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Cai H, Ternström S, Chaffanjon P, Henrich Bernardoni N. Effects on Voice Quality of Thyroidectomy: A Qualitative and Quantitative Study Using Voice Maps. J Voice 2024:S0892-1997(24)00082-1. [PMID: 38714436 DOI: 10.1016/j.jvoice.2024.03.012] [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: 12/29/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 05/09/2024]
Abstract
OBJECTIVES This study aims to explore the effects of thyroidectomy-a surgical intervention involving the removal of the thyroid gland-on voice quality, as represented by acoustic and electroglottographic measures. Given the thyroid gland's proximity to the inferior and superior laryngeal nerves, thyroidectomy carries a potential risk of affecting vocal function. While earlier studies have documented effects on the voice range, few studies have looked at voice quality after thyroidectomy. Since voice quality effects could manifest in many ways, that a priori are unknown, we wish to apply an exploratory approach that collects many data points from several metrics. METHODS A voice-mapping analysis paradigm was applied retrospectively on a corpus of spoken and sung sentences produced by patients who had thyroid surgery. Voice quality changes were assessed objectively for 57 patients prior to surgery and 2months after surgery, by making comparative voice maps, pre- and post-intervention, of six acoustic and electroglottographic (EGG) metrics. RESULTS After thyroidectomy, statistically significant changes consistent with a worsening of voice quality were observed in most metrics. For all individual metrics, however, the effect sizes were too small to be clinically relevant. Statistical clustering of the metrics helped to clarify the nature of these changes. While partial thyroidectomy demonstrated greater uniformity than did total thyroidectomy, the type of perioperative damage had no discernible impact on voice quality. CONCLUSIONS Changes in voice quality after thyroidectomy were related mostly to increased phonatory instability in both the acoustic and EGG metrics. Clustered voice metrics exhibited a higher correlation to voice complaints than did individual voice metrics.
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Affiliation(s)
- Huanchen Cai
- Division of Speech, Music and Hearing, KTH Royal Institute of Technology, Stockholm, Sweden.
| | - Sten Ternström
- Division of Speech, Music and Hearing, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Philippe Chaffanjon
- University of Grenoble Alpes, CNRS, Grenoble INP, GIPSA-lab, Grenoble, France; Medical School, Université Grenoble Alpes, Grenoble, France
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Li C, Zhang J, Dionigi G, Sun H. Assessment of different classification systems for predicting the risk of superior laryngeal nerve injury during thyroid surgery: a prospective cohort study. Front Endocrinol (Lausanne) 2023; 14:1301838. [PMID: 38075061 PMCID: PMC10703432 DOI: 10.3389/fendo.2023.1301838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
Background A multitude of anatomical variations have been noted in the external branch of the superior laryngeal nerve (EBSLN). In this study, intraoperative neuromonitoring (IONM) was used to assess the potential value of the different classical EBSLN classifications for predicting the risk of EBSLN injury. Methods In total, 136 patients with thyroid nodules were included in this prospective cohort study, covering 242 nerves at risk (NAR). The EBSLN was identified by observing the cricothyroid muscle twitch and/or typical electromyography (EMG) biphasic waveform. The EBSLNs were classified by Cernea classification, Kierner classification, and Friedman classification, respectively. The EMG parameters and outcomes of vocal acoustic assessment were recorded. Results The distribution of Cernea, Kiernea, and Friedman subtypes were, respectively, Cernea 1 (40.9%), Cernea 2A (45.5%), Cernea 2B (10.7%), Kierner 1 (40.9%), Kierner 2 (45.5%), Kierner 3 (10.7%), Kierner 4 (2.9%) and Friedman 1 (15.7%), Friedman 2 (33.9%), Friedman 3 (50.4%). The amplitudes of EBSLN decreased significantly after superior thyroid pole operation, respectively, in Cernea 2A (193.7 vs. 226.6μV, P=0.019), Cernea 2B (185.8 vs. 221.3μV, P=0.039), Kierner 2 (193.7vs. 226.6μV, P=0.019), Kierner 3 (185.8 vs. 221.3μV, P=0.039), Kierner 4 (126.8vs. 226.0μV, P=0.015) and Friedman type 2 (184.8 vs. 221.6μV, P=0.030). There were significant differences in Fmax and Frange for Cernea 2A (P=0.001, P=0.001), 2B (P=0.001, P=0.038), Kierner 2 (P=0.001), Kierner 3 (P=0.001, P=0.038), and Friedman 2 (P=0.004, P=0.014). In the predictive efficacy of EBSLN injury, the Friedman classification showed higher accuracy (69.8% vs. 44.3% vs. 45.0%), sensitivity (19.5% vs. 11.0% vs. 14.0%), and specificity (95.6% vs. 89.9% vs. 89.9%) than the Cernea and Kierner classifications. However, the false negative rate of Friedman classification was significantly higher than other subtypes (19.5% vs. 11.0% vs. 14.0%). Conclusion Cernea 2A and 2B; Kierner 2, 3, and 4; and Friedman 2 were defined as the high-risk subtypes of EBSLN. The risk prediction ability of the Friedman classification was found to be superior compared to other classifications.
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Affiliation(s)
- Changlin Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun, Jilin, China
| | - Jiao Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun, Jilin, China
| | - Gianlorenzo Dionigi
- Division of Surgery, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifco (IRCCS), Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun, Jilin, China
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Hiramitsu T, Tomosugi T, Okada M, Futamura K, Goto N, Narumi S, Watarai Y, Tominaga Y, Ichimori T. Preservation of the nonrecurrent laryngeal nerve using intraoperative nerve monitoring during endoscopic thyroidectomy. Asian J Endosc Surg 2022; 15:828-831. [PMID: 35570683 DOI: 10.1111/ases.13079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/28/2022] [Accepted: 04/30/2022] [Indexed: 11/29/2022]
Abstract
A 40-year-old woman underwent right lobe thyroidectomy for thyroid nodules that increased in size from 17 mm to 33.5 mm within 1 year. Identification of arteria lusoria using computed tomography suggested the presence of a right nonrecurrent laryngeal nerve (RNRLN). Endoscopic thyroidectomy was performed under general anesthesia. The right vagal nerve was first identified between the common carotid artery and jugular vein. A positive response was confirmed via intraoperative neuromonitoring (IONM), implying that the RNRLN did not branch from the central side of the stimulated point of the vagal nerve. The RNRLN was confirmed using IONM around the middle to lower pole of the right thyroid gland. The right thyroid lobe was successfully removed, with meticulous preservation of the RNRLN. The motion of the vocal cord, examined by an ear-nose-throat doctor postoperatively, was intact. We demonstrated the efficacy of IONM in patients with RNRLN who underwent endoscopic thyroidectomy.
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Affiliation(s)
- Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Toshihide Tomosugi
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Manabu Okada
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Yoshihiro Tominaga
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Toshihiro Ichimori
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
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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: 1.0] [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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Kuo EJ, Lee JA. To stim, or not to stim, that is the question. Am J Surg 2022; 224:834-835. [DOI: 10.1016/j.amjsurg.2022.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
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Davey MG, Cleere EF, Lowery AJ, Kerin MJ. Intraoperative recurrent laryngeal nerve monitoring versus visualisation alone - A systematic review and meta-analysis of randomized controlled trials. Am J Surg 2022; 224:836-841. [DOI: 10.1016/j.amjsurg.2022.03.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/01/2022] [Accepted: 03/23/2022] [Indexed: 02/08/2023]
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Seeing Is Not Believing: Intraoperative Nerve Monitoring (IONM) in the Thyroid Surgery. Indian J Surg Oncol 2022; 13:121-132. [PMID: 35462673 PMCID: PMC8986933 DOI: 10.1007/s13193-021-01348-y] [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: 10/12/2020] [Accepted: 05/12/2021] [Indexed: 10/21/2022] Open
Abstract
Ensuring the integrity of the recurrent laryngeal nerve (RLN), the external branch of superior laryngeal nerve (EBSLN) and preservation of normal voice are the prime 'functional' goals of thyroid surgery. More in-depth knowledge of neuronal mechanisms has revealed that anatomical integrity does not always translate into functional integrity. Despite meticulous dissection, neural injuries are not always predictable or visually evident. Intraoperative nerve monitoring (IONM) is designed to aid in nerve identification and early detection of functional impairment. With the evolution of technique, intermittent monitoring has given way to continuous-IONM. Over the years, IONM gathered both support and flak. Despite numerous randomised studies, systematic reviews, and meta-analyses, there still prevails a state of clinical equipoise concerning the utility of IONM and its cost-effectiveness. This article inspects the true usefulness of IONM, elaborates on the optimal way to practice it, and presents a critical literature review.
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Akritidou E, Douridas G, Spartalis E, Tsourouflis G, Dimitroulis D, Nikiteas NI. Complications of Trans-oral Endoscopic Thyroidectomy Vestibular Approach: A Systematic Review. In Vivo 2022; 36:1-12. [PMID: 34972695 DOI: 10.21873/invivo.12671] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 01/04/2023]
Abstract
This review focuses on complications linked to trans-oral endoscopic thyroidectomy via vestibular approach (TOETVA) and aimed to elucidate the procedure's initial safety profile. According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA), Pubmed, Embase, and the Cochrane databases were screened till May 2021. Twenty-eight articles, nine cohorts and nineteen case series, met the inclusion criteria. Procedure-related complications were analyzed, the most important being hypoparathyroidism: transient (range=0.94-22.2%), permanent (range=1.33-2.22%), and recurrent laryngeal nerve injury: transient (range=1.9-8.8%) and permanent (range=0.59-1.42%). Surgical trauma related complications, the most prevalent being seroma, emphysema, and hematoma accounted for 2.91%. Null mortality was reported. Although current evolving experience indicates that TOETVA is safe and linked to acceptable complication rates, the method needs to be compared with the gold standard of traditional thyroidectomy in the context of sufficiently numbered cohorts and ultimately randomized controlled trials.
