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Kao DD, Jensen CB, Bacon E, Hogikyan ND, Roman BR, Pitt SC. Communication of Voice-Related Complications in Thyroidectomy: A Qualitative Analysis. Otolaryngol Head Neck Surg 2025; 172:1560-1569. [PMID: 39963871 PMCID: PMC12035516 DOI: 10.1002/ohn.1162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2024] [Revised: 01/11/2025] [Accepted: 01/18/2025] [Indexed: 04/29/2025]
Abstract
OBJECTIVE This study aims to characterize patient-surgeon discussions of voice-related complications during thyroidectomy for low-risk thyroid cancer. STUDY DESIGN A qualitative study. SETTING Three academic medical centers. METHODS Pre-operative clinic visits between 14 surgeons (6 otolaryngologists and 8 endocrine surgeons) and 49 patients with low-risk (cT1-2, N0) thyroid cancer were audio-recorded and transcribed. Qualitative analysis was used to evaluate surgeon counseling strategies and patient concerns related to voice. RESULTS Patients aged from 20 to 77 years old were predominantly female (77.6%) and white (89.9%). Surgeons presented risk with negative framing and numerical percentages (1%-4%) and/or qualified the risk as "low" or "small" for a lobectomy, but a "much bigger deal" for bilateral nerve injury in total thyroidectomy. At a minimum, surgeons referred to voice dysfunction as "voice change." Some further described "hoarseness" or the "inability to project voice." Other surgeons imitated what voice dysfunction would sound like. A few surgeons probed the importance of voice to a patient's life. One surgeon imparted that having a voice-related complication "can be really emotional." Patients responded with varying degrees of concern about voice changes after surgery, from feeling "super concerned … about losing [their] voice" to feeling "ok" with it "as long as [they're] around to deal with it." CONCLUSION Significant variability exists in how surgeons describe and set expectations about voice-related complications. The degree to which patients value voice-related outcomes differed based on their occupation and hobbies, but this was tempered by their cancer diagnosis. Further research is needed to identify optimal disclosure of voice-related risks and expectations.
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Affiliation(s)
- Derek D. Kao
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Catherine B. Jensen
- Department of SurgeryUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Department of SurgeryUniversity of WisconsinMadisonWisconsinUSA
| | - Elizabeth Bacon
- Department of SurgeryUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Norman D. Hogikyan
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Benjamin R. Roman
- Department of Surgery, Division of Head and NeckMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Susan C. Pitt
- Department of SurgeryUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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Sanabria A, Novelli JL, Volpi E, Voogd A, Zund S, Kowalski LP, Dueñas JP. Use of technologies in thyroid surgery: Latin American Thyroid Society Surgical Affairs Committee Expert Opinion. Part 1. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2025; 69:e240111. [PMID: 40179268 PMCID: PMC11968079 DOI: 10.20945/2359-4292-2024-0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 12/12/2024] [Indexed: 04/05/2025]
Abstract
Thyroidectomyis the most frequent endocrine surgical treatment for problems such as goiter, thyroid cancer, and Graves' disease. The global incidence of goiter ranges from 5%-20%, with a notably high frequency in less wealthy countries, and the incidence of thyroid cancer is on the rise due to the greater use of diagnostic imaging. Despite medical options, surgery remains essential. Surgical advancements such as blood vessel sealing technology, intraoperative laryngeal nerve neuromonitoring (IONM), remote access surgery, and parathyroid fluorescence have transformed thyroid surgery. Vessel sealing technologies reduce operative time and blood loss, whereas IONM preserves the laryngeal nerves. Remote access surgery, which includes a variety of techniques, produces results similar to those of open thyroidectomy with a longer operative time. Fluorescence enhances parathyroid detection and lowers the risk of temporary hypoparathyroidism. Economic studies reveal cost discrepancies, with advantages particularly visible in health care systems that depend on surgical time. While these advancements promise better patient outcomes, their accessibility and cost-effectiveness remain issues, particularly in Latin America. Recognizing these concerns, the Latin American Thyroid Society's Surgical Affairs Committee conducted an extensive review of emerging thyroid surgery technologies to guarantee their proper use in the area.
