal palsy rates for potential associations during thyroidectomy. ANZ J Surg 2020; 90:1733-1737. [PMID: 32783252 DOI: 10.1111/ans.16166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are many clinical associations and potential mechanisms of injury resulting in recurrent laryngeal nerve palsy (RLNP) after thyroidectomy. One possible cause of RLNP is focal intralaryngeal compression of the recurrent laryngeal nerve (RLN), which may be associated with the tracheal tube (TT). Therefore, we examined current RLNP rates to investigate potential associations, including intralaryngeal, airway, anaesthetic and anthropometric factors. METHODS We analysed 1003 patients undergoing thyroid surgery at The Alfred from 2010 to 2017, who had anatomically intact RLNs at the conclusion of thyroidectomy. All included patients underwent pre- and post-operative flexible nasendoscopy. The primary outcome was RLNP rate. We analysed potential associated factors including age, sex, operative time, surgical indication, pathology, American Society of Anaesthesiologists Physical Status, Mallampati scores, body mass index, intubation grade, TT size and specimen weight. The independent risk factors were identified by logistic regression analysis. RESULTS Overall, RLNP occurred in 83 patients (8.3%) of which one was permanent (0.1%). On univariate analysis, RLNP was associated with male sex (P = 0.02), and duration of surgery (P = 0.002). On multivariate analysis, both male sex (P = 0.047) and duration of surgery (P = 0.04) remained significant. Further, factors postulated to cause intralaryngeal compression of the RLN, including TT size, body mass index, intubation grade and Mallampati score, were not significantly associated with RLNP. CONCLUSION Our study showed a RLNP rate of 8.3%, and associations with longer operative duration, and male sex. Potential intralaryngeal factors were not identified.
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Affiliation(s)
- Alayne Moreira
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Edward Forrest
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - James C Lee
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Eldho Paul
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Meei Yeung
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Simon Grodski
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Jonathan W Serpell
- Monash University Endocrine Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
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21
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Huang TY, Lin YC, Tseng HY, Dionigi G, Kim HY, Chai YJ, Lu IC, Chang PY, Chiang FY, Wu CW. Safety parameters of ferromagnetic device during thyroid surgery: Porcine model using continuous neuromonitoring. Head Neck 2020; 42:2931-2940. [PMID: 32567742 DOI: 10.1002/hed.26334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/28/2020] [Accepted: 05/30/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The ferromagnetic (FM) device is a new surgical energy modality. This study investigated dynamic recurrent laryngeal nerve (RLN) electromyographic (EMG) data to define safety parameters for using FM devices in thyroidectomy. METHODS Real-time EMG tracings obtained under continuous neuromonitoring were recorded from 24 RLNs (12 piglets). In the activation study, FM devices were activated at varying distances from the RLN. In the cooling study, FM devices were cooled for varying time intervals, or muscle touch maneuver was performed, before contact with the RLN. RESULTS During the FMwand/FMsealer activation, no adverse EMG events occurred at distances of 2 mm or longer. The cooling study revealed no adverse EMG events after 1-second (FMwand) or 3-second (FMsealer) intervals or after muscle touch maneuver. CONCLUSIONS An FM device should be activated at a distance of 2 mm from the RLN and should be adequately cooled before further contact with the RLN. Surgeons can avoid RLN injury by observing standard procedures for using FM devices.
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Affiliation(s)
- Tzu-Yen Huang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Biological Science and Technology, National Chiao Tung University, Taiwan
| | - Yi-Chu Lin
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Yi Tseng
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University College of Medicine, Seoul, South Korea
| | - Young Jun Chai
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.,Department of Otolaryngology, E-Da Hospital, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Faculty of Medicine, College of Medicine, and Cohort Research Center, Kaohsiung Medical University, Shin-Chuan 1st Road, Kaohsiung, Sanmin Dist., 80708, Taiwan
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22
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Amano S, Shibasaki S, Tomatsu M, Nakamura K, Nakauchi M, Nakamura T, Kikuchi K, Kadoya S, Inaba K, Uyama I. Clinical Experience with the Continuous Intraoperative Nerve Monitoring System in Mediastinoscopic Esophagectomy. THE JAPANESE JOURNAL OF GASTROENTEROLOGICAL SURGERY 2020; 53:524-532. [DOI: 10.5833/jjgs.2017.0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
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23
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Sinclair CF, Téllez MJ, Ulkatan S. Continuous Laryngeal Adductor Reflex Versus Intermittent Nerve Monitoring in Neck Endocrine Surgery. Laryngoscope 2020; 131:230-236. [PMID: 32364626 DOI: 10.1002/lary.28710] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/01/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Intraoperative neuromonitoring (IONM) techniques aim to identify and potentially prevent nerve injury during surgeries. Prior studies into the efficacy of recurrent laryngeal nerve (RLN) IONM convey mixed results, with some claiming equivalence between IONM and no monitoring at all. The goal of the current study was to compare continuous RLN monitoring using the laryngeal adductor reflex (LAR) to intermittent RLN monitoring (intermittent IONM) to determine whether continuous monitoring reduces the incidence of intraoperative RLN injury during neck endocrine surgeries. METHODS In this observational, historical case-control study, a historical cohort of patients monitored with intermittent-IONM (group 1, n = 130) were compared to prospectively collected data from consecutive nerves-at-risk monitored continuously with the LAR (LAR-CIONM, group 2, n = 205), at a single center by a single surgeon. The test benefit ratio and relative risk reduction (RRR) for LAR-CIONM over intermittent IONM were calculated. RESULTS For group 1, nine nerves at risk exhibited intraoperative LOS with transient postoperative vocal fold (VF) hypomobility (n = 2) or immobility (VFI, n = 7). For group 2, two nerves at risk (0.98%) had sudden intraoperative LAR LOS following bipolar cautery, resulting in postoperative transient VFI (P = .004). In each group, there was one case of permanent postoperative VFI. The test benefit rate ratio for LAR-CIONM demonstrated a dramatic effect at 5.23, with an RRR of 81.0%. CONCLUSION LAR-CIONM significantly decreased rates of postoperative transient VF paralysis and paresis over intermittent IONM alone (P = .004). Surgeons should be aware of the benefits and limitations of intermittent IONM versus CIONM. Intermittent IONM, although useful in nerve mapping and intraoperative decision making, has minimal benefit for the prevention of nerve injury, whereas CIONM can potentially reduce nerve injury rates and improve patient outcomes. LEVEL OF EVIDENCE 3 Laryngoscope, 131:230-236, 2021.