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Affiliation(s)
- Ellada Akritidou
- Department of Surgery, Thriassio General Hospital, Athens, Greece; .,Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece
| | | | - Eleftherios Spartalis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2 Department of Propaedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Tsourouflis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2 Department of Propaedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Dimitroulis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2 Department of Propaedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos I Nikiteas
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2 Department of Propaedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Zhao Y, Zhao Z, Zhang D, Han Y, Dionigi G, Sun H. Improving classification of the external branch of the superior laryngeal nerve with neural monitoring: a research appraisal and narrative review. Gland Surg 2021; 10:2847-2860. [PMID: 34733732 DOI: 10.21037/gs-21-518] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
Objective To review the published literature on external branch of superior laryngeal nerve (EBSLN) neural monitoring and propose a new EBSLN classification system using intraoperative neural monitoring (IONM). Background The injury rate of the external branch of the superior laryngeal nerve (EBSLN) in thyroid surgery is 0-58%. Symptoms of EBSLN injury are not consistent, and patients often complain of modification of the voice timbre with the preservation of vocal cord function. Standards for the diagnosis of EBSLN injury are lacking. Methods The PubMed database was searched using the terms 'External branch of the superior laryngeal nerve' and 'Intraoperative neuromonitoring' from 2010 through March 2020. Conclusions This paper reviewed the anatomy of the EBSLN, the diagnosis and treatment of injury, and the application of IONM in the EBSLN. The traditional EBSLN classification method was analyzed and compared with our new classification method. The diagnosis of EBSLN injury is a problem that still needs to be resolved. For anatomic classifications of the EBSLN, we found that the conventional classification systems may not accurately reflect the real status of the EBSLN and the surgical risks that may occur intraoperatively. Using IONM, we developed an EBSLN classification method that was consistent with conventional diagnosis and treatments and can be widely and easily utilized during surgery.
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Affiliation(s)
- Yishen Zhao
- 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, China
| | - Zihan Zhao
- 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, China
| | - Daqi Zhang
- 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, China
| | - Yujia Han
- 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, China
| | - Gianlorenzo Dionigi
- Division of General Surgery, Head, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - 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, China
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Yuan Q, Zheng L, Hou J, Zhou R, Xu G, Li C, Wu G. Visual identification and neuromonitoring vs. no sighting the external branch of the superior laryngeal nerve in thyroid surgery: a randomized clinical trial. Updates Surg 2021; 74:727-734. [PMID: 34327667 DOI: 10.1007/s13304-021-01138-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/20/2021] [Indexed: 01/15/2023]
Abstract
To evaluate the incidence of external branch of the superior laryngeal nerve (EBSLN) injuries after thyroid surgical procedures with or without the functional and visual identification of the EBSLN before ligation at the superior thyroid pole. Patients with papillary thyroid carcinoma (PTC) enrolled from a single tertiary referral academic medical center were assigned to functional and visual identification of EBSLN group (study group) or no identification of EBSLN group (controlled group). The main outcome measures were the incidence of EBSLN injury detected by the intraoperative neuromonitoring and Voice Handicap Index-10 (VHI-10) and Impairment Index-5 (VII-5) valuation questionnaires. Postoperative complications were recorded. A total of 140 (50.4%) patients were enrolled in study group and 138 (49.6%) in controlled group. In the study group, 110 (39.3%) EBSLNs were direct visual recognized and 170 (60.7%) nerves were visually identified with the help of neuromonitoring. Three patients in the study group and two patients in the controlled group were diagnosed with vocal cord paralysis. Six (4.4%) patients in the identification group and 37 (27.2%) patients in the no identification group presented no response from the stimulation of sternothyroid-laryngeal triangle. The VII-5 scores of the study group were significantly higher than those of the controlled group at one and three months postoperatively (P = 0.024 and P = 0.034). With significant lower scores of VII-5 and VHI-10, functional and visual identification of EBSLN might be necessary during thyroid surgery to protect the structural integrity and motor activity of the nerve.
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Affiliation(s)
- Qianqian Yuan
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Lewei Zheng
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Jinxuan Hou
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Rui Zhou
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Gaoran Xu
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Chengxin Li
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China
| | - Gaosong Wu
- Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, People's Republic of China.
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Can we routinely identify the external branch of the superior laryngeal nerves with neural monitoring?: a prospective report on 176 consecutive nerves at risk. Updates Surg 2021; 73:2275-2281. [PMID: 34041716 PMCID: PMC8606392 DOI: 10.1007/s13304-021-01084-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/05/2021] [Indexed: 01/15/2023]
Abstract
The external branch of the superior laryngeal nerve (EBSLN) provides motor function to the cricothyroid muscle (CTM). EBSLN damage produces changes in voice quality and projection. Intraoperative neuromonitoring (IONM) in thyroid surgery aims to optimize EBSLN control during dissection. We prospectively collected the data of 88 consecutive patients who underwent total thyroidectomy with IONM from July 2019 to December 2019. IONM was offered in the intermittent mode of application. We routinely searched for the EBSLN electromyographic (EMG) signal before (S1) and after (S2) dissection of the superior vascular peduncle. In the absence of the EMG signal, we observed the CTM twitch. We identified 141 (80%) S1 EMG signals, while we recorded the CTM twitch in 15 cases (8.5%). In 20 (11.3%) cases, we were unable to identify the EMG signal. Analysing the S2 results, we found loss of EBSLN signal in 11/141 cases (7.8%) identified with IONM in pre-dissection stimulation. Among the 20 cases without pre-dissection identification (we had not identified the external branch of the superior laryngeal nerve or the muscle twitch), in the post-dissection evaluation, we confirmed the loss of signal in 17 of 20 cases, equal to 85% (p < 0.001). Our data clearly show that intraoperative stimulation and recognition of EBSLN, performed before any dissection manoeuvre to the superior vascular thyroid pole, leads to a much higher rate of nerve conservation.
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Buczek E, Hicks M, Moroco A, Cottrill E. Neuroanatomy and Monitoring of the External Branch of the Superior Laryngeal Nerve. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00349-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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Kim J, Graves CE, Jin C, Duh QY, Gosnell JE, Shen WT, Suh I, Sosa JA, Roman SA. Intraoperative nerve monitoring is associated with a lower risk of recurrent laryngeal nerve injury: A national analysis of 17,610 patients. Am J Surg 2021; 221:472-477. [DOI: 10.1016/j.amjsurg.2020.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 09/21/2020] [Accepted: 10/08/2020] [Indexed: 01/21/2023]
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Zhang D, Wang C, Wang T, Du R, Li K, Yang M, Xue G, Dionigi G, Sun H. Clinical Experience of Use of Percutaneous Continuous Nervemonitoring in Robotic Bilateral Axillo-Breast Thyroid Surgery. Front Endocrinol (Lausanne) 2021; 12:817026. [PMID: 35211092 PMCID: PMC8862684 DOI: 10.3389/fendo.2021.817026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/31/2021] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE There is a need for a simplified technique for C-IONM in robotic surgery. The primary aim of this study was to describe our clinical experience with the use of percutaneous C-IONM in robotic bilateral axillary thyroid surgery. METHODS This study prospectively enrolled 304 consecutive patients who underwent robotic thyroidectomy via the bilateral axillo-breast approach and standardized C-IONM via percutaneous probe stimulation. RESULTS 323 RLNs were analyzed. C-IONM with percutaneous probes was feasible in all cases. During this study, we did not record any cases of probe displacement, and no additional robotic maneuvers were required. The average stimulation intensity was 2 mA. There were no adverse local or systemic C-IONM side effects. The mean time required for probe positioning was 3 minutes. The EMG amplitude signal of 48 RLNs decreased significantly, < 50% from the original V1 signal. In these cases, the surgical procedure was modified. CONCLUSION The proposed percutaneous C-IONM provides a simplification of the continuous monitoring procedure for robotics. The advantage of percutaneous C-IONM is that it does not require additional trocar space, repeated instrument changes, and unmodified cosmesis. To our knowledge, this is the first study on the application of percutaneous C-IONM in robotic thyroid surgery.
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Affiliation(s)
- Daqi Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Cheng Wang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Tie Wang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Rui Du
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Kunlin Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Mingyu Yang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Gaofeng Xue
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Gianlorenzo Dionigi
- Division of General Surgery, Istituto Auxologico Italiano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
- *Correspondence: Hui Sun, ; orcid.org/0000-0001-8348-4933
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Thong G, Brophy C, Sheahan P. Use of intraoperative neural monitoring for prognostication of recovery of vocal mobility and reduction of permanent vocal paralysis after thyroidectomy. Head Neck 2020; 43:7-14. [PMID: 32864795 DOI: 10.1002/hed.26440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 06/28/2020] [Accepted: 08/14/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The benefits of intraoperative neural monitoring (IONM) of recurrent laryngeal nerve (RLN) on post-thyroidectomy vocal cord palsy (VCP) rates are contentious. We wished to study impact of IONM on permanent VCP after thyroidectomy. METHODS Retrospective review of prospective series of 1011 (1539 nerves-at-risk) patients undergoing thyroidectomy without (418, group 1) and with (583, group 2) IONM. RESULTS There were three recognized nerve injuries in group 1, vs one in group 2 (P = .3). There were no differences in overall VCP rates. However, patients in group 2 with immediate postoperative VCP had higher likelihood of full recovery than patients in group 1 (55 of 56 vs 23 of 29 patients, P = .01), and lower incidence of total permanent VCP (2 of 917 vs 9 of 647 patients, P = .01). CONCLUSION Among patients with immediate postoperative VCP after thyroidectomy, IONM is associated with a higher likelihood of regaining normal vocal function. This may be related to better identification of RLN branching in IONM cases.
