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Beka E, Gimm O. Voice Changes Without Laryngeal Nerve Alterations After Thyroidectomy: The Need For Prospective Trials - A Review Study. J Voice 2024; 38:231-238. [PMID: 34404582 DOI: 10.1016/j.jvoice.2021.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/29/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Thyroidectomy is a commonly performed surgical procedure that is offered for different thyroid pathologies. The most frequent complication after total thyroidectomy is transient or permanent hypoparathyroidism followed by transient or permanent recurrent laryngeal nerve palsy. Patients may experience voice impairment despite intact laryngeal nerve function. These patients are of special interest because they experience subjective symptoms which are difficult to measure and therefore to treat. SUMMARY The Voice Handicap Index (VHI) and VHI-10 are the most commonly used subjective questionnaires. Their results correlate with objective findings. Female sex, in particular after menopause, is a dominant factor for developing voice impairment after thyroidectomy. The extent of neck surgery and the weight and volume of the removed thyroid correlates directly with both objective and subjective voice impairment after surgery. Videolaryngostroboscopy should be considered to examine vocal cord pathologies in this patient group. Surprisingly, there are no studies showing that speech and voice therapy are beneficial for patients with voice alterations but with intact laryngeal nerves. CONCLUSIONS While recurrent laryngeal nerve (RLN) paralysis can be evaluated by objective exams postoperatively, we are still left with the issue of possible partial or complete external branch of superior laryngeal nerve (EBSLN) injury. It is therefore quite difficult to segregate neural (RLN and EBSLN) and non-neural voice change populations, regardless of the method of literature evaluation. Perhaps patients' perspectives on how they experience voice functionality should play a superior role in deciding which patients should be investigated further with laryngoscopy, acoustic or perceptual analysis, and which patients should be offered treatment.
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Affiliation(s)
- Ervin Beka
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, 58183 Linköping, Sweden.
| | - Oliver Gimm
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, 58183 Linköping, Sweden
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Oscar D. Bruno
- Universidad de Buenos AiresUniversity of Buenos AiresBuenos AiresArgentinaUniversity of Buenos Aires. President of the Foundation of Endocrinology (FUNDAENDO), Buenos Aires, Argentina
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Abstract
The available evidence concerning the relationship between volume and outcome for thyroid surgery is assessed in this article. Morbidity forms the principal surrogate marker of thyroid surgery quality for which postoperative hypocalcaemia and recurrent laryngeal nerve injuries are most commonly reported upon. Whilst there is an abundance of published data for these outcomes, interpretation to recommend annual volume thresholds is challenging. This is due to a lack of consensus on definitions not only for outcomes but high and low volume surgeons. The evidence reviewed in this article supports the notion that high volume surgeons achieve superior outcomes in thyroid surgery quality though it is not possible to recommend minimal annual volumes on the basis of this evidence alone. Every thyroid surgeon should know their own outcomes and how they compare with their peers and engagement in thyroid surgery registries can facilitate this.
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Affiliation(s)
- Neil Patel
- Department of Endocrine and General Surgery, University Hospital of Wales, Heath Park Way, Heath Park, Cardiff, CF14 4XW, UK
| | - David Scott-Coombes
- Department of Endocrine and General Surgery, University Hospital of Wales, Heath Park Way, Heath Park, Cardiff, CF14 4XW, UK.
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Abstract
Surgical management of thyroid cancer requires careful consideration of the recurrent laryngeal nerve and its impact on glottic function. Management of the compromised recurrent laryngeal nerve is a complex task, requiring synthesis of multiple elements. The surgeon must have an appreciation for preoperative recurrent laryngeal nerve function, intraoperative anatomic and electromyographic information, disease characteristics, and relevant patient factors. Preoperative clinical evaluation including preoperative laryngoscopy and assessment of recurrent laryngeal nerve risk is essential to formulating a surgical plan and providing appropriate patient counseling. Intraoperative neuromonitoring information has significant implications for surgical management of the injured or invaded recurrent laryngeal nerve and informs strategy with respect to staging of bilateral surgery. Disease characteristics and patient-related factors, including patient preference, must be considered with intraoperative decision-making. Multidisciplinary discussion and patient communication are essential for effective management and successful surgical outcome.