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Affiliation(s)
- Catherine F Sinclair
- Department of Otolaryngology Head and Neck Surgery, Mount Sinai West Hospital, New York, NY, USA
| | - Maria J Téllez
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, NY, USA
| | - Sedat Ulkatan
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, NY, USA
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24
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Dahle GO, Setså EJ, Svendsen ØS, Stangeland L, Heimdal J, Henriksen B, Husby P, Brauckhoff K. Vocal cord function during recurrent laryngeal nerve injury assessed by accelerometry and EMG. Laryngoscope 2020; 130:1090-1096. [DOI: 10.1002/lary.28215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/13/2019] [Accepted: 07/09/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Geir Olav Dahle
- Department of Anaesthesia and Intensive CareHaukeland University Hospital Bergen Norway
| | - Erling Johan Setså
- Department of Breast and Endocrine SurgeryHaukeland University Hospital Bergen Norway
| | | | - Lodve Stangeland
- Department of Clinical ScienceUniversity of Bergen Bergen Norway
| | - John‐Helge Heimdal
- Clinic of SurgeryHaukeland University Hospital Bergen Norway
- Department of Clinical ScienceUniversity of Bergen Bergen Norway
| | - Bård Henriksen
- NORCE Norwegian Research Centre ASUniversity of Bergen Bergen Norway
| | - Paul Husby
- Department of Anaesthesia and Intensive CareHaukeland University Hospital Bergen Norway
- Department of Clinical MedicineUniversity of Bergen Bergen Norway
| | - Katrin Brauckhoff
- Department of Breast and Endocrine SurgeryHaukeland University Hospital Bergen Norway
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25
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Schneider R, Machens A, Lorenz K, Dralle H. Intraoperative nerve monitoring in thyroid surgery-shifting current paradigms. Gland Surg 2020; 9:S120-S128. [PMID: 32175252 DOI: 10.21037/gs.2019.11.04] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Over the past two decades, intraoperative neural monitoring (IONM) has matured into a powerful risk minimization tool. Meta-analyses of studies, most of which were limited by poor study designs and the sole use of intermittent nerve stimulation, failed to demonstrate superiority of IONM over anatomic recurrent laryngeal nerve (RLN) dissection in the absence of IONM. With the advent of continuous IONM (CIONM), intraoperative nerve electromyographic tracings, registered almost in real time during the operation, accurately predict postoperative vocal fold function when International Neural Monitoring Study Group quality standards are adhered to. CIONM aids in avoiding permanent traction-related nerve injury by urging surgeons to reverse harmful surgical maneuvers. CIONM also forms an integral part in the surgical concept of staged thyroidectomy. Delaying completion surgery on the other side until nerve function has recovered mitigates the risk of bilateral vocal fold palsy. CIONM has greatly furthered our understanding of functional RLN injury, enabling conception of effective risk minimization strategies tailored to the individual patient. The review summarizes the advances of continuous IONM technology that caused a quantum leap in risk minimization for thyroid surgery, shifting current paradigms.
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Affiliation(s)
- Rick Schneider
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Andreas Machens
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kerstin Lorenz
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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Sinclair CF, Téllez MJ, Sánchez Roldán MA, Ulkatan S. Laryngeal adductor reflex hyperexcitability may predict permanent vocal fold paralysis. Laryngoscope 2019; 130:E625-E627. [PMID: 31854459 DOI: 10.1002/lary.28477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/01/2019] [Accepted: 11/20/2019] [Indexed: 11/07/2022]
Abstract
Laryngeal adductor reflex-continuous intraoperative neuromonitoring (LAR-CIONM) is a novel method of continuous intraoperative neuromonitoring. In contrast to other vagal nerve monitoring techniques, which elicit a laryngeal compound muscle action potential, LAR-CIONM elicits a laryngeal reflex response (LAR). In 300 nerves at risk monitored with LAR-CIONM, two patients have had postoperative permanent vocal fold immobility (VFI). Both patients exhibited a significant LAR amplitude increase prior to complete loss of signal. No other patients have exhibited LAR hyperexcitability. If confirmed in a larger sample, this represents the first time that a vagal intraoperative neuromonitoring technique can distinguish transient from permanent VFI, which could improve patient outcomes. Laryngoscope, 2019 Laryngoscope, 130:E625-E627, 2020.
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Affiliation(s)
- Catherine F Sinclair
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai West Hospital, New York, New York, U.S.A
| | - Maria J Téllez
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York, U.S.A
| | - M Angeles Sánchez Roldán
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York, U.S.A
| | - Sedat Ulkatan
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York, U.S.A
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27
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Donatini G, Danion J, Zerrweck C, Etienne P, Lacoste L, Kraimps JL. Single Dose Steroid Injection After Loss of Signal (LOS) During Thyroid Surgery is Effective to Recover Electric Signal Avoiding Vocal Cord Palsy and the Need of Staged Thyroidectomy: Prospective Evaluation on 702 Patients. World J Surg 2019; 44:417-425. [PMID: 31741073 DOI: 10.1007/s00268-019-05295-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Gianluca Donatini
- General and Endocrine Surgery, CHU Poitiers, University of Poitiers, 2 Rue de la Miletrie, 86021, Poitiers, France.