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Affiliation(s)
- Gerard Thong
- Department of Otolaryngology - Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Catherine Brophy
- Department of Otolaryngology - Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Patrick Sheahan
- Department of Otolaryngology - Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork, Ireland.,Ear Nose Throat and Oral (ENTO) Research Institute, University College Cork, Cork, Ireland
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Han S, Kwon TK, Chai YJ, Park J, Lee DY, Lee KE, Kim HY, Hwang KT, Yi KH. Functional Voice and Swallowing Outcome Analysis After Thyroid Lobectomy: Transoral Endoscopic Vestibular Versus Open Approach. World J Surg 2020; 44:4127-4135. [DOI: 10.1007/s00268-020-05731-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 01/29/2023]
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Zhang GL, Zhang GL, Lin YM, Li B, Gao J, Chen YJ. Endoscopic thyroidectomy versus traditional open thyroidectomy for identification of the external branch of the superior laryngeal nerve. Surg Endosc 2020; 35:2831-2837. [PMID: 32754826 DOI: 10.1007/s00464-020-07718-x] [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: 01/12/2020] [Accepted: 06/09/2020] [Indexed: 11/24/2022]
Abstract
AIM To explore the anatomical features of the external branch of the superior laryngeal nerve (EBSLN) and determine an effective approach for its preservation during endoscopic thyroidectomy (ET). METHODS From January 2017 to December 2018, a total of 405 consecutive patients with thyroid disease were retrospectively analyzed. These patients were divided into the ET group and the open thyroidectomy (OT) group according to the surgical approaches. There were 195 cases in the ET group including 43 males and 152 females, and 210 cases in the OT group including 65 males and 145 females. The dissection process of EBSLN, detection rate, distribution of identification methods of the EBSLN and rate of voice change were recorded. RESULTS There were 205 EBSLNs detected under direct vision in ET group for a detection rate of 88.0%, while 158 EBSLNs were detected under direct vision in OT group for a detection rate of 58.1%. But with the assistant of intraoperative neuromonitoring (IONM), the number of EBSLNs detected visually reached up to 220 in ET group and 226 in OT group, respectively, for a visual detection rate of 94.4% and 83.1%, respectively. There were significant difference in the rate of direct visual identification, total visual identification with IONM. Stratified risk estimation indicated that the tumor size and location were risk factors for the direct visual dissection of EBSLN. Stratified analysis by tumor size indicated that when tumor diameter was ≤ 4 cm, the incidence of vocal cord fatigue and total vocal changes in ET group was significantly lower than that in OT group. CONCLUSIONS Recognition and exposure of the EBSLN can be facilitated by the magnification and focusing function of high-definition endoscopy and the advantage of a 30° variable angle. Full exposure of the sternothyroid-laryngeal triangle and fine dissection along the superior thyroid vessels is beneficial for recognizing the EBSLN.
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Affiliation(s)
- Guo-Liang Zhang
- Department of Thyroid Surgery, The Affiliated Hospital of Putian University, Fujian, 351100, China
| | - Guo-Lie Zhang
- Department of Thyroid Surgery, The Affiliated Hospital of Putian University, Fujian, 351100, China.
| | - Yuan-Mei Lin
- Department of Thyroid Surgery, The Affiliated Hospital of Putian University, Fujian, 351100, China
| | - Bing Li
- Department of Thyroid Surgery, The Affiliated Hospital of Putian University, Fujian, 351100, China
| | - Jian Gao
- Department of Thyroid Surgery, The Affiliated Hospital of Putian University, Fujian, 351100, China
| | - Yi-Jun Chen
- Department of Thyroid Surgery, The Affiliated Hospital of Putian University, Fujian, 351100, China
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Ji YB, Jeong JH, Wu CW, Chiang FY, Tae K. Neural Monitoring of the External Branch of the Superior Laryngeal Nerve During Transoral Thyroidectomy. Laryngoscope 2020; 131:E671-E676. [PMID: 32820531 DOI: 10.1002/lary.28883] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/24/2020] [Accepted: 06/03/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS There is no study regarding intraoperative neural monitoring (IONM) of the external branch of the superior laryngeal nerve (EBSLN) during transoral thyroidectomy. The objective of this study was to evaluate the feasibility and success rate of electrical identification of the EBSLN during transoral robotic or endoscopic thyroidectomy. STUDY DESIGN Case series study. METHODS We studied a cohort of 76 patients (87 nerves at risk, (NARs)) who underwent transoral robotic or endoscopic thyroidectomy and simultaneous intermittent IONM between July 2017 and May 2019. We performed the standard IONM procedure plus routine neural monitoring of the EBSLN. IONM and surgical outcome data were prospectively collected. RESULTS Sixty-one patients underwent the robotic procedure, and 15 patients underwent the endoscopic procedure. Thirty-seven external branches of the superior laryngeal nerves at risk (42.5%) were electrically identified using electromyography signals (31 NARs, 35.6%) or cricothyroid muscle twitches (6 NARs, 6.9%). The mean pre-(S1) and post-dissection (S2) amplitudes of the EBSLN were 372 ± 147 and 351 ± 159 μV, respectively. The identification rates were not different between the robotic and endoscopic procedures. In comparing the early 20 NARs (18 patients) and the later 67 NARs (58 patients), the identification rate was higher in the later cases, although the difference was not statistically significant (25.0% vs. 47.8%, P = .079). CONCLUSION IONM of the EBSLN is feasible and useful in identifying and preserving the nerve during transoral thyroidectomy, although the identification rate of the nerve is relatively low. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E671-E676, 2021.
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Affiliation(s)
- Yong Bae Ji
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Jin Hyeok Jeong
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, I-Shou University, School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Kyung Tae
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
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Sung ES, Shin SC, Kwon HK, Kim J, Park DH, Choi SW, Kim SH, Lee JC, Ro JH, Lee BJ. Application of Novel Intraoperative Neuromonitoring System Using an Endotracheal Tube With Pressure Sensor During Thyroid Surgery: A Porcine Model Study. Clin Exp Otorhinolaryngol 2020; 13:291-298. [PMID: 32668828 PMCID: PMC7435431 DOI: 10.21053/ceo.2019.01249] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/13/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES The loss of signal during intraoperative neuromonitoring (IONM) using electromyography (EMG) in thyroidectomy is one of the biggest problems. We have developed a novel IONM system with an endotracheal tube (ETT) with an attached pressure sensor instead of EMG to detect laryngeal twitching. The aim of the present study was to investigate the feasibility and reliability of this novel IONM system using an ETT with pressure sensor during thyroidectomy in a porcine model. METHODS We developed an ETT-attached pressure sensor that uses the piezoelectric effect to measure laryngeal muscle twitching. Stimulus thresholds, amplitude, and latency of laryngeal twitching evaluated using the pressure sensor were compared to those measured using transcartilage needle EMG. The measured amplitude changes by EMG and the pressure sensor during recurrent laryngeal nerve (RLN) traction injury were compared. RESULTS No significant differences in stimulus threshold intensity between EMG and the pressure sensor were observed. The EMG amplitude detected at 0.3 mA, increased with increasing stimulus intensity. When the stimulus was more than 1.0 mA, the amplitude showed a plateau. In a RLN traction injury experiment, the EMG amplitude did not recover even 20 minutes after stopping RLN traction. However, the pressure sensor showed a mostly recovery. CONCLUSION The change in amplitude due to stimulation of the pressure sensor showed a pattern similar to EMG. Pressure sensors can be feasibly and reliably used for RLN traction injury prediction, RLN identification, and preservation through the detection of laryngeal muscle twitching. Our novel IONM system that uses an ETT with an attached pressure sensor to measure the change of surface pressure can be an alternative to EMG in the future.
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Affiliation(s)
- Eui-Suk Sung
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Pusan National University and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sung-Chan Shin
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Pusan National University and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hyun-Keun Kwon
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Pusan National University and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jia Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Pusan National University and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Da-Hee Park
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Pusan National University and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seong-Wook Choi
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Pusan National University and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang-Hoon Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Pusan National University and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jin-Choon Lee
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Pusan National University and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jung-Hoon Ro
- Department of Biomedical Engineering, Pusan National University Hospital, Busan, Korea
| | - Byung-Joo Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Pusan National University and Medical Research Institute, Pusan National University Hospital, Busan, Korea
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20
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Zhang D, Wang T, Kim HY, Wang P, Dionigi G, Pino A, Sun H. Strategies for superior thyroid pole dissection in transoral thyroidectomy: a video operative guide. Surg Endosc 2020; 34:3711-3721. [PMID: 32382884 DOI: 10.1007/s00464-020-07577-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 04/17/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND The dissection of the superior thyroid gland pole is challenging when using the in TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) due to (a) the cranio-caudal approach, (b) cranial-caudal view, and (c) the restriction of maneuverability inside the narrow neck air pocket. METHODS In this paper and operative video guide, a series of TOETVA's tips and tricks are presented with an emphasis on the strategies for a safe approach to the superior thyroid gland pole structures. RESULTS Management of the upper thyroid pole structures includes: (a) use of a 5 mm/30°-45° endoscope; (b) retraction ports up to the limit of the lower jaw edge; (c) lateral retraction of 1/3 of the cranial strap muscles; (d) isthmectomy; (e) cutting the sternothyroid muscle cranially for 1 cm; (f) retraction of the thyroid upwards and laterally; (g) monitoring the external branch of the superior laryngeal nerve, and (h) sealing individual vessel branches. CONCLUSION Access to the superior thyroid pole space through the TOETVA approach presents some challenges, particularly when accessing thyroid vessels or nodules located or displaced more cranially. Strategies that enhance a critical view of the superior thyroid gland structures can protect them from damage and have the potential to improve the safety of the TOETVA and decrease potential conversion rates.