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Affiliation(s)
- Alvaro Sanabria
- Departamento de Cirugía, Facultad de Medicina, Universidad
de Antioquia, Medellín, Colombia
- CEXCA, Centro de Excelencia en Enfermedades de Cabeza y Cuello,
Medellín, Colombia
| | | | - Erivelto Volpi
- Departamento de Cirurgia de Cabeça e Pescoço,
Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brasil
| | - Ana Voogd
- Servicio de Cirugía de Cabeza y Cuello, Hospital
Universitario Austral, Pilar, Argentina
| | - Santiago Zund
- Departamento de Cirugía de Cabeza y Cuello, Instituto de
Oncología Ángel H. Roffo, Buenos Aires, Argentina
| | - Luiz Paulo Kowalski
- Departamento de Cirurgia de Cabeça e Pescoço e
Otorrinolaringologia, A.C.Camargo Cancer Center, São Paulo, SP, Brasil
- Departamento de Cirurgia de Cabeça e Pescoço,
Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP,
Brasil
| | - Juan Pablo Dueñas
- Departamento de Cirugía, Hospital Pablo Tobón Uribe,
Medellín, Colombia
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Patel R, Acharya R, Shah S, Desai C, Raveshia D, Panesar H, Patel N, Mcconaghie G, Cain DC, Parmar D, Banerjee R, Singh R. Five historical innovations that have shaped modern otolaryngological surgery. J Perioper Pract 2025; 35:102-111. [PMID: 38828977 DOI: 10.1177/17504589241244996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Throughout history, many innovations have contributed to the development of modern otolaryngological surgery, improving patient outcomes and expanding the range of treatment options available to patients. This article explores five key historical innovations that have shaped modern otolaryngological surgery: Operative Microscope, Hopkins Rigid Endoscope, Laryngeal Nerve monitoring, Cochlear implants and Laser surgery. The selection of innovations for inclusion in this article was meticulously determined through expert consensus and an extensive literature review. We will review the development, impact and significance of each innovation, highlighting their contributions to the field of otolaryngological surgery and their ongoing relevance in contemporary and perioperative practice.
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Affiliation(s)
- Ravi Patel
- Department of Trauma and Orthopaedics, The Shrewsbury and Telford Hospital NHS Trust, The Princess Royal Hospital, Telford, UK
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
| | - Radhika Acharya
- Department of Intensive Care, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Saumil Shah
- Department of Otolaryngology, The Princess Royal Hospital, Telford, UK
| | - Chaitya Desai
- Department of Urology, Walsall Manor Hospital, Walsall Healthcare NHS Trust, Walsall, UK
| | - Dimit Raveshia
- Department of General Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Harrypal Panesar
- Department of Otolaryngology, The Princess Royal Hospital, Telford, UK
| | | | - Greg Mcconaghie
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
| | - David Charles Cain
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
| | - Dilen Parmar
- Department of Otolaryngology, The Princess Royal Hospital, Telford, UK
| | - Robin Banerjee
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
| | - Rohit Singh
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
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Yu X, Zhu R, Zhu P, Du Y, Tanu C, Han Z, Jiang N, Pan L, Xie C, Zhao Q, Wang Y. Effectiveness and feasibility of nerve real-time monitoring and intermittent monitoring in endoscopic thyroidectomy: a multicenter retrospective cohort study of 1621 patients. Int J Surg 2025; 111:904-912. [PMID: 39093854 PMCID: PMC11745676 DOI: 10.1097/js9.0000000000001970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Protecting recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN), a crucial indicator for assessing the quality of thyroid surgery, poses a challenge in endoscopic thyroidectomy. The aim of this study was to investigate the effectiveness and feasibility of nerve real-time monitoring and intermittent monitoring in endoscopic thyroidectomy. METHODS In this retrospective cohort study, patients underwent endoscopic thyroidectomy were included, and the characteristics and outcomes of real-time monitoring and intermittent monitoring groups were compared. Thereafter, the outcomes of four surgical types (unilateral lobectomy, total thyroidectomy, unilateral lobectomy + lymph node dissection (LND), and total thyroidectomy + LND) were compared in both groups. RESULTS A total of 1621 patients were enrolled. Compared to intermittent monitoring group, real-time monitoring group significantly shortened operation durations in the four surgical types (30.8±6.1 min vs. 35.7±5.7 min, 54.7±4.4 min vs. 59.1±5.2 min, 39.3±4.6 min vs. 42.0±4.7 min, 59.1±4.9 min vs. 66.0±5.8 min, respectively). As for surgical complications, compared to intermittent monitoring group, real-time monitoring group had lower rates of transient vocal cord paralysis among the four surgical types (0.0 vs. 3.3%, 0.0% vs. 4.0%, 0.8 vs. 3.2%, 2.8 vs. 6.7%, respectively), and lower rates of EBSLN injury (1.1 vs. 4.4%, 0.0 vs. 12.0%, 0.8 vs. 3.8%, 0.9 vs. 4.8%, respectively). Clinicopathologic characteristics and postoperative inflammatory reactions were similarly paralleled in both groups. CONCLUSION Implementation of real-time monitoring in endoscopic thyroidectomy effectively protects the RLN and EBSLN while shortening operation duration, demonstrating its feasibility and efficacy in enhancing nerve protection and surgical efficiency.