| | - Jerome Danion
- General and Endocrine Surgery, CHU Poitiers, University of Poitiers, 2 Rue de la Miletrie, 86021, Poitiers, France
| | | | - Pierre Etienne
- General and Endocrine Surgery, CHU Poitiers, University of Poitiers, 2 Rue de la Miletrie, 86021, Poitiers, France
| | - Louis Lacoste
- Department of Anesthesia CHU Poitiers, University of Poitiers, Poitiers, France
| | - Jean-Louis Kraimps
- General and Endocrine Surgery, CHU Poitiers, University of Poitiers, 2 Rue de la Miletrie, 86021, Poitiers, France
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28
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Changes in Tracheal Tube Cuff Pressure and Recurrent Laryngeal Nerve Conductivity During Thyroid Surgery. World J Surg 2019; 44:328-333. [DOI: 10.1007/s00268-019-05185-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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29
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Schneider R, Machens A, Randolph G, Kamani D, Lorenz K, Dralle H. Impact of continuous intraoperative vagus stimulation on intraoperative decision making in favor of or against bilateral surgery in benign goiter. Best Pract Res Clin Endocrinol Metab 2019; 33:101285. [PMID: 31221571 DOI: 10.1016/j.beem.2019.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The advent of continuous vagus stimulation (CVS), eliminating lag time between nerve preparation with potential trauma and stimulation, has transformed the intraoperative surgical strategy in thyroid surgery. Continuous intraoperative nerve monitoring empowers the surgeon to be optimally aware of traction-related injury to the recurrent laryngeal nerve (RLN). Electromyographic precursor lesions, called combined events, prompt surgeons to cease harmful surgical maneuvers and release the nerve before damage to the nerve is established. Complete RLN recovery, defined as restitution of the nerve amplitude to ≥50% of baseline, assures the surgeon that it is safe to pursue completion surgery of the contralateral side in one procedure. If this restitution is incomplete or absent (<50% of amplitude baseline) immediate vocal cord paralysis is likely and it is advisable to delay completion surgery until the nerve has fully recovered. This review summarizes the tremendous progress made in this dynamic field, delineating the extent to which CVS has changed the landscape: tailoring intraoperative decision making to determine the safest course of action for patients with benign goiter.
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Affiliation(s)
- Rick Schneider
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
| | - Andreas Machens
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Gregory Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA; Division of Surgical Oncology, Endocrine Surgery Service, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Kerstin Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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30
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Sun H, Kim HY, Carcoforo P, Dionigi G. Cost and training are diffusion patterns limits for neural monitoring in thyroid surgery. Gland Surg 2019; 8:334-335. [PMID: 31538633 PMCID: PMC6723017 DOI: 10.21037/gs.2018.11.08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 11/25/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun 130033, China
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, Korea
| | - Paolo Carcoforo
- Department of Surgery and Department of Morphology, Surgery and Experimental Medicine, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University Hospital G. Martino, University of Messina, Messina, Italy
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31
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Randolph GW, Kamani D. In Response to letter to the editor regarding International Neuromonitoring Study Group Guidelines 2018: Part II: Optimal Recurrent Laryngeal Nerve Management for Invasive Thyroid Cancer-Incorporation of Surgical, Laryngeal, and Neural Electrophysiologic Data. Laryngoscope 2019; 129:E306. [PMID: 31070243 DOI: 10.1002/lary.28055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 04/22/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Gregory W Randolph
- Department of Otolaryngology, Thyroid and Parathyroid Endocrine Surgery Division, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Dipti Kamani
- Department of Otolaryngology, Thyroid and Parathyroid Endocrine Surgery Division, Massachusetts Eye and Ear, Boston, Massachusetts
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32
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Wu CW, Dionigi G, Barczynski M, Chiang FY, Dralle H, Schneider R, Al-Quaryshi Z, Angelos P, Brauckhoff K, Brooks JA, Cernea CR, Chaplin J, Chen AY, Davies L, Diercks GR, Duh QY, Fundakowski C, Goretzki PE, Hales NW, Hartl D, Kamani D, Kandil E, Kyriazidis N, Liddy W, Miyauchi A, Orloff L, Rastatter JC, Scharpf J, Serpell J, Shin JJ, Sinclair CF, Stack BC, Tolley NS, Slycke SV, Snyder SK, Urken ML, Volpi E, Witterick I, Wong RJ, Woodson G, Zafereo M, Randolph GW. International neuromonitoring study group guidelines 2018: Part II: Optimal recurrent laryngeal nerve management for invasive thyroid cancer-incorporation of surgical, laryngeal, and neural electrophysiologic data. Laryngoscope 2018; 128 Suppl 3:S18-S27. [PMID: 30291765 DOI: 10.1002/lary.27360] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/22/2018] [Accepted: 05/24/2018] [Indexed: 12/30/2022]
Abstract
The purpose of this publication was to inform surgeons as to the modern state-of-the-art evidence-based guidelines for management of the recurrent laryngeal nerve invaded by malignancy through blending the domains of 1) surgical intraoperative information, 2) preoperative glottic function, and 3) intraoperative real-time electrophysiologic information. These guidelines generated by the International Neural Monitoring Study Group (INMSG) are envisioned to assist the clinical decision-making process involved in recurrent laryngeal nerve management during thyroid surgery by incorporating the important information domains of not only gross surgical findings but also intraoperative recurrent laryngeal nerve functional status and preoperative laryngoscopy findings. These guidelines are presented mainly through algorithmic workflow diagrams for convenience and the ease of application. These guidelines are published in conjunction with the INMSG Guidelines Part I: Staging Bilateral Thyroid Surgery With Monitoring Loss of Signal. Level of Evidence: 5 Laryngoscope, 128:S18-S27, 2018.