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Affiliation(s)
- Daqi Zhang
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine On Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, 126 Xiantai Blvd, Changchun city, Jilin province, People's Republic of China
| | - Tie Wang
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine On Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, 126 Xiantai Blvd, Changchun city, Jilin province, People's Republic of China
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, Korea
| | - Ping Wang
- Department of Thyroid Surgery, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, People's Republic of China
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Antonella Pino
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy.
| | - Hui Sun
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine On Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, 126 Xiantai Blvd, Changchun city, Jilin province, People's Republic of China.
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21
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Nerve Monitoring for Transoral Thyroid Surgery: Why, How, and What to Expect. CURRENT OTORHINOLARYNGOLOGY REPORTS 2019. [DOI: 10.1007/s40136-019-00251-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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22
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Sung ES, Lee JC, Shin SC, Kwon HK, Na HS, Park DH, Choi SW, Ro JH, Lee BJ. Development of a Novel Intraoperative Neuromonitoring System Using an Accelerometer Sensor in Thyroid Surgery: A Porcine Model Study. Clin Exp Otorhinolaryngol 2019; 12:420-426. [PMID: 31195791 PMCID: PMC6787476 DOI: 10.21053/ceo.2019.00423] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/20/2019] [Indexed: 11/22/2022] Open
Abstract
Objectives. The sensitivity and positive predictive value of widely used intraoperative neuromonitoring (IONM) using electromyography (EMG) of the vocalis muscle in thyroid surgery are controversial. Thus, we developed a novel IONM system with an accelerometer sensor that uses the piezoelectric effect instead of EMG to detect laryngeal twitching. The objective of this study was to evaluate the feasibility and safety of this novel IONM system during thyroid surgery in a porcine model. Methods. We developed an accelerometer sensor that uses the piezoelectric effect to measure laryngeal twitching in three dimensions. This novel accelerometer sensor was placed in the anterior neck skin (transcutaneous) or postcricoid area. Stimulus thresholds, amplitude, and latency of laryngeal twitching measured using the accelerometer sensor were compared to those measured through EMG of the vocalis muscle. Results. The amplitudes of the accelerometer sensor at the anterior neck and postcricoid area were significantly lower than those of EMG because of differences in the measurement method used to evaluate laryngeal movement. However, no significant differences in stimulus thresholds between the EMG endotracheal tube and transcutaneous or postcricoid accelerometer sensors were observed. Conclusion. Accelerometer sensors located at the anterior neck or postcricoid area were able to identify laryngeal twitching. The stimulus intensity measured with these sensors was equivalent to that from conventional vocalis EMG. Our novel IONM system with an accelerometer sensor that checks changes in surface acceleration can be an alternative to EMG of the vocalis muscle for IONM in the future.
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Affiliation(s)
- Eui-Suk Sung
- Department of Otolaryngology-Head and Neck Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University College of Medicine, Yangsan, Korea
| | - Jin-Choon Lee
- Department of Otolaryngology-Head and Neck Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University College of Medicine, Yangsan, Korea
| | - Sung-Chan Shin
- Department of Otolaryngology-Head and Neck Surgery, Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
| | - Hyun-Keun Kwon
- Department of Otolaryngology-Head and Neck Surgery, Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
| | - Han-Seul Na
- Department of Otolaryngology-Head and Neck Surgery, Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
| | - Da-Hee Park
- Department of Otolaryngology-Head and Neck Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University College of Medicine, Yangsan, Korea
| | - Seong-Wook Choi
- Department of Otolaryngology-Head and Neck Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University College of Medicine, Yangsan, Korea
| | - Jung-Hoon Ro
- Department of Biomedical Engineering, Pusan National University Hospital, Busan, Korea
| | - Byung-Joo Lee
- Department of Otolaryngology-Head and Neck Surgery, Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
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Sanabria A, Kowalski LP, Nixon I, Angelos P, Shaha A, Owen RP, Suarez C, Rinaldo A, Ferlito A. Methodological Quality of Systematic Reviews of Intraoperative Neuromonitoring in Thyroidectomy: A Systematic Review. JAMA Otolaryngol Head Neck Surg 2019; 145:563-573. [PMID: 30973598 DOI: 10.1001/jamaoto.2019.0092] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Systematic reviews and meta-analyses are considered the best evidence for clinical decision making. Many reviews of intraoperative neuromonitoring (IONM) in thyroidectomy have conflicting results, owing in large part to methodological quality. Objective To assess the methodological quality and the causes of heterogeneous results of systematic reviews that compare routine IONM vs visual identification of the recurrent laryngeal nerve (RLN) in patients undergoing thyroidectomy. Data Sources A systematic search was performed of MEDLINE (PubMed), Embase, the Cochrane Library, LILACS (Literatura Latino Americana e do Caribe em Ciências da Saúde), Web of Science, and Google from January 1, 1968, through June 30, 2018. Data were analyzed from July 17 to November 30, 2018. Study Selection Studies that mentioned performance of a systematic review/meta-analysis during the search period. Data Extraction and Synthesis Data including study characteristics, type of patients, numbers of nerves at risk, and temporary and definitive RLN paralysis by group were extracted. Data about methodological characteristics, type of statistical analysis and summary estimator, endorsement of systematic review/meta-analysis guidelines, heterogeneity, publication bias, funding, conflict of interest, and statistical analysis were also recorded. The methodological quality was measured with the AMSTAR2 (A Measurement Tool to Assess Systematic Reviews) tool by 2 independent evaluators. Main Outcomes and Measures Methodological quality. Results The search identified 13 systematic reviews that included patients who underwent open or minimally invasive thyroidectomy, second operations, and a mixture of low- and high-risk procedures. The mean compliance with the AMSTAR2 overall criteria was 53% (range, 11%-83%); with critical criteria, 71% (range, 50%-94%). The percentage of nerves at risk from RCTs was 4.8%. The mean (SD) crude rate of definitive RLN paralysis was 0.81% (0.22%; median, 0.75% [range, 0.53%-1.30%]) in the monitoring group and 1.14% (0.56%; median, 0.96% [range, 0.57%-2.56%]) in the control group. Conclusions and Relevance A substantial number of systematic reviews of IONM in thyroidectomy have conflicting results, but their mean methodological quality is critically low. Design of a systematic review should comply with methodological standards and recommendations to offer relevant and practical information for decision making.
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Affiliation(s)
- Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia, Fundación Colombiana de Cancerología-Clínica Vida, Medellin, Colombia
| | - Luiz P Kowalski
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
| | - Iain Nixon
- Ear, Nose and Throat Department, NHS Lothian, Edinburgh, United Kingdom
| | - Peter Angelos
- Department of Surgery and MacLean Center for Clinical Ethics, University of Chicago Medicine, Chicago, Illinois
| | - Ashok Shaha
- Head & Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Randall P Owen
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carlos Suarez
- Instituto de Investigacion Sanitaria del Principado de Asturias, University of Oviedo, Fundación de Investigación e Innovación Biosanitaria del Principado de Asturias, Oviedo, Spain
| | - Alessandra Rinaldo
- Ear, Nose, and Throat Section, University of Udine School of Medicine, Udine, Italy
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
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Xie QP, Xiang C, Wang Y, Yan HC, Zhao QZ, Yu X, Zhang ML, Wang P. The patterns and treatment of postoperative hemorrhage and hematoma in total endoscopic thyroidectomy via breast approach: experience of 1932 cases. Endocrine 2019; 63:422-429. [PMID: 30652236 DOI: 10.1007/s12020-018-01837-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 12/31/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Postoperative hemorrhage and hematoma formation is a potentially lethal complication in thyroid surgery, although the patterns and treatment of hemorrhage after total endoscopic thyroidectomy (TET) via breast approach has not been reported previously. We aim to share our experience about postoperative bleeding. METHODS A retrospective analysis of 1932 patients who underwent TET from April 2008 to May 2018 in our institution was carried out. The patterns of postoperative hemorrhage and hematoma formation that need surgical treatment were summarized and focused on the relation to the source of bleeding and the time interval between first surgery and hemorrhage. Related risk factors were analyzed by univariate or multivariate analysis processes. RESULTS The overall rate of hemorrhage and hematoma occurrence was only 0.724% (14 in 1932 patients). Of them, 12 occurred in the first 24 h after surgery, and the other two occurred after withdrawal of the drainage tube. The principle independent risk factors for postoperative hemorrhage and hematoma were age (older than 35 years old) and lateral compartment dissection (LCD) revealed by multivariate regression. During re-exploration, obvious bleeding points were detected in 13 patients. Among them, 12 bled from the vessels in the main trocar cavity and another 1 bled from a broken vein located between the two heads of the sternocleidomastoid (SCM) muscle with LCD. CONCLUSIONS Hemorrhage after TET usually occurs within 24 h, and the main video trocar cavity was the area most likely to bleed. Age and LCD may increase the bleeding risk. Appropriate dissection level is the main solution to prevent postoperative hemorrhage.
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Affiliation(s)
- Qiu-Ping Xie
- The Department of Surgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Cheng Xiang
- The Department of Surgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Yong Wang
- The Department of Surgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Hai-Chao Yan
- The Department of Surgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Qun-Zi Zhao
- The Department of Surgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Xing Yu
- The Department of Surgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Mao-Lin Zhang
- The Department of Surgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Ping Wang
- The Department of Surgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China.
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25
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Naytah M, Ibrahim I, da Silva S. Importance of incorporating intraoperative neuromonitoring of the external branch of the superior laryngeal nerve in thyroidectomy: A review and meta-analysis study. Head Neck 2019; 41:2034-2041. [PMID: 30706616 DOI: 10.1002/hed.25669] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 12/17/2018] [Accepted: 01/15/2019] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Voice changes are frequently reported after thyroidectomy due to injury to the external branch of the superior laryngeal nerve (EBSLN) and paralysis of the cricothyroid muscle, The objective is to evaluate the advantage of intraoperative neuromonitoring (IONM) in identifying EBSLN during thyroid surgery. METHODS Data sources were MEDLINE, PubMed, Web of Science, and Cochrane Library from January 1, 1995, through July 1, 2018. Published studies of adult patients who had thyroid surgery and an attempt to identify EBSLN done by conventional methods and/or IONM were selected. RESULTS Seven studies met all inclusion criteria. Patients who had IONM during thyroid surgery had a significantly increased number of identified EBSLN at risk, compared to the control group. CONCLUSION The use of IONM during open thyroid surgery increases EBSLN identification/visualization, and hence it may decrease the incidence of post-thyroidectomy voice disorders.