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Affiliation(s)
- Marika D Russell
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, San Francisco, CA, USA.
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA.
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA; Division of Surgical Oncology, Endocrine Surgery Service, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Wijerathne S, Goh X, Parameswaran R. Ipsilateral nonrecurrent laryngeal nerve palsy and delayed palsy of the contralateral recurrent laryngeal nerve in a case of third-time reoperative thyroid surgery. Ann R Coll Surg Engl 2019; 101:e55-e58. [PMID: 30371103 PMCID: PMC6351873 DOI: 10.1308/rcsann.2018.0191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2018] [Indexed: 01/26/2023] Open
Abstract
The occurrence of nonrecurrent laryngeal nerve and delayed nerve palsy of the contralateral nerve occurring simultaneously has never been described. A 67-year-old woman underwent reoperative completion thyroidectomy for enlarging thyroid nodules with recurrent hyperthyroidism and obstructive symptoms. Preoperative computed tomography of the neck showed a large compressive goitre with an aberrant right subclavian artery. At surgery, a type 1 nonrecurrent laryngeal nerve was found and inadvertently transected due to dense adhesions. It was repaired with ansa cervicalis graft. A fully preserved and functional recurrent laryngeal nerve was seen on the contralateral side at the end of surgery. However, the patient developed a delayed palsy on day 4 of the recurrent laryngeal nerve requiring a tracheostomy. Following successful speech and swallowing therapy, the patient was decannulated with good phonation and recovery of the left cord. Patients are at risk of bilateral nerve injury and late onset palsy in reoperative thyroid surgery. Management can be challenging and should be recognised to ensure appropriate therapy.
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Affiliation(s)
- S Wijerathne
- Department of Endocrine Surgery, National University Hospital, Singapore
| | - X Goh
- Department of Otolaryngology and Head and Neck Surgery, National University Hospital, Singapore
| | - R Parameswaran
- Department of Endocrine Surgery, National University Hospital, Singapore
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Abstract
BACKGROUND The optimum therapy for Graves' disease (GD) is chosen following discussion between physician and patient regarding benefits, drawbacks, potential side effects, and logistics of the various treatment options, and it takes into account patient values and preferences. This cohort study aimed to provide useful information for this discussion regarding the usage, efficacy, and adverse-effect profile of radioactive iodine (RAI), antithyroid drugs (ATDs), and thyroidectomy in a tertiary healthcare facility. METHODS The cohort included consecutive adults diagnosed with GD from January 2002 to December 2008, who had complete follow-up after treatment at the Mayo Clinic, Rochester, Minnesota. Data on treatment modalities, disease relapses, and adverse effects were extracted manually and electronically from the electronic medical records. Kaplan-Meier analyses were performed to evaluate the association of treatments with relapse-free survival. RESULTS The cohort included 720 patients with a mean age of 49.3 years followed for a mean of 3.3 years. Of these, 76.7% were women and 17.1% were smokers. The initial therapy was RAI in 75.4%, ATDs in 16.4%, and thyroidectomy in 2.6%, while 5.6% opted for observation. For the duration of follow-up, ATDs had an overall failure rate of 48.3% compared with 8% for RAI (hazard ratio = 7.6; p < 0.0001). Surgery had a 100% success rate; 80% of observed patients ultimately required therapy. Adverse effects developed in 43 (17.3%) patients treated with ATDs, most commonly dysgeusia (4.4%), rash (2.8%), nausea/gastric distress (2.4%), pruritus (1.6%), and urticaria (1.2%). Eight patients treated with RAI experienced radiation thyroiditis (1.2%). Thyroidectomy resulted in one (2.9%) hematoma and one (2.85%) superior laryngeal nerve damage, with no permanent hypocalcemia. CONCLUSIONS RAI was the most commonly used modality within the cohort and demonstrated the best efficacy and safety profile. Surgery was also very effective and relatively safe in the hands of experienced surgeons. While ATDs allow preservation of thyroid function, a high relapse rate combined with a significant adverse-effect profile was documented. These data can inform discussion between physician and patient regarding choice of therapy for GD.