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Affiliation(s)
- Xing Yu
- Department of Thyroid Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine
| | | | - Peifeng Zhu
- The First People’s Hospital of Huzhou, The First Affiliated Hospital of Huzhou University
| | - Yu Du
- Department of Thyroid Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine
| | | | - Zhenyi Han
- Department of Thyroid Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine
| | | | - Lei Pan
- Tongde Hospital of Zhejiang Province, Hangzhou
| | - Chaoran Xie
- Ningbo Zhenhai People’s Hospital, Ningbo, People’s Republic of China
| | - Qunzi Zhao
- Department of Thyroid Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine
| | - Yong Wang
- Department of Thyroid Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine
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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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Kirke DN, Sinclair CF. Recurrent Laryngeal Nerve Monitoring: Nuts and Bolts. Otolaryngol Clin North Am 2024; 57:53-61. [PMID: 37684153 DOI: 10.1016/j.otc.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Intraoperative neuromonitoring (IONM) of the laryngeal nerves has become an important tool for neck endocrine surgery. In this article, the authors review the current evidence behind its use in neck endocrine procedures. The subtypes of IONM, including intermittent IONM, continuous vagal IONM (vagal-CIONM), and laryngeal adductor reflex CIONM, will be discussed. Finally, the authors review recent advances in IONM, and how standardization of outcomes reporting will help minimise conjecture regarding the usefulness of IONM.
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Affiliation(s)
- Diana N Kirke
- Department of Otolaryngology - Head & Neck Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1189, Annenberg 10-40, New York, NY 10029, USA
| | - Catherine F Sinclair
- Department of Surgery, Monash University, Melbourne, Victoria, Australia; Department of Otolaryngology - Head & Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Melbourne Thyroid Surgery, 159 Wattletree Road, Malvern, Victoria 3144, Australia.
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Cozzi AT, Ottavi A, Lozza P, Maccari A, Borloni R, Nitro L, Felisati EG, Alliata A, Martino B, Cacioppo G, Fuccillo M, Rosso C, Pipolo C, Felisati G, De Pasquale L, Saibene AM. Intraoperative Neuromonitoring Does Not Reduce the Risk of Temporary and Definitive Recurrent Laryngeal Nerve Damage during Thyroid Surgery: A Systematic Review and Meta-Analysis of Endoscopic Findings from 73,325 Nerves at Risk. J Pers Med 2023; 13:1429. [PMID: 37888040 PMCID: PMC10607766 DOI: 10.3390/jpm13101429] [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: 09/05/2023] [Revised: 09/19/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND While intraoperative neuromonitoring (IONM) helps the early identification of recurrent laryngeal nerve (RLN) damage, IONM's role in RLN damage prevention is not defined, given the lack of large studies on the subject. METHODS In a PRISMA-compliant framework, all original thyroid surgery prospective studies providing early postoperative endoscopic data for all patients were pooled in a random-effects meta-analysis. We compared the temporary (and definitive where available) RLN damage rates according to IONM use and IONM type (intermittent, I-IONM, or continuous, C-IONM). RESULTS We identified 2358 temporary and 257 definitive RLN injuries in, respectively, 73,325 and 66,476 nerves at risk. The pooled temporary and definitive RLN injury rates were, respectively, 3.15% and 0.422% considering all procedures, 3.29% and 0.409% in cases using IONM, and 3.16% and 0.463 in cases not using IONM. I-IONM and C-IONM, respectively, showed a pooled temporary RLN injury rate of 2.48% and 2.913% and a pooled definitive injury rate of 0.395% and 0.4%. All pooled rates had largely overlapping 95% confidence intervals. CONCLUSIONS Our data suggest that IONM does not affect the temporary or definitive RLN injury rate following thyroidectomy, though its use can be advised in selected cases and for bilateral palsy prevention.