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Affiliation(s)
- Mai Naytah
- Department of Otolaryngology-Head and Neck Surgery, Royal Victoria Hospital, McGill University, Montréal, Québec, Canada
- Department of Otolaryngology-Head and Neck Surgery, King Fahd Hospital, Ministry of Health, Jeddah, Kingdom of Saudi Arabia
| | - Iman Ibrahim
- Department of Otolaryngology-Head and Neck Surgery, Royal Victoria Hospital, McGill University, Montréal, Québec, Canada
- Audio-vestibular Medicine Unit, Department of Otolaryngology-Head and Neck Surgery, Kasr AlAini Hospital, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sabrina da Silva
- Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital, McGill University, Montréal, Québec, Canada
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Cirocchi R, Arezzo A, D'Andrea V, Abraha I, Popivanov GI, Avenia N, Gerardi C, Henry BM, Randolph J, Barczyñski M. Intraoperative neuromonitoring versus visual nerve identification for prevention of recurrent laryngeal nerve injury in adults undergoing thyroid surgery. Cochrane Database Syst Rev 2019; 1:CD012483. [PMID: 30659577 PMCID: PMC6353246 DOI: 10.1002/14651858.cd012483.pub2] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Injuries to the recurrent inferior laryngeal nerve (RILN) remain one of the major post-operative complications after thyroid and parathyroid surgery. Damage to this nerve can result in a temporary or permanent palsy, which is associated with vocal cord paresis or paralysis. Visual identification of the RILN is a common procedure to prevent nerve injury during thyroid and parathyroid surgery. Recently, intraoperative neuromonitoring (IONM) has been introduced in order to facilitate the localisation of the nerves and to prevent their injury during surgery. IONM permits nerve identification using an electrode, where, in order to measure the nerve response, the electric field is converted to an acoustic signal. OBJECTIVES To assess the effects of IONM versus visual nerve identification for the prevention of RILN injury in adults undergoing thyroid surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, ICTRP Search Portal and ClinicalTrials.gov. The date of the last search of all databases was 21 August 2018. We did not apply any language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing IONM nerve identification plus visual nerve identification versus visual nerve identification alone for prevention of RILN injury in adults undergoing thyroid surgery DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts for relevance. One review author carried out screening for inclusion, data extraction and 'Risk of bias' assessment and a second review author checked them. For dichotomous outcomes, we calculated risk ratios (RRs) with 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) with 95% CIs. We assessed trials for certainty of the evidence using the GRADE instrument. MAIN RESULTS Five RCTs with 1558 participants (781 participants were randomly assigned to IONM and 777 to visual nerve identification only) met the inclusion criteria; two trials were performed in Poland and one trial each was performed in China, Korea and Turkey. Inclusion and exclusion criteria differed among trials: previous thyroid or parathyroid surgery was an exclusion criterion in three trials. In contrast, this was a specific inclusion criterion in another trial. Three trials had central neck compartment dissection or lateral neck dissection and Graves' disease as exclusion criteria. The mean duration of follow-up ranged from 6 to 12 months. The mean age of participants ranged between 41.7 years and 51.9 years.There was no firm evidence of an advantage or disadvantage comparing IONM with visual nerve identification only for permanent RILN palsy (RR 0.77, 95% CI 0.33 to 1.77; P = 0.54; 4 trials; 2895 nerves at risk; very low-certainty evidence) or transient RILN palsy (RR 0.62, 95% CI 0.35 to 1.08; P = 0.09; 4 trials; 2895 nerves at risk; very low-certainty evidence). None of the trials reported health-related quality of life. Transient hypoparathyroidism as an adverse event was not substantially different between intervention and comparator groups (RR 1.25; 95% CI 0.45 to 3.47; P = 0.66; 2 trials; 286 participants; very low-certainty evidence). Operative time was comparable between IONM and visual nerve monitoring alone (MD 5.5 minutes, 95% CI -0.7 to 11.8; P = 0.08; 3 trials; 1251 participants; very low-certainty evidence). Three of five included trials provided data on all-cause mortality: no deaths were reported. None of the trials reported socioeconomic effects. The evidence reported in this review was mostly of very low certainty, particularly because of risk of bias, a high degree of imprecision due to wide confidence intervals and substantial between-study heterogeneity. AUTHORS' CONCLUSIONS Results from this systematic review and meta-analysis indicate that there is currently no conclusive evidence for the superiority or inferiority of IONM over visual nerve identification only on any of the outcomes measured. Well-designed, executed, analysed and reported RCTs with a larger number of participants and longer follow-up, employing the latest IONM technology and applying new surgical techniques are needed.
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Affiliation(s)
- Roberto Cirocchi
- University of PerugiaDepartment of General SurgeryTerniItaly05100
| | - Alberto Arezzo
- University of TorinoDepartment of Surgical SciencesCorso Achille Mario Dogliotti 14TurinItaly10126
| | - Vito D'Andrea
- Sapienza University of RomeDepartment of Surgical SciencesViale Regina Elena, 324RomeItaly00161
| | - Iosief Abraha
- Regional Health Authority of UmbriaHealth Planning ServicePerugiaItaly06124
| | - Georgi I Popivanov
- Medical Military Academy of SofiaDepartment of Surgery"Sv. Georgi Sofiiski" 3SofiaBulgaria1606
| | - Nicola Avenia
- University of PerugiaDepartment of Surgical SciencesPerugiaItaly06034
| | - Chiara Gerardi
- IRCCS Istituto di Ricerche Farmacologiche Mario NegriVia La Masa, 19MilanItaly20156
| | - Brandon Michael Henry
- Cincinnati Children’s Hospital Medical CenterDivision of Cardiology3333 Burnet AveCincinnatiOhioUSA45229
| | - Justus Randolph
- Mercer UniversityGeorgia Baptist College of Nursing3001 Mercer University Dr.AtlantaGAUSA30341
| | - Marcin Barczyñski
- Jagiellonian University, Medical CollegeDepartment of Endocrine Surgery, Third Chair of General Surgery37 Pradnicka StreetKrakowPoland31‐202
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Zhao Y, Li C, Liu X, Zhou L, Zhang D, Xin J, Wang T, Li S, Sun H, Dionigi G. Investigation on EMG Profiles of the Superior Laryngeal Nerve in a In Vivo Porcine Model. J INVEST SURG 2019; 33:596-604. [PMID: 30644804 DOI: 10.1080/08941939.2018.1547462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The electromyographic (EMG) profiles of external branch of the superior laryngeal nerve (EBSLN) have been defined and the optimal intensity of the stimulation of EBSLN in an in vivo porcine model has been explored. MATERIALS EMG was simultaneously registered by the surface of endotracheal tube and needle electrodes by applying a monopolar stimulation probe in 12 piglets (22 EBSLNs). Vagal nerve (VN), RLN and EBSLN were excited to record the EMG tracings and cricothyroid muscle twitch (CTM). VN, RLN and EBSLN were stimulated from 0.1 to 1.0 mA. Cmin and Cmax have been defined as the minimum and maximal stimulation to evoke an EMG response. RESULTS The stimulation resulted in a dose-response curve. Cmin were 0.19 mA (0.04-0.4), 0.19 mA (0.08-0.3) and 0.21 mA (0.1-0.4) for EBSLN, RLN and VN (p > 0.05) respectively. Cmax were 0.6 mA along with an amplitude value of 396 ± 330 μV, 0.5 mA including 1058 ± 382 μV, 0.8 mA coupled with 870 ± 382 μV, equally for EBSLN, RLN and VN (p > 0.05) respectively. No asymmetry of amplitude responses each side for EBSLN, RLN and VN (p = 0.317, p = 0.203 and p = 0.468, respectively) was noted. The amplitudes of EBSLN were significantly lower than RLNs and VN (42% of RLN and 50% of VN amplitude rates). Also, CTM twitch was always detectable with the stimulation of EBSLN. CONCLUSIONS Cmin and Cmax of EBSLN were comparable to RLN and VN standards. The amplitude stimulus-response curves of RLN, VN and EBSLN were highly variable. It has been suggested to apply a stimulation of 1.0 mA and a visual appreciation of CTM twitch for the identification of EBSLN.