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Affiliation(s)
- Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Marcin Barczynski
- Department of Endocrine Surgery, Jagiellonian University, Third Chair of General Surgery, Krakow, Poland
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Henning Dralle
- Department of General Surgery, University Hospital Halle, Halle/Saale, Germany
| | - Rick Schneider
- Department of General, Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Zaid Al-Quaryshi
- Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Peter Angelos
- Division of Endocrine Surgery, Department of Surgery, University of Chicago, Chicago, Illinois, U.S.A
| | - Katrin Brauckhoff
- Department of Breast and Endocrine Surgery, Haukeland University Hospital, Bergen, Norway
| | - Jennifer A Brooks
- Department of Otolaryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Claudio R Cernea
- Department of Head and Neck Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - John Chaplin
- Department of Otolaryngology-Head and Neck Surgery, Gillies Hospital and Clinics, Epsom, New Zealand
| | - Amy Y Chen
- VA Endocrine Surgery, Department of Otolaryngology Emory University School of Medicine, Atlanta, GA, USA
| | - Louise Davies
- Outcomes Group, Veterans Affairs Medical Center, Norwich, Vermont, U.S.A
| | - Gill R Diercks
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Quan Yang Duh
- Department of Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Christopher Fundakowski
- Department of Otolaryngology-Head and Neck Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, U.S.A
| | - Peter E Goretzki
- P.G. Stadtische Kliniken Neuss Lukaskrankenhaus GmbH, Neuss, Nordrhein-Westfalen, DE
| | - Nathan W Hales
- Department of Otolaryngology, Uniformed Services of the Health Sciences, San Antonio, Texas, U.S.A.,San Antonio Head and Neck, San Antonio, Texas, U.S.A
| | - Dana Hartl
- Department of Otolaryngology Head and Neck Surgery, Gustave Roussy Institute, Villejuif, France
| | - Dipti Kamani
- Department of Otolaryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Natalia Kyriazidis
- Department of Otolaryngology, State University of New York Upstate Medical University, Syracuse, New York, U.S.A
| | - Whitney Liddy
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | | | - Lisa Orloff
- Department of Otolaryngology, Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Jeff C Rastatter
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Joseph Scharpf
- Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Jonathan Serpell
- Breast, Endocrine and General Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University School of Languages, Literatures, Cultures, and Linguistics, Clayton, Victoria, Australia
| | - Jennifer J Shin
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Catherine F Sinclair
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Beth Israel, Icahn School of Medicine, New York, New York, U.S.A
| | - Brendan C Stack
- Department of Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Neil S Tolley
- Department of Otolaryngology-Head and Neck Surgery, Imperial College Hospitals NHS Trust, St. Mary's Hospital, London, United Kingdom
| | | | - Samuel K Snyder
- Department of General Surgery, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, U.S.A
| | - Mark L Urken
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Beth Israel, Icahn School of Medicine, New York, New York, U.S.A
| | - Erivelto Volpi
- Clinics Hospital, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ian Witterick
- Department of Otolaryngology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Richard J Wong
- Department of Surgery-Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York, U.S.A
| | | | - Mark Zafereo
- Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Gregory W Randolph
- Department of Otolaryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A.,Division of Surgical Oncology, Endocrine Surgery Service, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
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33
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Schneider R, Randolph GW, Dionigi G, Wu CW, Barczynski M, Chiang FY, Al-Quaryshi Z, Angelos P, Brauckhoff K, Cernea CR, Chaplin J, Cheetham J, Davies L, Goretzki PE, Hartl D, Kamani D, Kandil E, Kyriazidis N, Liddy W, Orloff L, Scharpf J, Serpell J, Shin JJ, Sinclair CF, Singer MC, Snyder SK, Tolley NS, Van Slycke S, Volpi E, Witterick I, Wong RJ, Woodson G, Zafereo M, Dralle H. International neural monitoring study group guideline 2018 part I: Staging bilateral thyroid surgery with monitoring loss of signal. Laryngoscope 2018; 128 Suppl 3:S1-S17. [DOI: 10.1002/lary.27359] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Rick Schneider
- Martin Luther University Halle-Wittenberg; Department of General, Visceral, and Vascular Surgery; Halle Germany
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Harvard Medical School; Boston Massachusetts
- Division of Surgical Oncology, Endocrine Surgery Service, Department of Surgery; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - Gianlorenzo Dionigi
- Division for Endocrine Surgery, at the Department of Human Pathology in Adulthood and Childhood “G. Barresi,” University Hospital G. Martino; University of Messina; Italy
| | - Che-Wei Wu
- Kaohsiung Medical University Hospital, Kaohsiung Medical University; Otolaryngology-Head and Neck Surgery; Kaohsiung Taiwan
| | - Marcin Barczynski
- Jagiellonian University, Department of Endocrine Surgery, Third Chair of General Surgery; Krakow Poland
| | - Feng-Yu Chiang
- Kaohsiung Medical University Hospital, Kaohsiung Medical University; Otolaryngology-Head and Neck Surgery; Kaohsiung Taiwan
| | - Zaid Al-Quaryshi
- University of Iowa Hospitals and Clinics, Otolaryngology; Iowa City Iowa
| | - Peter Angelos
- University of Chicago; Division of Endocrine Surgery, Department of Surgery; Chicago Illinois
| | - Katrin Brauckhoff
- Haukeland Universitetssjukehus; Department of Breast and Endocrine Surgery; Bergen Norway
| | - Claudio R. Cernea
- University of Sao Paulo Medical School; Department of Head and Neck Surgery; Sao Paulo SP Brazil
| | | | - Jonathan Cheetham
- Cornell University, Clinical Sciences, College of Veterinary Medicine; Ithaca New York
| | - Louise Davies
- VA Outcomes Group at the Veterans Affairs Medical Center; Norwich Vermont
| | - Peter E. Goretzki
- Stadtische Kliniken Neuss Lukaskrankenhaus GmbH; Neuss Nordrhein-Westfalen Germany
| | - Dana Hartl