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Affiliation(s)
- Vishnu Sundaresh
- Division of Endocrinology, Metabolism, and Diabetes, University of Utah, Salt Lake City, Utah
- Geriatrics and Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Juan P. Brito
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit in Endocrinology (KER_Endo), Mayo Clinic, Rochester, Minnesota
| | - Prabin Thapa
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Rebecca S. Bahn
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Marius N. Stan
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
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Keseroglu K, Bayir O, Umay EK, Saylam G, Tatar EC, Ozdek A, Korkmaz MH. Laryngeal electromyographic changes in postthyroidectomy patients with normal vocal cord mobility. Eur Arch Otorhinolaryngol 2017; 274:1925-1931. [PMID: 28132134 DOI: 10.1007/s00405-016-4442-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 12/22/2016] [Indexed: 11/27/2022]
Abstract
Thyroidectomy has been used for the treatment of thyroid disease for more than 100 years. In spite of the advancement of surgical techniques, there is still a risk of laryngeal nerve injury. The risk of partial or complete injury still depends on some surgical and disease-related factors. The aim of this study is to show the partial injury and to establish these risk factors via laryngeal electromyographic analysis (LEMG) in postthyroidectomy patients with normal vocal cord motion and mucosal anatomy. Patients who had undergone thyroid surgery were enrolled in this prospective study. LEMG analysis was performed to all patients with normal vocal cord mobility preoperatively and was repeated after the first and the third months of surgery. Thyroarytenoid (TA) and cricothyroid (CT) muscles were used to evaluate recurrent and external branch of superior laryngeal nerves, respectively. Four of the 32 patients had mild-to-moderate degrees of partial LEMG changes during preoperative LEMG analysis of TA and CT muscles on each side. After 3 months of surgery, there was a statistically significant worsening of LEMG findings in the right and left external branches of superior and left recurrent laryngeal nerves. Disease and surgery-related risk factors were analyzed. However, there was no significant relationship on the progression of LEMG findings according to these parameters. This is the first prospective study which supports the risk of progression of LEMG changes in patients with normal laryngoscopic examination after thyroid surgery. No reliable significant risk factor was found influencing the LEMG progression.
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Affiliation(s)
- Kemal Keseroglu
- Otolaryngology Department, Diskapi Yildirim Beyazit Training and Research Hospital, 1426 Street No: 28/11 Cukurambar, 06510, Ankara, Turkey.
| | - Omer Bayir
- Otolaryngology Department, Diskapi Yildirim Beyazit Training and Research Hospital, 1426 Street No: 28/11 Cukurambar, 06510, Ankara, Turkey
| | - Ebru Karaca Umay
- Physical Medicine and Rehabilitation Department, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Guleser Saylam
- Otolaryngology Department, Diskapi Yildirim Beyazit Training and Research Hospital, 1426 Street No: 28/11 Cukurambar, 06510, Ankara, Turkey
| | - Emel Cadalli Tatar
- Otolaryngology Department, Diskapi Yildirim Beyazit Training and Research Hospital, 1426 Street No: 28/11 Cukurambar, 06510, Ankara, Turkey
| | | | - Mehmet Hakan Korkmaz
- Faculty of Medicine Otolaryngology Department, Yildirim Beyazit University, Ankara, Turkey
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Dinc T, Kayilioglu SI, Simsek B, Guldogan CE, Gulseren MO, Saylam B, Coskun F. The evaluation of the complications observed in patients with bilateral total and bilateral near total thyroidectomy. Ann Ital Chir 2017; 88:198-201. [PMID: 28247855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
AIM The objective was to compare the recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN) injuries in patients with bilateral total thyroidectomy (BTT) and bilateral near total thyroidectomy (BNTT) with the frequency of the hypocalcemic complications regarding the operation procedures. MATERIALS AND METHODS Patients, who underwent BTT and BNTT in our clinic between January 1999 and January 2011, were included in this retrospective clinical study. Patients' files are evaluated. Demographic information, pre-operative complete blood cell count and biochemical analysis, thyroid function tests, ultrasonographic results, results of the fine needle aspiration biopsy, implemented operative procedures (BTT or BNTT), vocal cord investigation, post-operative calcium levels, postoperative complications were analyzed. RESULTS In 328 of 408 (80.4%) patients BTT was the preferred method and 80 underwent BNTT (19.6 %). Postoperative hypocalcemia was observed in 59 patients in the BTT group (17.9 %) and in 11 patients in the BNTT group (13.7 %) . Hypocalcemia persisted in 8 patients in BTT group (2.4 %) and in 6 patients in BNTT group (7.5%). Unilateral RLN paralysis was observed in 22 patients in BTT group (6.7 %) and in 13 patients in the BNTT group (16.2 %). CONCLUSION In this study, the likelihood of the temporary RLN paralysis and permanent hypoparathyroidism is found to be higher in the patients with BNTT compared to the patients with BTT. BNTT may be the preferred choice of treatment in suitable patients. KEY WORDS Complication, Hypocalcemia, Nervus laryngealis recurrens, Nervus laryngealis superior, Thyroidectomy.