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Affiliation(s)
- Anna Teresa Cozzi
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Alice Ottavi
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Paolo Lozza
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Alberto Maccari
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Roberto Borloni
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Letizia Nitro
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Elena Giulia Felisati
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Andrea Alliata
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Barbara Martino
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Giancarlo Cacioppo
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Manuela Fuccillo
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Cecilia Rosso
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Carlotta Pipolo
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Giovanni Felisati
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Loredana De Pasquale
- Thyroid and Parathyroid Surgery Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy;
| | - Alberto Maria Saibene
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
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TM R, Krishnan K, Thiagarajan S, Balaji A, Chaukar D. Results of Swallowing Assessment in the Immediate Postoperative Period in Patients Following Surgery for Thyroid Malignancies. Indian J Otolaryngol Head Neck Surg 2023; 75:1474-1479. [PMID: 37636624 PMCID: PMC10447709 DOI: 10.1007/s12070-023-03608-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/17/2023] [Indexed: 03/06/2023] Open
Affiliation(s)
- Rukmangathan TM
- MASLP Speech and Swallowing Therapist Division. of Head & Neck Oncology, Tata Memorial Hospital, Mumbai, India
| | - Kartik Krishnan
- Division of Head & Neck Oncology, Dept. of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shivakumar Thiagarajan
- Division of Head & Neck Oncology, Dept. of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Arun Balaji
- Mr. Arun Balaji MASLP Speech and Swallowing Therapist Division. of Head & Neck Oncology, Tata Memorial Centre, Mumbai, India
| | - Devendra Chaukar
- Division of Head & Neck Oncology, Dept. of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
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Papagoras D, Tzikos G, Douridas G, Arseniou P, Panagiotou D, Kanara M, Papavramidis T. Visualization of the recurrent laryngeal nerve alone versus intraoperative nerve monitoring in primary thyroidectomy: a framework approach to a missing typology. Front Surg 2023; 10:1176511. [PMID: 37560316 PMCID: PMC10406577 DOI: 10.3389/fsurg.2023.1176511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/13/2023] [Indexed: 08/11/2023] Open
Abstract
INTRODUCTION Surgical studies evaluating a device or technology in comparison to an established surgical technique should accurately report all the important components of the surgical technique in order to reduce the risk of intervention bias. In the debate of visualization of the recurrent laryngeal nerve alone (VONA) versus intraoperative nerve monitoring (IONM) during thyroidectomy, surgical technique plays a key role in both strategies. Our aim was to investigate whether the surgical technique was considered as a risk of intervention bias by relevant meta-analyses and reviews and if steps of surgical intervention were described in their included studies. METHODS We searched PUBMED, CENTRAL-Cochrane library, PROSPERO and GOOGLE for reviews and meta-analyses focusing on the comparison of IONM to VONA in primary open thyroidectomy. Τhen, primary studies were extracted from their reference lists. We developed a typology for surgical technique applied in primary studies and a framework approach for the evaluation of this typology by the meta-analyses and reviews. RESULTS Twelve meta-analyses, one review (388,252 nerves at risk), and 84 primary studies (128,720 patients) were included. Five meta-analyses considered the absence of typology regarding the surgical technique as a source of intervention bias; 48 primary studies (57.14%) provided information about at least one item of the typology components and only 1 for all of them. DISCUSSION Surgical technique of thyroidectomy in terms of a typology is underreported in studies and undervalued by meta-analyses comparing VONA to IONM. This missing typology should be reconsidered in the comparative evaluation of these two strategies.