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Affiliation(s)
- Yishen Zhao
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun City, China
| | - Changlin Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun City, China
| | - Xiaoli Liu
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun City, China
| | - Le Zhou
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun City, China
| | - Daqi Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun City, China
| | - Jingwei Xin
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun City, China
| | - Tie Wang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun City, China
| | - Shijie Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun City, China
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun City, China
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy
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Surgical anatomy of the external branch of the superior laryngeal nerve: a systematic review and meta-analysis. Langenbecks Arch Surg 2018; 403:811-823. [PMID: 30430230 DOI: 10.1007/s00423-018-1723-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 10/22/2018] [Indexed: 01/12/2023]
Abstract
PURPOSE To provide a comprehensive evidence-based assessment of the anatomical characteristics of the external branch of the superior laryngeal nerve (EBSLN). MATERIALS AND METHODS A thorough systematic search was performed on the major electronic databases PubMed, EMBASE, Cochrane library, and ScienceDirect to identify eligible studies. Data were extracted and pooled into a meta-analysis. The primary outcomes were the EBSLN identification rate (total number of EBSLN identified divided by the total number of dissected hemilarynges) and the prevalence of various EBSLN types. RESULTS A total of 56 studies (n = 13,444 hemilarynges) were included. The overall pooled EBSLN identification rate was 89.24% (95% CI 85.49-92.49). This rate was higher for cadaveric (95.00%; 95% CI 89.73-99.35) compared to that reported in intraoperative studies (86.99%; 95% CI 82.37-91.01). Significantly higher identification rates were reported for studies in which intraoperative nerve monitoring was used (95.90%; 95% CI 94.30-97.25) compared to those which only relied on direct visual identification of the EBSLN (76.56%; 95% CI 69.34-83.08). Overall, Cernea type IIa (nerves crossing the superior thyroid artery less than 1 cm above the upper edge of the superior thyroid pole) and Friedman type 1 (nerves running their entire course superficial to the inferior pharyngeal constrictor) were the most prevalent (41.84%; 95% CI 33.28-48.08 and 50%; 95% CI 29.90-65.62, respectively). The combined prevalence of Cernea IIa and IIb (nerves crossing the superior thyroid artery below the upper edge of the superior thyroid pole) was higher in intraoperative studies compared to that in cadaveric studies (64.3% vs 49.4%). The EBSLN coursed medial to the superior thyroid artery in 70.98% (95% CI 55.14-84.68) of all cases. CONCLUSION The use of intraoperative nerve monitoring improves EBSLN identification rates. In light of the highly variable anatomical patterns displayed by the EBSLN, thorough pre-operative knowledge of its anatomy can be crucial in minimizing incidences of its iatrogenic injury.
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Protective Effects of Intraoperative Nerve Monitoring (IONM) for Recurrent Laryngeal Nerve Injury in Thyroidectomy: Meta-analysis. Sci Rep 2018; 8:7761. [PMID: 29773852 PMCID: PMC5958090 DOI: 10.1038/s41598-018-26219-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 05/04/2018] [Indexed: 12/13/2022] Open
Abstract
Recurrent laryngeal nerve (RLN) injury is an intractable complication of thyroidectomy. Intraoperative nerve monitoring (IONM) was designed to prevent RLN injury. However, the results concerning the protective effect of IONM on RLN injury are still controversial. We searched all eligible databases from 1980 to 2017. Meta-analysis was performed to evaluate the effect of IONM on RLN injury. Sensitivity analysis was also conducted to check the stability of our results. There were 34 studies included in the analysis. Overall analysis found a significant decrease in total injury (RR = 0.68, 95%CI: 0.55 to 0.83), transient injury (RR = 0.71, 95%CI: 0.57 to 0.88), and permanent injury (RD = −0.0026, 95%CI: −0.0039 to −0.0012) with IONM. Subgroup analysis found IONM played a preventive role of total, transient and permanent injury in patients undergoing bilateral thyroidectomy. IONM also reduced the incidence of total and transient injury for malignancy cases. Operations with IONM were associated with fewer total and transient RLN injuries in operation volume < 300 NARs per year and fewer total and permanent RLN injuries in operation volume ≥ 300 NARs per year. The application of IONM could reduce the RLN injury of thyroidectomy. Particularly, we recommend routine IONM for use in bilateral operations and malignancy operations.
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Zhang D, Li S, Dionigi G, Wang T, Zhang J, Xue G, Sun H. Feasibility of Continuous Intraoperative Neural Monitoring During Transoral Endoscopic Thyroidectomy Vestibular Approach in a Porcine Model. J Laparoendosc Adv Surg Tech A 2018; 29:1592-1597. [PMID: 29746219 DOI: 10.1089/lap.2018.0054] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Experimental study to evaluate feasibility of continuous intraoperative neural monitoring (C-IONM) in transoral endoscopic thyroidectomy vestibular approach (TOETVA). Methods: Duroc-Landrace pigs were orally intubated with electromyogram endotracheal tube. Automatic periodic stimulation (APS) electrode was allocated in the operative field through the 5-mm ports. APS was then repose on vagal nerve (VN) with different approaches: (1) median, that is, between sternothyroid and thyroid gland; and (2) lateral, that is, between sternocleidomastoid and sternothyroid. VN was stimulated proximally and distally to the APS location to verify whether the dissection and/or placement determined VN injury. Video presentation is offered. Results: Assembled APS accessory was feasible in large-brained animals. The two basic options for VN approaches were tested. Baseline obtained had amplitude values >1000 μV, bilaterally. Conclusions: C-IONM was feasible in TOETVA in porcine models, but simplification of electrode design and application is needed.
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Affiliation(s)
- Daqi Zhang
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Shijie Li
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi," University Hospital G. Martino, University of Messina, Messina, Italy
| | - Tie Wang
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Jiao Zhang
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Gaofeng Xue
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Hui Sun
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
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Sung ES, Chang JH, Kim J, Cha W. Is cricothyroid muscle twitch predictive of the integrity of the EBSLN in Thyroid Surgery? Laryngoscope 2018; 128:2654-2661. [DOI: 10.1002/lary.27158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/27/2018] [Accepted: 02/08/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Eui-Suk Sung
- Department of Otorhinolaryngology-Head and Neck Surgery and Research Institute for Convergence of Biomedical Science and Technology; Pusan National University Yangsan Hospital; Yangsan
| | - Jae Hyeok Chang
- Department of Rehabilitation Medicine; Busan Republic of Korea
| | - Jia Kim
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute; Pusan National University Hospital; Busan Republic of Korea
| | - Wonjae Cha
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute; Pusan National University Hospital; Busan Republic of Korea
- Department of Otorhinolaryngology-Head and Neck Surgery; Pusan National University School of Medicine; Busan Republic of Korea
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Yıldırım D, Dönmez T, Çakır M, Aktürk OM, Hut A, Kocakuşak A, Çekiç E, Tigrel LZ, Yıldız T. Is the use of intraoperative nerve monitoring an effective method to reduce the rate of permanent recurrent laryngeal nerve paralysis? ARCHIVES OF CLINICAL AND EXPERIMENTAL MEDICINE 2018. [DOI: 10.25000/acem.383033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Dionigi G, Wu CW, Tufano RP, Rizzo AG, Anuwong A, Sun H, Carcoforo P, Antonino C, Portinari M, Kim HY. Monitored transoral endoscopic thyroidectomy via long monopolar stimulation probe. J Vis Surg 2018; 4:24. [PMID: 29445610 PMCID: PMC5803135 DOI: 10.21037/jovs.2017.12.25] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 12/27/2017] [Indexed: 12/14/2022]
Abstract
This video aimed to describe the role of intraoperative neuromonitoring (IONM) during transoral endoscopic thyroidectomy vestibular approach (TOETVA) with emphasis given to IONM technical and technological notes, the identification of recurrent laryngeal nerve (RLN). Standardized technique of IONM consist in identifying and monitoring both the vagus nerve and the RLNs before and after resection (V1, V2, R1, R2). According to this report, IONM during TOETVA is feasible and safe in providing identification and function of laryngeal nerves. IONM enable surgeons to feel more comfortable with their initial approach to TOETVA or extended indications. Larger series are needed for appropriated evaluation of IONM in reduction of the rates for RLN complications.
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Affiliation(s)
- Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy
| | - Che-Wei Wu
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ralph P. Tufano
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Antonio Giacomo Rizzo
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy
| | - Angkoon Anuwong
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hui Sun
- Minimally Invasive and Endocrine Division, Department of Surgery, Police General Hospital, Bangkok, Thailand
| | - Paolo Carcoforo
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, China Japan Union Hospital of Jilin University, Changchun 130033, China
- Department of Surgery, S. Anna University Hospital, Ferrara, Italy
| | - Cancellieri Antonino
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy
| | - Mattia Portinari
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, China Japan Union Hospital of Jilin University, Changchun 130033, China
- Department of Surgery, S. Anna University Hospital, Ferrara, Italy
| | - Hoon Yub Kim
- Department of Morphology, Surgery, and Experimental Medicine, University of Ferrara, Ferrara, Italy
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Calò PG, Medas F, Conzo G, Podda F, Canu GL, Gambardella C, Pisano G, Erdas E, Nicolosi A. Intraoperative neuromonitoring in thyroid surgery: Is the two-staged thyroidectomy justified? Int J Surg 2018; 41 Suppl 1:S13-S20. [PMID: 28506407 DOI: 10.1016/j.ijsu.2017.02.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/02/2017] [Accepted: 02/05/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the diagnostic accuracy of intraoperative neuromonitoring (IONM) in predicting postoperative nerve function during thyroid surgery and its consequent ability to assist the surgeon in intraoperative decision making. MATERIALS AND METHODS A total of 2365 consecutive patients were submitted to thyroidectomy by the same surgical team. Group A included 1356 patients (2712 nerves at risk) in whom IONM was utilized, and Group B included 1009 patients (2018 nerves at risk) in whom IONM was not utilized. RESULTS In Group A, loss of signal (LOS) was observed in 37 patients; there were 29 true positive, 1317 true negative, 8 false positive, and 2 false negative cases. Accuracy was 99.3%, positive predictive value was 78.4%, negative predictive value was 99.8%, sensitivity was 93.6%, and specificity was 99.4%. A total of 29 (2.1%) cases of unilateral paralysis were observed, 23 (1.7%) of which were transient and 6 (0.4%) of which were permanent. Bilateral palsy was observed in two (0.1%) cases requiring a tracheostomy. In Group A, 31 (2.3%) injuries were observed, 25 (1.8%) of which were transient and 6 (0.4%) of which were permanent. In Group B, 26 (2.6%) unilateral paralysis cases were observed, 20 (2%) of which were transient and 6 (0.6%) of which were permanent; bilateral palsy was observed in 2 (0.2%) cases. In Group B, 28 (2.8%) injuries were observed, 21 (2.1%) of which were transient and 7 (0.7%) of which were permanent. Differences between the two groups were not statistically significant. CONCLUSIONS Our results show that IONM has a very high sensitivity and negative predictive value, but also good specificity and positive predictive value. For these reasons, in selected patients with LOS, the surgical strategy should be reconsidered. However, patients need to be informed preoperatively about potential strategy changes during the planned bilateral surgery. Future larger and multicenter studies are needed to confirm the benefits of this therapeutic strategy.