- Institut Gustave Roussy, Otolaryngology Head & Neck Surgery; Villejuif France
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Harvard Medical School; Boston Massachusetts
| | - Emad Kandil
- Department of Surgery; Tulane University School of Medicine; New Orleans Louisiana
| | - Natalia Kyriazidis
- State University of New York Upstate Medical University; Otolaryngology; Syracuse New York
| | - Whitney Liddy
- Northwestern University Feinberg School of Medicine Department of Psychiatry and Behavioral Sciences, Otolaryngology; Chicago Illinois
| | - Lisa Orloff
- Stanford University School of Medicine, Otolaryngology, Division of Head and Neck Surgery; Stanford California
| | | | - Jonathan Serpell
- Alfred Hospital; Melbourne Victoria Australia
- Monash University School of Languages Literatures Cultures and Linguistics; Clayton Victoria Australia
| | | | | | - Michael C. Singer
- Henry Ford Hospital, Otolaryngology-Head & Neck Surgery; Detroit Michigan
| | - Samuel K. Snyder
- University of Texas Rio Grande Valley School of Medicine; Department of General Surgery; Edinburg Texas
| | - Neil S. Tolley
- St. Mary's Hospital, Imperial College Hospitals NHS Trust, St. Mary's Hospital; London United Kingdom
| | | | - Erivelto Volpi
- Hospital das Clinicas-University of Sao Paulo Medical School; Sao Paulo Brazil
| | - Ian Witterick
- Mount Sinai Hospital; Department of Otolaryngology; Toronto Ontario Canada
| | - Richard J. Wong
- Memorial Sloan-Kettering Cancer Center, Department of Surgery, Head and Neck Service; New York New York
| | | | - Mark Zafereo
- MD Anderson Cancer Center, Head and Neck Surgery; Houston Texas U.S.A
| | - Henning Dralle
- Allgemeinchirurgie, Uniklinik Halle; Halle/Saale Germany
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34
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Schneider R, Randolph G, Dionigi G, Barczynski M, Chiang FY, Wu CW, Musholt T, Uludag M, Makay Ö, Sezer A, Teksöz S, Weber T, Sekulla C, Lorenz K, Özdemir M, Machens A, Dralle H. Prediction of Postoperative Vocal Fold Function After Intraoperative Recovery of Loss of Signal. Laryngoscope 2018; 129:525-531. [DOI: 10.1002/lary.27327] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 05/09/2018] [Accepted: 05/16/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Rick Schneider
- Department of Visceral, Vascular, and Endocrine Surgery; University Hospital of Martin Luther University; Halle (Saale) Germany
| | - Gregory Randolph
- Division of Thyroid and Parathyroid Surgery; Harvard Medical School; Boston Massachusetts U.S.A
| | - Gianlorenzo Dionigi
- Department of Human Pathology in Adulthood and Childhood “G. Barresi”; University Hospital “G. Martino,” University of Messina; Messina Italy
| | - Marcin Barczynski
- Department of Endocrine Surgery, Third Chair of General Surgery; Jagiellonian University Medical College, Faculty of Medicine; Kraków Poland
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery; Kaohsiung Medical University; Kaohsiung Taiwan
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery; Kaohsiung Medical University; Kaohsiung Taiwan
| | - Thomas Musholt
- Endocrine Surgery Section, Clinic of General, Visceral and Transplantation Surgery; University Medical Center; Mainz Germany
| | - Mehmet Uludag
- Department of General Surgery, Sisli Hamidiye Etfal Medical Practice and Research Center; University of Health Sciences; Istanbul Turkey
| | - Özer Makay
- Department of General Surgery; Ege University; Izmir Turkey
| | - Atakan Sezer
- Department of General Surgery; Trakya University; Edirne Turkey
| | - Serkan Teksöz
- Department of General Surgery; Cerrahpasa Medical Faculty; Istanbul Turkey
| | - Theresia Weber
- Department of Endocrine Surgery; Catholic Hospital; Mainz Germany
| | - Carsten Sekulla
- Department of Visceral, Vascular, and Endocrine Surgery; University Hospital of Martin Luther University; Halle (Saale) Germany
| | - Kerstin Lorenz
- Department of Visceral, Vascular, and Endocrine Surgery; University Hospital of Martin Luther University; Halle (Saale) Germany
| | - Murat Özdemir
- Department of General Surgery; Ege University; Izmir Turkey
| | - Andreas Machens
- Department of Visceral, Vascular, and Endocrine Surgery; University Hospital of Martin Luther University; Halle (Saale) Germany
| | - Henning Dralle
- Department of General, Visceral, and Transplantation Surgery, Section of Endocrine Surgery; University of Duisburg-Essen; Essen Germany
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35
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Marin Arteaga A, Peloni G, Leuchter I, Bedat B, Karenovics W, Triponez F, Sadowski SM. Modification of the Surgical Strategy for the Dissection of the Recurrent Laryngeal Nerve Using Continuous Intraoperative Nerve Monitoring. World J Surg 2018; 42:444-450. [PMID: 28986621 DOI: 10.1007/s00268-017-4277-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to describe first experiences and changes in management using continuous intraoperative neuromonitoring (C-IONM) in thyroid and parathyroid surgery. METHOD Retrospective analysis of patients who underwent surgery with C-IONM since 2012. Surgical maneuvers were modified when electrophysiologic events occurred. Patients with persistent loss of signal (LOS) underwent postoperative laryngoscopy. RESULTS One hundred and one patients (of 1586 neck surgeries) were included and 19 had events: In 13 these were temporary (resolved before end of surgery) and led to intraoperative modifications in surgical approach; in all cases traction was released, and in 8, recurrent laryngeal nerve (RLN) approach was changed [superior approach (2), inferior approach (2), both (4)]. Six patients had persistent LOS (5.9%, present at end of procedure), with RLN palsy (RLNP) on postoperative day 1: In three, LOS occurred at electrode placement on the vagus nerve, leading to distal placement of the electrode allowing ipsilateral dissection under continuous monitoring; all three had complete recovery at 6 months. In the three other patients, LOS occurred on the RLN: one probable thermal, one traction lesion and one accidental section of the anterior RLN branch. The RLN recovered within 6 months in two patients, and in the third, RLNP persisted after 6 months (1/101 = 1%). CONCLUSION C-IONM provides real-time evaluation of the RLN function, allowing for adaptation of surgical maneuvers to prevent RLNP. It seems particularly useful in difficult cases like redo neck surgery, invasive thyroid cancer and intrathoracic or large goiter. Care should be given at electrode placement on the vagus nerve.