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Affiliation(s)
| | - Georgios Tzikos
- 1st Propedeutic Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Gerasimos Douridas
- Department of Surgery, Thriassio General Hospital of Elefsina, Elefsina, Greece
| | | | | | - Maria Kanara
- Department of Surgery, General Hospital of Trikala, Trikala, Greece
| | - Theodosios Papavramidis
- 1st Propedeutic Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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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; 160:S88-S94. [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] [MESH Headings] [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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11
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Scheller B, Culié D, Poissonnet G, Dassonville O, D'Andréa G, Bozec A. Recent Advances in the Surgical Management of Thyroid Cancer. Curr Oncol 2023; 30:4787-4804. [PMID: 37232819 DOI: 10.3390/curroncol30050361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/25/2023] [Accepted: 05/04/2023] [Indexed: 05/27/2023] Open
Abstract
A growing incidence of differentiated thyroid cancer (DTC) has been reported in most developed countries, corresponding mainly to incidentally discovered small papillary thyroid carcinomas. Given the excellent prognosis of most patients with DTC, optimal therapeutic management, minimizing complications, and preserving patient quality of life are essential. Thyroid surgery has a central role in both the diagnosis, staging, and treatment of patients with DTC. Thyroid surgery should be integrated into the global and multidisciplinary management of patients with DTC. However, the optimal surgical management of DTC patients is still controversial. In this review article, we discuss the recent advances and current debates in DTC surgery, including preoperative molecular testing, risk stratification, the extent of thyroid surgery, innovative surgical tools, and new surgical approaches.
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Affiliation(s)
- Boris Scheller
- Face and Neck University Institute, 31 Av. de Valombrose, 06103 Nice, France
- Antoine Lacassagne Center, 33 Av. de Valombrose, 06189 Nice, France
| | - Dorian Culié
- Face and Neck University Institute, 31 Av. de Valombrose, 06103 Nice, France
- Antoine Lacassagne Center, 33 Av. de Valombrose, 06189 Nice, France
| | - Gilles Poissonnet
- Face and Neck University Institute, 31 Av. de Valombrose, 06103 Nice, France
- Antoine Lacassagne Center, 33 Av. de Valombrose, 06189 Nice, France
| | - Olivier Dassonville
- Face and Neck University Institute, 31 Av. de Valombrose, 06103 Nice, France
- Antoine Lacassagne Center, 33 Av. de Valombrose, 06189 Nice, France
| | - Grégoire D'Andréa
- Face and Neck University Institute, 31 Av. de Valombrose, 06103 Nice, France
- University Hospital Center of Nice, 30 Av. de la Voie Romaine, 06000 Nice, France
| | - Alexandre Bozec
- Face and Neck University Institute, 31 Av. de Valombrose, 06103 Nice, France
- Antoine Lacassagne Center, 33 Av. de Valombrose, 06189 Nice, France
- Faculty of Medecine, Cte D'Azur University, 28 Av. Valrose, 06108 Nice, France
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12
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Yan S, Lin L, Zhao W, Wang B, Zhang L, Cai S. An improved method of searching inferior parathyroid gland for the patients with papillary thyroid carcinoma based on a retrospective study. Front Surg 2023; 9:955855. [PMID: 36684190 PMCID: PMC9852712 DOI: 10.3389/fsurg.2022.955855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 10/21/2022] [Indexed: 01/07/2023] Open
Abstract
Objective Many surgeons knew the importance of parathyroid gland (PG) in the thyroid surgery, but it was even more difficult to be protected. This study aimed at evaluating the effectiveness of the improved method of searching inferior parathyroid gland (IPG). Methods 213 patients were enrolled and divided into test and control groups according to different methods of searching IPG in the surgery. Consequently, we compared the surgical outcome parameters between the two groups, including the operative time, numbers of PG identifying (PG protection in situ, PG auto-transplantation, and PG accidental removal), numbers of the total lymph node (LN) and metastatic LN, parathyroid hormone (PTH), transient hypoparathyroidism, transient recurrent laryngeal nerve palsy, and postoperative bleeding. Results We identified 194 (194/196, 98.98%) and 215 (215/230, 93.48%) PGs in the test group and control group, respectively, and there was a significant difference (P = 0.005), and this result was due to IPG identification differences (96/98, 97.96% vs. 100/115, 86.96%, P = 0.004). Meanwhile, there was a lower ratio of IPG auto-transplantation in the test group compared with that in the control group (46.94% vs. 64.35%, P = 0.013). Serum PTH one day after the operation was 3.65 ± 1.86 vs. 2.96 ± 1.64 (P = 0.043) but with no difference at 6 months. There were no differences in metastatic LN and recurrent laryngeal nerve palsy between two groups. Conclusion The improved method of searching IPG was simple, efficient, and safe, which was easy to be implemented for searching IPG and protecting it well.