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10
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Abstract
BACKGROUND There is growing evidence that the external branch of the superior laryngeal nerve (eSLN) participates in thyroarytenoid (TA) contraction, but little data quantify its role in vocal cord adduction. Injury to the eSLN, such as in thyroid surgery, is difficult to diagnose and likely underappreciated. It is the authors' belief that eSLN injury contributes to aspiration by depriving its contribution to the laryngeal plexus. The goal of this study was to measure the glottic closing force (GCF) from eSLN stimulation in a porcine model. METHODS The recurrent laryngeal nerve (RLN) and eSLN were identified bilaterally in four porcine necks. Bilateral RLNs and eSLNs were stimulated simultaneously to obtain a control GCF using a pressure transducer placed in the glottis. Subsequently, bilateral eSLNs were stimulated and the GCF measured to quantify its percent contribution to the control value. RESULTS Stimulation of the RLNs and the eSLNs each led to TA muscle contraction and a measureable GCF in all four porcine necks. The control GCF was 1000.1 mmHg, while the eSLN mediated CGF was 800 mmHg. The percentage GCF attributable to the eSLN was thus 800/1000 = 80%. CONCLUSIONS Reflex glottic closure is one of the most important mechanisms for the prevention of aspiration during deglutition. The biomechanical quantification of glottic closure can be shown as the GCF. This study has shown that the eSLN contributes in a significant way to the GCF in a porcine model, a finding that has not been quantified to the best of the authors' knowledge. Therefore, greater focus should be placed on preserving this nerve in thyroid surgery.
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Affiliation(s)
- David Folk
- Yale Larynx Laboratory, Department of Surgery, Section of Otolaryngology, Yale School of Medicine, New Haven, Connecticut
| | - Basim Wahba
- Department of Otolaryngology, Cairo University of Egypt, Cairo, Egypt
| | - Clarence T. Sasaki
- Yale Larynx Laboratory, Department of Surgery, Section of Otolaryngology, Yale School of Medicine, New Haven, Connecticut
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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12
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Abstract
Immediate postoperative complications are common after lobectomy. The most effective management of postoperative crises is prevention, which starts with preoperative preparation and patient screening. There are many factors that can be controlled and improved by the patient. Equally important is patient selection, which is influenced by pulmonary function tests, cardiopulmonary reserve, and preexisting comorbidities. After the operation, the care team can also greatly improve outcomes with aggressive cardiopulmonary therapies, ambulation, vigilant monitoring, and frequent assessments of the patient. Prevention strategies can minimize risks; however, when they occur, a proactive approach may minimize the long-term sequelae.
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Affiliation(s)
- Elena Ziarnik
- Department of Thoracic Surgery, Vanderbilt University Medical Center, 1313 21st Avenue South, Nashville, TN 37232, USA
| | - Eric L Grogan
- Department of Thoracic Surgery, Tennessee Valley Healthcare System, Nashville Campus, Vanderbilt University Medical Center, 609 Oxford House, 1313 21st Avenue South, Nashville, TN 37232, USA.