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Affiliation(s)
- Andres Marin Arteaga
- General Surgery, University Hospitals of Geneva, Geneva, Switzerland
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Rue Gabrielle Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Giuseppe Peloni
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Rue Gabrielle Perret-Gentil 4, 1211, Geneva 14, Switzerland
- Ospedale Regionale di Mendrisio, Via Turconi 23, 6850, Mendrisio, Switzerland
| | - Igor Leuchter
- Ear-Nose-Throat Division, University Hospitals of Geneva, Geneva, Switzerland
| | - Benoit Bedat
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Rue Gabrielle Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Wolfram Karenovics
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Rue Gabrielle Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Frederic Triponez
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Rue Gabrielle Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Samira Mercedes Sadowski
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Rue Gabrielle Perret-Gentil 4, 1211, Geneva 14, Switzerland.
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Pardal-Refoyo JL, Parente-Arias P, Arroyo-Domingo MM, Maza-Solano JM, Granell-Navarro J, Martínez-Salazar JM, Moreno-Luna R, Vargas-Yglesias E. Recomendaciones sobre el uso de la neuromonitorización en cirugía de tiroides y paratiroides. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2018; 69:231-242. [DOI: 10.1016/j.otorri.2017.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 06/15/2017] [Indexed: 11/27/2022]
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Recommendations on the Use of Neuromonitoring in Thyroid and Parathyroid Surgery. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2018. [DOI: 10.1016/j.otoeng.2017.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Schneider R, Machens A, Sekulla C, Lorenz K, Weber F, Dralle H. Twenty-year experience of paediatric thyroid surgery using intraoperative nerve monitoring. Br J Surg 2018. [PMID: 29532905 DOI: 10.1002/bjs.10792] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND There are few data on intermittent and continuous intraoperative nerve monitoring (IONM) during thyroidectomy in children. METHODS All children aged 18 years or younger who had standard thyroid operations using intermittent or continuous IONM between January 1998 and December 2016 were included in the study. The impact of age and type of IONM on basal amplitude, latency and complications after thyroidectomy were assessed. RESULTS A total of 504 children were included in the study. With continuous IONM, median basal amplitude and latency increased significantly with age, more on the left side (from 199 to 870 μV, and from 3·88 to 5·75 ms) than on the right (from 340 to 778 μV, and from 2·63 to 3·50 ms). Compared with intermittent IONM with needle electrode, continuous IONM with tube electrode resulted in an increase in median basal amplitude in children aged 13-18 years on both sides (from 675 to 778 μV on the right and from 450 to 870 μV on the left), and a decrease in median latency in all children older than 3 years: in children aged 4-6 years, from 4·20 to 3·00 ms on the right and from 6·10 to 4·63 ms on the left; in children aged 7-12 years, from 4·60 to 3·50 ms and from 6·00 to 5·25 ms respectively; and in children aged 13-18 years, from 4·60 to 3·50 ms and from 6·40 to 5·75 ms. Overall, wound infection, but not bleeding/haematoma or vocal fold palsy, affected younger children more: 3 per cent of children aged 3 years or less; 2 per cent of children aged 4-6 years; and 0 per cent of children aged over 6 years (P = 0·031). With continuous IONM, no wound infection, bleeding/haematoma or permanent vocal fold palsy was noted in any age group. CONCLUSION Continuous IONM measures nerve electrophysiology more accurately than intermittent IONM during thyroidectomy in children.
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Affiliation(s)
- R Schneider
- Department of General, Visceral and Vascular Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - A Machens
- Department of General, Visceral and Vascular Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - C Sekulla
- Department of General, Visceral and Vascular Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - K Lorenz
- Department of General, Visceral and Vascular Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - F Weber
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
| | - H Dralle
- Department of General, Visceral and Vascular Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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Schneider R, Machens A, Randolph GW, Kamani D, Lorenz K, Dralle H. Opportunities and challenges of intermittent and continuous intraoperative neural monitoring in thyroid surgery. Gland Surg 2017; 6:537-545. [PMID: 29142846 DOI: 10.21037/gs.2017.06.08] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The number of thyroid operations and there radically continues to rise in the western hemisphere, bringing prevention of recurrent laryngeal nerve (RLN) palsy to the fore. Overall, the incidence of RLN palsy is fairly low but continues to prompt litigation for malpractice. In an effort to diminish transient, and more importantly permanent, RLN palsy rates, intraoperative neuromonitoring (IONM) has been advocated as a risk minimization tool. Recent meta-analyses of studies, many of which were limited by poor study design and the sole use of intermittent nerve stimulation, were unable to demonstrate superiority of IONM over mere anatomic RLN dissection. This is where continuous IONM (CIONM) comes into play: this technology enables the surgeon to (I) identify impending nerve injury as it unfolds; (II) release distressed nerves by reversing causative surgical maneuvers; and (III) verify functional nerve recovery after intraoperative loss of the electromyographic signal. Despite this superiority, CIONM is not devoid of methodological limitations, which need to be accounted for. This review summarizes the current key achievements of IONM; outlines opportunities for improvement regarding clinical implementation; and suggests areas of future research in this rapidly evolving field.