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Affiliation(s)
- Shouyi Yan
- Fujian Medical University, Fuzhou, China,Department of Thyroid Surgery, Fujian Medical University Union Hospital, Fuzhou, China,The Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Minimal Invasive Center, Fujian Medical University Union Hospital, Fuzhou, China
| | - Lanqin Lin
- The Department of Anesthesia and Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Wenxin Zhao
- Fujian Medical University, Fuzhou, China,Department of Thyroid Surgery, Fujian Medical University Union Hospital, Fuzhou, China,The Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Minimal Invasive Center, Fujian Medical University Union Hospital, Fuzhou, China,Correspondence: Wenxin Zhao
| | - Bo Wang
- Fujian Medical University, Fuzhou, China,Department of Thyroid Surgery, Fujian Medical University Union Hospital, Fuzhou, China,The Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Minimal Invasive Center, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liyong Zhang
- Fujian Medical University, Fuzhou, China,Department of Thyroid Surgery, Fujian Medical University Union Hospital, Fuzhou, China,The Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Minimal Invasive Center, Fujian Medical University Union Hospital, Fuzhou, China
| | - Shaojun Cai
- Fujian Medical University, Fuzhou, China,Department of Thyroid Surgery, Fujian Medical University Union Hospital, Fuzhou, China,The Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Minimal Invasive Center, Fujian Medical University Union Hospital, Fuzhou, China
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Melfa G, Siragusa G, Cocorullo G, Guzzino M, Raspanti C, Albanese L, Mazzola S, Richiusa P, Orlando G, Scerrino G. Effects of Intraoperative Nerve Monitoring Techniques on Voice and Swallowing Disorders after Uncomplicated Thyroidectomy: Preliminary Report of a Bi-Institutional Prospective Study. J Clin Med 2022; 12:jcm12010305. [PMID: 36615105 PMCID: PMC9821617 DOI: 10.3390/jcm12010305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/12/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023] Open
Abstract
Background: Voice and swallowing problems are frequently associated with thyroidectomy. Intermittent nerve monitoring (i-IONM) seems to provide a positive effect in reducing its prevalence. The aim of this study was to test the hypothesis that continuous intraoperative nerve monitoring (c-IONM) may reduce the prevalence of these disorders even further than i-IONM. Methods: This 3-arm prospective bi-institutional study compared 179 consecutive patients that underwent thyroidectomy: 56 without IONM, 55 with i-IONM and 67 with c-IONM. Neck dissections and laryngeal nerve palsies were excluded. Two questionnaires (VHI-10 for voice disorders and EAT-10 for swallowing disorders; both validated for Italian language use) were administered before and 1 month after surgery. Statistical significance was analyzed by the chi-squared test. Results: After thyroidectomy, no statistically significant differences were found in the three groups concerning EAT-10. although these symptoms seemed to be influenced by gastro-esophageal reflux. VHI-10 worsened in the “no-IONM” group compared with both i-IONM (p < 0.09, not quite statistically significant) and c-IONM (p < 0.04). Conclusion: Both i- and c-IONM improve voice quality independently of laryngeal nerve integrity. Reduced dissection and particularly restrained manipulation could explain these results, being particularly favorable for c-IONM.