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13
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Iacobone M, Citton M, Pagura G, Viel G, Nitti D. Increased and safer detection of nonrecurrent inferior laryngeal nerve after preoperative ultrasonography. Laryngoscope 2015; 125:1743-7. [PMID: 25960168 DOI: 10.1002/lary.25093] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 10/18/2014] [Accepted: 11/19/2014] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Right nonrecurrent inferior laryngeal nerve (NRLN) is an anatomical variant reported with a variable prevalence (0.3%-6%). It is associated with some arterial abnormalities (absence of the brachiocephalic trunk and presence of a right aberrant subclavian lusorian artery) that may be identified by preoperative ultrasonography (pUS). NRLN represents a major morbidity risk factor during neck surgery. The aim of this study was to verify pUS accuracy in predicting NRLN and to assess the impact of this technique on NRLN detection rate and laryngeal morbidity. STUDY DESIGN Retrospective. METHODS The study included 1,477 patients undergoing thyroid and parathyroid surgery with right-side inferior laryngeal nerve exploration. pUS was performed in 878 patients (pUS group); no preoperative attempts were performed in the remaining 599 patients (controls). Demographics, disease type, intraoperative inferior laryngeal nerve anatomy, and laryngeal morbidity were compared. RESULTS No differences occurred between the two groups concerning demographics and disease type. NRLN was detected in 17 patients (1.9%) of the pUS group and in four patients (0.6%) of controls (P < 0.05). pUS predicted NRLN in all cases, with an overall accuracy > 98%. Overall laryngeal nerves morbidity was 1.8% in the pUS group and 4.2% in the controls (P < 0.05). NRLN palsy never occurred in the pUS group, whereas it occurred three times in the controls (P < 0.005). CONCLUSION NRLN is accurately predicted by pUS. It occurs more frequently than expected because it may be misdiagnosed when no preoperative suspicion is available. Preoperative NRLN detection by pUS prevents inferior laryngeal nerve injuries.
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Affiliation(s)
- Maurizio Iacobone
- Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Marilisa Citton
- Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Giulia Pagura
- Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Giovanni Viel
- Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Donato Nitti
- Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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14
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Abstract
Nerve injuries are a rare complication of airway management. Two cases of Tapia's syndrome following orotracheal intubation are reported. Case 1: a 23-year-old male patient underwent an otorhinolaryngology (ENT) surgical procedure with orotracheal intubation. A left-sided Tapia's syndrome was verified 3 days later. Case 2: a 67-year-old patient developed a right-sided Tapia's syndrome following an arthroscopic intervention of the left shoulder in the beach-chair position. In both cases there was permanent damage of both nerves. On the basis of a comprehensive literature survey the reasons for an intubation-induced Tapia's syndrome are discussed. In order to avoid a glottis or immediate subglottic position it is recommended to check and to document the position of the cuff (depth of intubation) and the measured cuff pressure immediately after intubation. It also seems to be advisable to document an overstretched head position if required for the operation.
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Affiliation(s)
- L Brandt
- -, Ernst-Udet-Str. 9, 85764, Oberschleißheim, Deutschland,
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15
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Dionigi G, Kim HY, Wu CW, Lavazza M, Ferrari C, Leotta A, Spampatti S, Rovera F, Rausei S, Boni L, Chiang FY. Vagus nerve stimulation for standardized monitoring: technical notes for conventional and endoscopic thyroidectomy. Surg Technol Int 2013; 23:95-103. [PMID: 23860931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Standardization of the intraoperative neuromonitoring (IONM) technique is an essential aspect of modern monitored thyroid surgery. The standardized technique involves vagal nerve stimulation. VN stimulation is useful for technical problem solving, detecting non-recurrent laryngeal nerve (non-RLN), recognizing any recurrent laryngeal nerve (RLN) lesions, and precisely predicting RLN postoperative function. Herein, we present technical notes for the VN identification to achieve the critical view of safety of the VN stimulation with or without dissection.