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Affiliation(s)
- Pietro Giorgio Calò
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Fabio Medas
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Giovanni Conzo
- Università degli Studi della Campania "Luigi Vanvitelli" - School of Medicine, Division of General Surgery and Surgical Oncology, Via Gen.G.Orsini 42, 80132, Naples, Italy.
| | - Francesco Podda
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Gian Luigi Canu
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Claudio Gambardella
- Università degli Studi della Campania "Luigi Vanvitelli" - School of Medicine, Division of General Surgery and Surgical Oncology, Via Gen.G.Orsini 42, 80132, Naples, Italy.
| | - Giuseppe Pisano
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Enrico Erdas
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Angelo Nicolosi
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
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Potenza AS, Araujo Filho VJF, Cernea CR. Injury of the external branch of the superior laryngeal nerve in thyroid surgery. Gland Surg 2017; 6:552-562. [PMID: 29142848 DOI: 10.21037/gs.2017.06.15] [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: 11/06/2022]
Abstract
The external branch of the superior laryngeal nerve (EBSLN) innervates the cricothyroid muscle (CTM) to promote lengthening and thinning of the vocal fold, thus increasing voice pitch. The close relation with the superior thyroid vessels (STV) puts the EBSLN in risk every time the superior pole of the thyroid is dissected. It travels downward to innervate the CTM, lateral to the thyroid cartilage and to the inferior pharyngeal constrictor muscle (IPCM), being eventually covered by this muscle fibers as it approaches its entry point. During its descending course, the EBSLN curves and crosses the STV posteriorly. The lower this crossing occurs in the neck, the higher the risk of surgical damage to the nerve by transection, traction, entrapment, thermal damage or disrupted blood supply. The chances of surgical trauma are also increased by size and weight of the specimen, shorter neck length and non-white ethnicity. Voice changes following thyroid surgery are common and multifactorial. The actual rate of vocal impairment due to EBSLN injury is unclear, since changes to the everyday speaking voice can be minimal and laryngeal findings are usually subtle and controversial. CTM electroneuromyography (EMG) is the most accurate tool to diagnose abnormal EBSLN conductivity, but it is technically difficult and barely applicable in routine practice. Recommended approaches to prevent injury include: (I) individual distal ligature of the STV by the thyroid capsule; (II) visual identification of the nerve and its trajectory and (III) electrostimulation with either observation of CTM twitch or intraoperative nerve monitoring (IONM) via dedicated endotracheal tube electrodes. There is accumulating evidence that a combination of visual and standardized electrophysiological EBSLN identification with meticulous division of the STV improves preservation rates. IONM bears the additional benefits of prognostication, quantification and documentation of neural function once it allows intraoperative laryngeal EMG.
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Affiliation(s)
- Andre S Potenza
- Department of Surgery, Head and Neck Surgery Service of the Hospital das Clínicas, Faculty of Medicine of the University of Sao Paulo, Sao Paulo, Brazil
| | - Vergilius J F Araujo Filho
- Department of Surgery, Head and Neck Surgery Service of the Hospital das Clínicas, Faculty of Medicine of the University of Sao Paulo, Sao Paulo, Brazil
| | - Claudio R Cernea
- Department of Surgery, Head and Neck Surgery Service of the Hospital das Clínicas, Faculty of Medicine of the University of Sao Paulo, Sao Paulo, Brazil
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Aygün N, Uludağ M, İşgör A. Contribution of intraoperative neuromonitoring to the identification of the external branch of superior laryngeal nerve. Turk J Surg 2017; 33:169-174. [PMID: 28944328 DOI: 10.5152/turkjsurg.2017.3645] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 08/10/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We evaluated the contribution of intraoperative neuromonitoring to the visual and functional identification of the external branch of the superior laryngeal nerve. MATERIAL AND METHODS The prospectively collected data of patients who underwent thyroid surgery with intraoperative neuromonitoring for external branch of the superior laryngeal nerve exploration were assessed retrospectively. The surface endotracheal tube-based Medtronic NIM3 intraoperative neuromonitoring device was used. The external branch of the superior laryngeal nerve function was evaluated by the cricothyroid muscle twitch. In addition, contribution of external branch of the superior laryngeal nerve to the vocal cord adduction was evaluated using electromyographic records. RESULTS The study included data of 126 (female, 103; male, 23) patients undergoing thyroid surgery, with a mean age of 46.2±12.2 years (range, 18-75 years), and 215 neck sides were assessed. Two hundred and one (93.5%) of 215 external branch of the superior laryngeal nerves were identified, of which 60 (27.9%) were identified visually before being stimulated with a monopolar stimulator probe. Eighty-nine (41.4%) external branch of the superior laryngeal nerves were identified visually after being identified with a probe. Although 52 (24.1%) external branch of the superior laryngeal nerves were identified with a probe, they were not visualized. Intraoperative neuromonitoring provided a significant contribution to visual (p<0.001) and functional (p<0.001) identification of external branch of the superior laryngeal nerves. Additionally, positive electromyographic responses were recorded from 160 external branch of the superior laryngeal nerves (74.4%). CONCLUSION Intraoperative neuromonitoring provides an important contribution to visual and functional identification of external branch of the superior laryngeal nerves. We believe that it can not be predicted whether the external branch of the superior laryngeal nerve is at risk or not and the nerve is often invisible; thus, intraoperative neuromonitoring may routinely be used in superior pole dissection. Glottic electromyography response obtained via external branch of the superior laryngeal nerve stimulation provides quantifiable information in addition to the simple visualization of the cricothyroid muscle twitch.
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Affiliation(s)
- Nurcihan Aygün
- Department of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Mehmet Uludağ
- Department of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Adnan İşgör
- Department of General Surgery, Bahçeşehir University School of Medicine, İstanbul, Turkey
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Superior laryngeal nerve in thyroid surgery: anatomical identification and monitoring. Eur Arch Otorhinolaryngol 2017; 274:3519-3526. [DOI: 10.1007/s00405-017-4666-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 07/03/2017] [Indexed: 10/19/2022]
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38
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Dionigi G, Kim HY, Wu CW, Lavazza M, Materazzi G, Lombardi CP, Anuwong A, Tufano RP. Neuromonitoring in endoscopic and robotic thyroidectomy. Updates Surg 2017; 69:171-179. [DOI: 10.1007/s13304-017-0442-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 04/01/2017] [Indexed: 12/01/2022]
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Salari B, Hammon RJ, Kamani D, Randolph GW. Staged Surgery for Advanced Thyroid Cancers: Safety and Oncologic Outcomes of Neural Monitored Surgery. Otolaryngol Head Neck Surg 2017; 156:816-821. [DOI: 10.1177/0194599817697189] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objective Thyroidectomy with extensive multicompartment bilateral neck dissections for advanced-stage thyroid cancer may lead to increased risk of complications, including bilateral recurrent laryngeal nerve (RLN) paralysis and hypoparathyroidism. A planned staged approach derived from a detailed preoperative radiographic map is associated with a low complication profile. This study evaluates oncologic results and safety of neural monitored, staged thyroid cancer surgery for management of advanced thyroid cancer. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods With institutional review board approval, 35 consecutive patients with advanced thyroid malignancy and extensive nodal disease managed with staged surgery between January 2004 and May 2013 by the senior author (G.W.R.) were identified, and the oncologic and surgical outcomes were reviewed. Results In total, 37.2% of patients had stage III or IV disease, with extrathyroidal extension in 71.4%, vascular invasion in 51.4%, and RLN invasion in 17% of patients. A total of 34% patients had positive lymph nodes in more than 5 nodal compartments; the average positive lymph node yield was 17, and extranodal extension was present in 51%. Three patients had RLN sacrifice, and there were no other cases of temporary or permanent RLN paralysis; permanent hypoparathyroidism and chyle leak occurred in one patient each. Locoregional recurrence occurred in 5.7% of patients after a 147-week mean follow-up. In patients with papillary thyroid carcinoma, median postoperative nonstimulated and stimulated thyroglobulin levels were 0.2 and 0.75 ng/mL, respectively. Conclusion A neural monitored, staged surgical approach was conducted without significant adverse events in this small sample and represents and effective alternative strategy option to simultaneous bilateral surgery in the management of thyroid cancer with extensive neck metastases.