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Affiliation(s)
- Rick Schneider
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Andreas Machens
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Kerstin Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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Brauckhoff K, Svendsen ØS, Stangeland L, Biermann M, Aas T, Husby PJA. Injury mechanisms and electromyographic changes after injury of the recurrent laryngeal nerve: Experiments in a porcine model. Head Neck 2017; 40:274-282. [DOI: 10.1002/hed.24940] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/19/2017] [Accepted: 07/28/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Katrin Brauckhoff
- Department of Breast and Endocrine Surgery; Haukeland University Hospital; Bergen Norway
| | - Øyvind S. Svendsen
- Department of Anesthesia and Intensive Care; Haukeland University Hospital; Bergen Norway
| | - Lodve Stangeland
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - Martin Biermann
- Department of Radiology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Turid Aas
- Department of Breast and Endocrine Surgery; Haukeland University Hospital; Bergen Norway
| | - Paul J. A. Husby
- Department of Anesthesia and Intensive Care; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
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Zhang D, Li F, Wu CW, Liu X, Xin J, Chiang FY, Sun H. Percutaneous probe stimulation for intraoperative neuromonitoring in total endoscopic thyroidectomy: A preliminary experience. Head Neck 2017; 39:1001-1007. [PMID: 28245074 DOI: 10.1002/hed.24734] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 11/19/2016] [Accepted: 12/29/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Daqi Zhang
- Department of Thyroid Surgery; China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine; Changchun City Jilin Province People's Republic of China
| | - Fang Li
- Department of Thyroid Surgery; China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine; Changchun City Jilin Province People's Republic of China
| | - Che-Wei Wu
- Department of Otolaryngology - Head and Neck Surgery; Kaohsiung Medical University Hospital; Faculty of Medicine, College of Medicine, Kaohsiung Medical University; Kaohsiung City Taiwan
| | - Xiaoli Liu
- Department of Thyroid Surgery; China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine; Changchun City Jilin Province People's Republic of China
| | - Jingwei Xin
- Department of Thyroid Surgery; China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine; Changchun City Jilin Province People's Republic of China
| | - Feng-Yu Chiang
- Department of Otolaryngology - Head and Neck Surgery; Kaohsiung Medical University Hospital; Faculty of Medicine, College of Medicine, Kaohsiung Medical University; Kaohsiung City Taiwan
| | - Hui Sun
- Department of Thyroid Surgery; China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine; Changchun City Jilin Province People's Republic of China
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Schneider R, Randolph GW, Barczynski M, Dionigi G, Wu CW, Chiang FY, Machens A, Kamani D, Dralle H. Continuous intraoperative neural monitoring of the recurrent nerves in thyroid surgery: a quantum leap in technology. Gland Surg 2016; 5:607-616. [PMID: 28149807 PMCID: PMC5233836 DOI: 10.21037/gs.2016.11.10] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 10/18/2016] [Indexed: 12/28/2022]
Abstract
The continuous intraoperative neural monitoring (CIONM) technique is increasingly acknowledged as a useful tool to recognize impending nerve injury and to abort the related manoeuvre to prevent nerve injury during thyroid surgery. CIONM provides valuable real-time information constantly, which is really useful during complex thyroid surgeries especially in the settings of unusual anatomy. Thus, CIONM overcomes the key methodological limitation inherent in intermittent nerve monitoring (IINOM); which is allowing the nerve to be at risk in between the stimulations. The clinically important combined electromyographic (EMG) event, indicative of impending recurrent laryngeal nerve (RLN) injury, prevents the majority of traction related injuries to the anatomically intact RLN enabling modification of the causative surgical manoeuvre in 80% of cases. These EMG changes can progress to loss of EMG signal with postoperative vocal cord palsy (VCP) if corrective action is not taken. As a further extension, CIONM also helps to identify intraoperative functional nerve recovery with restitution of amplitude to ≥50% of initial baseline; this allows continuing of resection of contralateral side. CIONM facilitates for early corrective action before permanent damage to the nerve has been done. CIONM is a recent but rapidly evolving technique, constantly being refined by various studies focusing on improvement in its implementation and interpretation, as well as on the elimination of the technical snags.
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Affiliation(s)
- Rick Schneider
- Medical Faculty, Department of General, Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Surgery Harvard Medical School, Boston, Massachusetts, USA
| | - Marcin Barczynski
- Department of Endocrine Surgery, 3 Chair of General Surgery, Jagiellonian University, Krakow, Poland
| | | | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Andreas Machens
- Medical Faculty, Department of General, Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Surgery Harvard Medical School, Boston, Massachusetts, USA
| | - Henning Dralle
- Medical Faculty, Department of General, Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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Continuous intraoperative monitoring of vagus and recurrent laryngeal nerve function in patients with advanced atrioventricular block. Langenbecks Arch Surg 2016; 401:551-6. [DOI: 10.1007/s00423-016-1433-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/07/2016] [Indexed: 10/21/2022]
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Brauckhoff K, Aas T, Biermann M, Husby P. EMG changes during continuous intraoperative neuromonitoring with sustained recurrent laryngeal nerve traction in a porcine model. Langenbecks Arch Surg 2016; 402:675-681. [PMID: 27086308 PMCID: PMC5437198 DOI: 10.1007/s00423-016-1419-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 03/30/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Traction is the most common cause of injury to the recurrent laryngeal nerve (RLN) in endocrine neck surgery. The purpose of this study was to evaluate specific alterations to the electromyogram (EMG) and verify safe alarm limits in a porcine model of sustained traction of the RLN using continuous intraoperative neuromonitoring (C-IONM). METHODS Sixteen Norwegian Landrace pigs were anesthetized and intubated with a tracheal tube with a stick-on laryngeal electrode. EMG was recorded at baseline (BL) and during sustained traction applied to each RLN until 70 % amplitude decrease from BL, and during 30-min recovery. RESULTS In 29 nerves at risk (NAR), BL amplitude and latency values were 1098 ± 418 (586-2255) μV (mean ± SD (range)) (right vagus) and 845 ± 289 (522-1634) μV (left vagus), and 4.7 ± 0.5 (4.1-5.9) ms and 7.9 ± 0.8 (6.7-9.6) ms, respectively. At 50 % amplitude decrease, latency increased by 14.0 ± 5.7 % (right side) and 14.5 ± 9.1 % (left side) compared with BL. Corresponding values for 70 % amplitude depression were 17.9 ± 6.1 % and 17.3 ± 12.8 %. Traction time to 50 and 70 % amplitude decrease ranged from 3 to 133 min and 3.9-141 min, respectively. In 16 NAR (55 %), time from 50 to 70 % reduction in amplitude was ≤5 min, but in six NAR (21 %) ≤1 min. In only 11 (38 %) of 29 nerves, the amplitude recovered to more than 50 % of BL. CONCLUSIONS Latency increase may be the first warning of RLN stretch injury. Given the short interval between 50 and 70 % amplitude reduction of the EMG, amplitude reduction by 50 % can be taken as an appropriate alert limit.