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Affiliation(s)
- Gianlorenzo Dionigi
- Director, 1st Division of General Surgery Director, Endocrine Surgery Research Center Department of Surgical Sciences and Human Morphology University of Insubria, Varese, Italy
| | - Hoon Yub Kim
- Department of Surgery Korea University College of Medicine Seoul, Korea
| | - Che-Wei Wu
- Department of Otolaryngology Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung City, Taiwan
| | - Matteo Lavazza
- Department of Surgical Sciences Endocrine Surgery Research Center University of Insubria, Varese, Italy
| | - Cesare Ferrari
- Department of Surgical Sciences Endocrine Surgery Research Center University of Insubria, Varese, Italy
| | - Andrea Leotta
- Department of Surgical Sciences Endocrine Surgery Research Center University of Insubria, Varese, Italy
| | - Sebastiano Spampatti
- Department of Surgical Sciences Endocrine Surgery Research Center University of Insubria, Varese, Italy
| | - Francesca Rovera
- 1st Division of General Surgery Department of Surgical Sciences Endocrine Surgery Research Center University of Insubria, Varese, Italy
| | - Stefano Rausei
- Department of Surgical Sciences Endocrine Surgery Research Center University of Insubria, Varese, Italy
| | - Luigi Boni
- Director, Minimally Invasive Surgery Research Center 1st Division of General Surgery Department of Surgical Sciences and Human Morphology Endocrine Surgery Research Center University of Insubria, Varese, Italy
| | - Feng-Yu Chiang
- Department of Otolaryngology Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung City, Taiwan
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Sterniuk IM. [Role of perioperative neuromonitoring in preservation of external branch of the nervus laryngeus superior]. Klin Khir 2013:78-79. [PMID: 24501938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Barczyński M, Konturek A, Stopa M, Honowska A, Nowak W. Randomized controlled trial of visualization versus neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy. World J Surg 2012; 36:1340-7. [PMID: 22402975 PMCID: PMC3348444 DOI: 10.1007/s00268-012-1547-7] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Injury to the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy results in a lowered fundamental frequency of the voice and deteriorated voice performance in producing high-frequency sounds. It remains unclear if the use of intraoperative nerve monitoring (IONM) can improve the clinical outcome of thyroidectomy in terms of preserved individual voice performance. This study was designed to test that hypothesis. METHODS A total of 210 consenting female patients planned for total thyroidectomy were randomly assigned to two groups equal in size (n = 105): visual inspection of the EBSLN and RLN vs. this plus additional EBSLN and RLN monitoring. The primary outcome was the identification rate of the EBSLN. The secondary outcomes included: anatomical variability of the EBSLN according to the Cernea classification and changes in postoperative voice performance. Voice assessment included pre- and postoperative videostrobolaryngoscopy and an analysis of maximum phonation time (MPT), voice level (VL), fundamental frequency (Fo), and voice quality rating on the GRBAS scale. RESULTS The following differences were found for operations without vs. with IONM: identification rate of the EBSLN was 34.3 % vs. 83.8 % (p < 0.001), whereas a 10 % or higher decrease in phonation parameters was found in 10 % vs. 2 % patients for MPT (p = 0.018), 13 % vs. 2 % for VL (p = 0.003), and 9 % vs. 1 % for Fo (p = 0.03), a change in the GRBAS scale > 4 points in 7 % vs. 1 % (p = 0.03), and temporary RLN injury was found in 2 % vs. 1 % (p = 0.56), respectively. CONCLUSIONS The use of IONM significantly improved the identification rate of the EBSLN during thyroidectomy, as well as reduced the risk of early phonation changes after thyroidectomy.
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Affiliation(s)
- Marcin Barczyński
- Department of Endocrine Surgery, 3rd Chair of General Surgery, Jagiellonian University College of Medicine, 37 Prądnicka Street, 31-202 Kraków, Poland.
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John A, Etienne D, Klaassen Z, Shoja MM, Tubbs RS, Loukas M. Variations in the locations of the recurrent laryngeal nerve in relation to the ligament of Berry. Am Surg 2012; 78:947-951. [PMID: 22964202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Injury to the recurrent laryngeal nerve (RLN) is one of the most common iatrogenic complications of thyroid surgery. The anatomical course of the nerve also increases its susceptibility to injury and many variations have been documented in the literature. The topographical relationship of the RLN to the ligament of Berry has been extensively studied over the past decades. The consensus in the literature is divided with several authors reporting the nerve to be embedded within the ligament and others reporting a constant finding of the nerve being posterolateral to the ligament. A new operative concept has been recently introduced as a possible resolution for the conflicting reports among authors. Further investigations are needed, however, to assess its reliability and overall effects on clinical outcomes.