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Affiliation(s)
- Behzad Salari
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary & Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca J. Hammon
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary & Harvard Medical School, Boston, Massachusetts, USA
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary & Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary & Harvard Medical School, Boston, Massachusetts, USA
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, & Harvard Medical School Boston, Massachusetts, USA
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Uludag M, Aygun N, Kartal K, Besler E, Isgor A. Is intraoperative neural monitoring necessary for exploration of the superior laryngeal nerve? Surgery 2017; 161:1129-1138. [DOI: 10.1016/j.surg.2016.10.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 10/06/2016] [Accepted: 10/06/2016] [Indexed: 11/15/2022]
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41
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Systematic review with meta-analysis of intraoperative neuromonitoring during thyroidectomy. Int J Surg 2017; 39:104-113. [DOI: 10.1016/j.ijsu.2017.01.086] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/16/2017] [Accepted: 01/19/2017] [Indexed: 11/23/2022]
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42
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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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43
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Uludag M, Aygun N, Kartal K, Citgez B, Besler E, Yetkin G, Kaya C, Ozsahin H, Mihmanli M, Isgor A. Contribution of intraoperative neural monitoring to preservation of the external branch of the superior laryngeal nerve: a randomized prospective clinical trial. Langenbecks Arch Surg 2016; 402:965-976. [PMID: 28035477 DOI: 10.1007/s00423-016-1544-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 12/16/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the effect of intraoperative neuromonitoring (IONM) on the injury rate of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy. METHODS A total of 133 consenting patients (98 female, 35 male; mean age, 45.6 ± 11.7 years) undergoing thyroidectomy were randomly assigned to 2 groups. In group 1 (n = 65 patients, 105 nerves), superior thyroid pole dissection was performed with no attempt to identify the EBSLN; in group 2 (n = 68 patients, 106 nerves), IONM was used to identify the EBSLN during surgery. EBSLN function was evaluated by intraoperative electromyography of the cricothyroid muscle. The EBSLN Voice Impairment Index-5 (VII-5) was conducted preoperatively and at 1, 3, and 6 months postoperatively. The primary outcome was the prevalence of EBSLN injury. The secondary outcomes were the identification rate of the EBSLN using IONM and changes in postoperative voice performance. RESULTS EBSLN injury was detected in eight (12.3%) patients and nine (8.6%) nerves in group 1 and in one (1.5%) patient and one (0.9%) nerve in group 2 (patients, p = 0.015; nerves, p = 0.010). IONM contributed significantly to visual (p < 0.001) and functional (p < 0.001) nerve identification in group 2. The VII-5 indicated more voice changes in group 1 than 2 at 1, 3, and 6 months postoperatively (p = 0.012, p = 0.015, and p = 0.02, respectively). CONCLUSION IONM contributes to visual and functional identification of the EBSLN and decreases the rate of EBSLN injury during superior pole dissection. Routine use of IONM to identify the EBSLN will minimize the risk of injury during thyroidectomy.
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Affiliation(s)
- Mehmet Uludag
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey.
| | - Nurcihan Aygun
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Kinyas Kartal
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Bulent Citgez
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Evren Besler
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Gurkan Yetkin
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Cemal Kaya
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Hamdi Ozsahin
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Mihmanli
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Adnan Isgor
- General Surgery, Bahcesehir University Medical Faculty, Istanbul, Turkey
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Lombardi CP, Carnassale G, Damiani G, Acampora A, Raffaelli M, De Crea C, Bellantone R. “The final countdown”: Is intraoperative, intermittent neuromonitoring really useful in preventing permanent nerve palsy? Evidence from a meta-analysis. Surgery 2016; 160:1693-1706. [DOI: 10.1016/j.surg.2016.06.049] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 06/23/2016] [Accepted: 06/23/2016] [Indexed: 10/21/2022]
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Del Rio P, Viani L, Montana CM, Cozzani F, Sianesi M. Minimally invasive thyroidectomy: a ten years experience. Gland Surg 2016; 5:295-9. [PMID: 27294036 DOI: 10.21037/gs.2016.01.04] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The conventional thyroidectomy is the most frequent surgical procedure for thyroidal surgical disease. From several years were introduced minimally invasive approaches to thyroid surgery. These new procedures improved the incidence of postoperative pain, cosmetic results, patient's quality of life, postoperative morbidity. The mini invasive video-assisted thyroidectomy (MIVAT) is a minimally invasive procedure that uses a minicervicotomy to treat thyroidal diseases. METHODS We present our experience on 497 consecutively treated patients with MIVAT technique. We analyzed the mean age, sex, mean operative time, rate of bleeding, hypocalcemia, transitory and definitive nerve palsy (6 months after the procedure), postoperative pain scale from 0 to 10 at 1 hour and 24 hours after surgery, mean hospital stay. RESULTS The indications to treat were related to preoperative diagnosis: 182 THYR 6, 184 THYR 3-4, 27 plummer, 24 basedow, 28 toxic goiter, 52 goiter. On 497 cases we have reported 1 case of bleeding (0,2%), 12 (2,4%) cases of transitory nerve palsy and 4 (0,8%) definitive nerve palsy. The rate of serologic hypocalcemia was 24.9% (124 cases) and clinical in 7.2% (36 cases); 1 case of hypoparathyroidism (0.2%). CONCLUSIONS The MIVAT is a safe approach to surgical thyroid disease, the cost are similar to CT as the adverse events. The minicervicotomy is really a minimally invasive tissue dissection.
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Affiliation(s)
- Paolo Del Rio
- Unit of general Surgery and Organ Transplantation, University Hospital of Parma, Parma, Italy
| | - Lorenzo Viani
- Unit of general Surgery and Organ Transplantation, University Hospital of Parma, Parma, Italy
| | - Chiara Montana Montana
- Unit of general Surgery and Organ Transplantation, University Hospital of Parma, Parma, Italy
| | - Federico Cozzani
- Unit of general Surgery and Organ Transplantation, University Hospital of Parma, Parma, Italy
| | - Mario Sianesi
- Unit of general Surgery and Organ Transplantation, University Hospital of Parma, Parma, Italy
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Hei H, Zhai Y, Qin J, Song Y. Intermittent Intraoperative Neural Monitoring Technology in Minimally Invasive Video-Assisted Thyroidectomy: A Preliminary Study. J INVEST SURG 2016; 29:93-7. [DOI: 10.3109/08941939.2015.1073411] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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47
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Xie Q, Wang P, Yan H, Wang Y. Feasibility and Effectiveness of Intraoperative Nerve Monitoring in Total Endoscopic Thyroidectomy for Thyroid Cancer. J Laparoendosc Adv Surg Tech A 2016; 26:109-15. [PMID: 26690784 DOI: 10.1089/lap.2015.0401] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Qiuping Xie
- Department of Surgery, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Ping Wang
- Department of Surgery, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Haichao Yan
- Department of Surgery, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Yong Wang
- Department of Surgery, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
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Hurtado-López LM, Díaz-Hernández PI, Basurto-Kuba E, Zaldívar-Ramírez FR, Pulido-Cejudo A. Efficacy of Intraoperative Neuro-Monitoring to Localize the External Branch of the Superior Laryngeal Nerve. Thyroid 2016; 26:174-8. [PMID: 26560965 DOI: 10.1089/thy.2015.0190] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND This study investigated whether visual localization of the external branch of the superior laryngeal nerve (EBSLN) coincides with its localization via intraoperative neuro-monitoring (IONM) during thyroidectomy and whether its use influences the frequency of injuries. METHODS A prospective, comparative, cross-sectional, observational study was performed in 240 superior thyroid poles. The metrics were visual identification of the EBSLN and its corroboration with IONM. The frequency of EBSLN injuries was also determined. Statistical analysis was achieved via kappa and chi-square tests, as well as odds ratios (OR). RESULTS Of the 240 superior thyroid poles, IONM identified 234 (97.5%) EBSLN, whereas 190 (79.1%) were identified visually: OR = 10.35 [CI 4.37-24.65] p < 0.0001. Of the 190 EBSLN identified visually, 150 were confirmed through IONM. Indeed, their structure corresponded to an EBSLN to yield a kappa with a linear weighting value of 0.362. The standard error was 0.0467 [CI 0.2686-0.4554], indicating a fair agreement between the visual and IONM classification. CONCLUSION IONM identified 97.5% of EBSLN cases. It was higher than the visual identification. There were no injuries to EBSLN identified through IONM.
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Affiliation(s)
| | | | - Erich Basurto-Kuba
- Thyroid Clinic, General Surgery Service, General Hospital of Mexico , Mexico City, Mexico
| | | | - Abraham Pulido-Cejudo
- Thyroid Clinic, General Surgery Service, General Hospital of Mexico , Mexico City, Mexico
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49
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Lee HY, Lee JY, Dionigi G, Bae JW, Kim HY. The Efficacy of Intraoperative Neuromonitoring During Robotic Thyroidectomy: A Prospective, Randomized Case-Control Evaluation. J Laparoendosc Adv Surg Tech A 2015; 25:908-14. [DOI: 10.1089/lap.2014.0544] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hye Yoon Lee
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Ju-Young Lee
- Department of Surgery, Korea Cancer Center Hospital, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Gianlorenzo Dionigi
- 1st Division of Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Morphology, University of Insubria, Varese, Italy
| | - Jeoung Won Bae
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Hoon Yub Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
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Deniwar A, Kandil E, Randolph G. Electrophysiological neural monitoring of the laryngeal nerves in thyroid surgery: review of the current literature. Gland Surg 2015; 4:368-75. [PMID: 26425449 DOI: 10.3978/j.issn.2227-684x.2015.04.04] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Recurrent laryngeal nerve (RLN) injury is one of the most common complications of thyroid surgery. RLN injury can cause vocal cord paralysis, affecting the patient's voice and the quality of life. Injury of the external branch of the superior laryngeal nerve (EBSLN) can cause cricothyroid muscle denervation affecting high vocal tones. Thus, securing the laryngeal nerves in these surgeries is of utmost importance. Visual identification of the nerves has long been the standard method for this precaution. Intraoperative neuromonitoring (IONM) has been introduced as a novel technology to improve the protection of the laryngeal nerves and reduce the rate of RLN injury. The aim of this article is to provide a brief description of the technique and review the literature to illustrate the value of IONM. IONM can provide early identification of anatomical variations and unusual nerve routes, which carry a higher risk of injury if not detected. IONM helps in prognosticating postoperative nerve function. Moreover, by detecting nerve injury intraoperatively, it aids in staging bilateral surgeries to avoid bilateral vocal cord paralysis and tracheostomy. The article will discuss the value of continuous IONM (C-IOMN) that may prevent nerve injury by detecting EMG waveform changes indicating impending nerve injury. Herein, we are also discussing anatomy of laryngeal nerves and aspects of its injury.
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Affiliation(s)
- Ahmed Deniwar
- 1 Department of Surgery, School of Medicine, Tulane University, New Orleans, USA ; 2 Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, USA
| | - Emad Kandil
- 1 Department of Surgery, School of Medicine, Tulane University, New Orleans, USA ; 2 Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, USA
| | - Gregory Randolph
- 1 Department of Surgery, School of Medicine, Tulane University, New Orleans, USA ; 2 Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, USA
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