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Affiliation(s)
- Giuseppina Melfa
- Unit of General and Emergency Surgery, Department of Surgical Oncological and Oral Sciences, Policlinico “P. Giaccone”—University of Palermo, 90127 Palermo, Italy
| | | | - Gianfranco Cocorullo
- Unit of General and Emergency Surgery, Department of Surgical Oncological and Oral Sciences, Policlinico “P. Giaccone”—University of Palermo, 90127 Palermo, Italy
| | - Marianna Guzzino
- Villa Serena Clinic—Unit of General Surgery, 90100 Palermo, Italy
| | - Cristina Raspanti
- Unit of General and Emergency Surgery, Department of Surgical Oncological and Oral Sciences, Policlinico “P. Giaccone”—University of Palermo, 90127 Palermo, Italy
| | - Leone Albanese
- Villa Serena Clinic—Unit of General Surgery, 90100 Palermo, Italy
| | - Sergio Mazzola
- Unit of Clinical Epidemiology and Tumor Registry, Department of Laboratory Diagnostics, Policlinico “P. Giaccone”—University of Palermo, 90127 Palermo, Italy
| | - Pierina Richiusa
- Section of Endocrinology—Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Giuseppina Orlando
- Unit of General and Emergency Surgery, Department of Surgical Oncological and Oral Sciences, Policlinico “P. Giaccone”—University of Palermo, 90127 Palermo, Italy
- Correspondence:
| | - Gregorio Scerrino
- Unit of Endocrine Surgery, Department of Surgical Oncological and Oral Sciences, Policlinico “P. Giaccone”—University of Palermo, 90127 Palermo, Italy
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Farafonova UV, Pankova PA, Boriskova ME, Feshenko NS, Totskiy EA. The efficacy and safety of tension-free thyroidectomy in the clinical work of the Endocrine Surgery Department Pavlov State Medical University, pilot study. ENDOCRINE SURGERY 2022. [DOI: 10.14341/serg12733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND: Despite the intensive development of safe thyroid surgery technologies, it has not yet been possible to achieve a significant reduction in the level of specific complications. One of the possible reasons is the method of the conventional surgical operation especially possible traction during thyroid tissue rotation on the way to n.reccurence. In 2022, group of authors led by I.V. Sleptsov proposed a new technique for Tention-Free Thyroidectomy (TFT), which demonstrated a significant reduction in the level of specific complications.AIM: To conduct a pilot study to assess the reproducibility, efficacy and safety of TFT in the work of the endocrine surgery department of Pavlov First St. Petersburg State Medical University.MATERIALS AND METHODS: The study was conducted at the Department of Endocrine Surgery in the period from January to April 2022. Patients with surgical thyroid disease underwent a new proposed TFT intervention. The method is fully consistent with the author’s description in patent No. 2772015, and the surgeons performing the new surgical technique underwent an internship with the authors of TFT before the initiation of the study. The study is prospective, non-randomized, uncontrolled. Persistent laryngeal dysfunction and persistent hypoparathyroidism were considered the primary endpoint. Secondary endpoints were transient vocal cord paresis, hypocalcemia and hypoparathyroidism.RESULTS: The study included 20 people. The indications for surgery were endocrinological and oncological. The number of performed hemithyroidectomies were 15, thyroidectomy (TE) — 5 (one with central lymph node dissection), the volume of the thyroid gland varied from 4 cm3 to 280 cm3 . None of the patients reached the primary endpoint. There were no permanent dysfunction of the larynx in our study. Only in one patient in the postoperative period, a violation of the mobility of the vocal fold was revealed, however, during follow up on the 30th day of the postoperative period the mobility of the vocal fold was restored (confirmed by direct laryngoscopy). Hypoparathyroidism and hypocalcemia were not detected. However, it is necessary to mention the number of TE was too small.CONCLUSION: Thus, the new proposed TFT method is fully reproducible in the work of a specialized department of endocrine surgery. The method has demonstrated high rates of efficiency and safety in real clinical practice. However, further studies with a higher evidence base are required.