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Affiliation(s)
- Alana John
- Department of Anatomical Sciences, St. George's University, School of Medicine, Grenada, West Indies
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Sakorafas GH, Kokoropoulos P, Lappas C, Sampanis D, Smyrniotis V. External branch of the superior laryngeal nerve: applied surgical anatomy and implications in thyroid surgery. Am Surg 2012; 78:986-991. [PMID: 22964209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The external branch of the superior laryngeal nerve (EBSLN) is the only motor supply to the cricothyroid muscle and has an important role during phonation in high frequencies. Iatrogenic injury of the EBSLN, most commonly during thyroid surgery, is associated with varying levels of alterations in phonation, which may have an impact on a patient's life, especially when his or her career depends on the full range of voice. EBSLN injury incidence after thyroid surgery ranges widely in the literature (0 to 58%). Despite this wide variation, it appears that EBSLN injury is a not uncommon, and frequently overlooked, complication of thyroid surgery. An in-depth knowledge of the surgical anatomy of the EBSLN is therefore required from the part of the operating surgeon to protect this nerve during thyroid surgery.
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Affiliation(s)
- George H Sakorafas
- 4th Department of Surgery, Athens University, Medical School, Attikon University Hospital, Athens, Greece.
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Giordano D, Valcavi R, Thompson GB, Pedroni C, Renna L, Gradoni P, Barbieri V. Complications of central neck dissection in patients with papillary thyroid carcinoma: results of a study on 1087 patients and review of the literature. Thyroid 2012; 22:911-7. [PMID: 22827494 DOI: 10.1089/thy.2012.0011] [Citation(s) in RCA: 248] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Prophylactic central neck dissection (CND) has been proposed in the treatment of patients affected by papillary thyroid carcinoma (PTC) with clinically negative neck lymph nodes. The procedure allows pathologic staging of lymph nodes of the central compartment and treatment of the micrometastases. Nevertheless, the morbidity that its routine use adds to the total thyroidectomy must be taken into account. The aim of this study was to characterize the morbidity that CND adds to the total thyroidectomy. METHODS This was a retrospective study of 1087 patients with PTC and clinically negative neck lymph nodes. Patients were divided into three study groups: Group A, total thyroidectomy; Group B, total thyroidectomy and ipsilateral CND; Group C, total thyroidectomy and bilateral CND. Primary endpoints of the study were evaluated by comparing the rates of transient and permanent recurrent laryngeal nerve (RLN) injury and hypoparathyroidism in the three study groups. RESULTS Analysis of data showed no significant differences in the rate of transient (Group A: 3.6%, Group B: 3.9%, and Group C: 5.5%; p=0.404) and permanent (Group A: 1%, Group B: 0.5%, and Group C: 2.3%; p=0.099) RLN injury between the three study groups. Both ipsilateral CND and bilateral CND were associated with a higher rate of transient hypoparathyroidism (Group: A 27.7%, Group B: 36.1%, and Group C: 51.9%; p=0.014; odds ratio [OR]: 1.477; 95% confidence interval [CI]: 1.091-2.001; p<0.001; OR: 2.827; 95% CI: 2.065-3.870, respectively). Bilateral CND had a higher rate of permanent hypoparathyroidism (Group A: 6.3%, Group B: 7%, and Group C: 16.2%; p<0.001; OR: 2.860; 95% CI: 1.725-4.743). CONCLUSIONS The increased rates of transient and permanent hypoparathyroidism in our series suggest a critical review of indications for the routine use of prophylactic CND for PTC. Prophylactic CND ipsilateral to the tumor associated with total thyroidectomy may represent an effective strategy for reducing the rate of permanent hypoparathyroidism. Concomitant completion contralateral paratracheal lymph node neck dissection should be performed in presence of lymph node metastasis on intraoperative frozen-section pathology. This approach limits the use of bilateral CND to patients with intraoperative pathological findings of lymph node metastases.
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Affiliation(s)
- Davide Giordano
- Otolaryngology Unit, Department of Surgery, Center for Clinical and Basic Research, Arcispedale Santa Maria Nuova, viale Risorgimento 80, Reggio Emilia, Italy.
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