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Affiliation(s)
- Katrin Brauckhoff
- Department of Endocrine Surgery, Haukeland University Hospital, Jonas Lies vei 65, N-5021, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Turid Aas
- Department of Endocrine Surgery, Haukeland University Hospital, Jonas Lies vei 65, N-5021, Bergen, Norway
| | - Martin Biermann
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Paul Husby
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
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Recurrent laryngeal nerve injury with incomplete loss of electromyography signal during monitored thyroidectomy—evaluation and outcome. Langenbecks Arch Surg 2016; 402:691-699. [DOI: 10.1007/s00423-016-1381-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 02/08/2016] [Indexed: 11/27/2022]
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46
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Schneider R, Randolph G, Dionigi G, Barczyński M, Chiang FY, Triponez F, Vamvakidis K, Brauckhoff K, Musholt TJ, Almquist M, Innaro N, Jimenez-Garcia A, Kraimps JL, Miyauchi A, Wojtczak B, Donatini G, Lombardi D, Müller U, Pezzullo L, Ratia T, Van Slycke S, Nguyen Thanh P, Lorenz K, Sekulla C, Machens A, Dralle H. Prospective study of vocal fold function after loss of the neuromonitoring signal in thyroid surgery: The International Neural Monitoring Study Group's POLT study. Laryngoscope 2015; 126:1260-6. [PMID: 26667156 DOI: 10.1002/lary.25807] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Intraoperative neuromonitoring identifies recurrent laryngeal nerve (RLN) injury and gives prognostic information regarding postoperative glottic function. Loss of the neuromonitoring signal (LOS) signifies segmental type 1 or global type 2 RLN injury. This study aimed at identifying risk factors for RLN injury and determining vocal fold (VF) function initially and 6 months after definitive LOS. STUDY DESIGN Prospective study encompassing 21 hospitals from 13 countries. METHODS Included in this study were patients with persistent intraoperative LOS. RESULTS At first postoperative laryngoscopy, early VF palsy was present in 94 of all 115 patients with LOS (81.7%): in 53 of 56 patients (94.6%) with type 1 injury and 41 of 59 patients (69.5%) with type 2 injury. In LOS type 1, women outnumbered men >5-fold. Traction produced LOS type 1 in 38 of 56 patients (67.9%) and LOS type 2 in 54 of 59 patients (91.5%). Course of the RLN posterior and/or anterior to the inferior thyroid artery, extralaryngeal branching, or tuberculum of Zuckerkandl did not increase VF palsy rates. Permanent VF palsy rates were also lower (P = .661) after LOS type 2 than after LOS type 1: 6.8% (four of 59 patients) versus 10.7% (six of 56 patients). Intraoperative administration of steroids did not diminish postoperative VF palsy rates. CONCLUSIONS LOS type 1 entails more severe nerve damage than LOS type 2, affecting women disproportionately. Both LOS types, being primarily associated with traction injury, are unaffected by variant neck anatomy in expert hands and unresponsive to steroids. LEVEL OF EVIDENCE 2b Laryngoscope, 126:1260-1266, 2016.
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Affiliation(s)
- Rick Schneider
- Department of General, Visceral, and Vascular Surgery, University Hospital of Martin Luther University, Halle (Saale), Germany
| | - Gregory Randolph
- Division of Thyroid and Parathyroid Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
| | | | - Marcin Barczyński
- Department of Endocrine Surgery, 3rd Chair of General Surgery, Jagiellonian University, Krakow, Poland
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Frédéric Triponez
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | | | - Katrin Brauckhoff
- Department of Surgery, Haukeland University Hospital, Bergen, Norway
| | - Thomas J Musholt
- Endocrine Surgery Section, Clinic of General, Visceral, and Transplantation Surgery, University Medical Center, Mainz, Germany
| | - Martin Almquist
- Department of Surgery, Lund University Hospital, Lund, Sweden
| | - Nadia Innaro
- Department of General Surgery, University of Catanzaro, Catanzaro, Italy
| | | | - Jean-Louis Kraimps
- Department of Endocrine Surgery, University Hospital of Poitiers, Poitiers, France
| | | | - Beata Wojtczak
- Department of General, Gastroenterological and Endocrine Surgery, Medical University Wrocław, Wrocław, Poland
| | - Gianluca Donatini
- Department of Endocrine Surgery, University Hospital of Poitiers, Poitiers, France
| | - Davide Lombardi
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Uwe Müller
- Department of General, Viszeral and Thoracic Surgery, Bundeswehr Hospital, Berlin, Germany
| | - Luciano Pezzullo
- Thyroid and Parathyroid Surgery Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori, Fondazione G. Pascale, Naples, Italy
| | - Tomas Ratia
- Department of General Surgery, "Principe de Asturias" University Hospital, Madrid, Spain
| | - Sam Van Slycke
- Department of General and Endocrine Surgery, OLV Clinic Aalst, Aalst, Belgium
| | - Phuong Nguyen Thanh
- Department of General, Visceral, and Vascular Surgery, University Hospital of Martin Luther University, Halle (Saale), Germany
| | - Kerstin Lorenz
- Department of General, Visceral, and Vascular Surgery, University Hospital of Martin Luther University, Halle (Saale), Germany
| | - Carsten Sekulla
- Department of General, Visceral, and Vascular Surgery, University Hospital of Martin Luther University, Halle (Saale), Germany
| | - Andreas Machens
- Department of General, Visceral, and Vascular Surgery, University Hospital of Martin Luther University, Halle (Saale), Germany
| | - Henning Dralle
- Department of General, Visceral, and Vascular Surgery, University Hospital of Martin Luther University, Halle (Saale), Germany
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