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Intra-operative nerve monitoring and recurrent laryngeal nerve injury during thyroid surgery: a network meta-analysis of prospective studies. Langenbecks Arch Surg 2022; 407:3209-3219. [PMID: 35953619 DOI: 10.1007/s00423-022-02651-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE Recurrent laryngeal nerve (RLN) injury is a feared complication of thyroid surgery occurring in 1-5% of cases. The present approaches to RLN preservation include RLN visualization with no nerve monitoring (No-NM), intermittent intra-operative nerve monitoring (I-IONM) and continuous intra-operative nerve monitoring (C-IONM). There is ambiguity as to which of these strategies should be the preferred method of RLN preservation. METHODS A systematic review of the PubMed, Embase and the Cochrane Collaboration databases was undertaken with network meta-analysis (NMA) performed according to the PRISMA and Cochrane Collaboration guidelines. A Bayesian NMA was conducted using R packages netmeta with outcomes expressed as odds ratios (ORs) with 95% credible intervals (CrI). Only prospective studies were included. RESULTS Eighteen studies met inclusion criteria, including 22,080 patients and 40,642 nerves at risk (NAR). Overall, 23,364 NARs (57.5%) underwent I-IONM, 17,176 (42.3%) No-NM and 98 (0.2%) underwent C-IONM. There were no significant differences between groups regarding the incidence of permanent RLN injury following thyroid surgery (I-IONM vs.No-NM, OR 0.84, 95% CrI 0.55-1.19; C-IONM vs. No-NM, OR 0.44, 95% CrI 0.02-5.00). Pooled analysis showed that IONM (I-IONM or C-IONM) demonstrated a protective effect versus No-NM in reducing the incidence of transient RLN injury (OR 0.75, 95% CI 0.59-0.97, p = 0.03). CONCLUSIONS IONM strategies did not significantly reduce the incidence of permanent RLN injury following thyroid surgery. However, the small number of C-IONM NARs limits conclusions that may be drawn. Further well-designed prospective studies will be required to definitively assess the utility of C-IONM.
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16
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Chiu KL, Lien CF, Wang CC, Wang CC, Hwang TZ, Shih YC, Yu WHV, Wu CW, Dionigi G, Huang TY, Chiang FY. Intraoperative EMG recovery patterns and outcomes after RLN traction-related amplitude decrease during monitored thyroidectomy. Front Endocrinol (Lausanne) 2022; 13:888381. [PMID: 36034434 PMCID: PMC9403328 DOI: 10.3389/fendo.2022.888381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/27/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Traction injury is the most common type of recurrent laryngeal nerve (RLN) injury in thyroid surgery. Intraoperative neuromonitoring (IONM) facilitates early detection of adverse electromyography (EMG) effect, and this corrective maneuver can reduce severe and repeated nerve injury. This study aimed to evaluate intraoperative patterns and outcomes of EMG decrease and recovery by traction injury. METHODS 644 patients received nerve monitored thyroidectomy with 1142 RLNs at risk were enrolled. Intermittent IONM with stimulating dissecting instrument (real-time during surgical procedure) and trans-thyroid cartilage EMG recording method (without electrode malpositioning issue) were used for nerve stimulation and signal recording. When an EMG amplitude showed a decrease of >50% during RLN dissection, the surgical maneuver was paused immediately. Nerve dissection was restarted when the EMG amplitude was stable. RESULTS 44/1142 (3.9%) RLNs exhibited a >50% EMG amplitude decrease during RLN dissection and all (100%) showed gradual progressive amplitude recovery within a few minutes after releasing thyroid traction (10 recovered from LOS; 34 recovered from a 51-90% amplitude decrease). Three EMG recovery patterns were noted, A-complete EMG recovery (n=14, 32%); B-incomplete EMG recovery with an injury point (n=16, 36%); C-incomplete EMG recovery without an injury point (n=14, 32%). Patients with postoperative weak or fixed vocal cord mobility in A, B, and C were 0(0%), 7(44%), and 2(14%), respectively. Complete EMG recovery was found in 14 nerves, and incomplete recovery was found in another 30 nerves. Temporary vocal cord palsy was found in 6 nerves due to unavoidable repeated traction. CONCLUSION Early detection of traction-related RLN amplitude decrease allows monitoring of intraoperative EMG signal recovery during thyroid surgery. Different recovery patterns show different vocal cord function outcomes. To elucidate the recovery patterns can assist surgeons in the intraoperative decision making and postoperative management.
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Affiliation(s)
- Kuan-Lin Chiu
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Ching-Feng Lien
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chih-Chun Wang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chien-Chung Wang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Tzer-Zen Hwang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yu-Chen Shih
- Department of Otolaryngology, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Wing-Hei Viola Yu
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tzu-Yen Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Tzu-Yen Huang, ; Feng-Yu Chiang,
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- *Correspondence: Tzu-Yen Huang, ; Feng-Yu Chiang,
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