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Saxe A, Idris M, Gemechu J. Does the Use of Intraoperative Neuromonitoring during Thyroid and Parathyroid Surgery Reduce the Incidence of Recurrent Laryngeal Nerve Injuries? A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2024; 14:860. [PMID: 38732275 PMCID: PMC11083343 DOI: 10.3390/diagnostics14090860] [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: 03/02/2024] [Revised: 04/07/2024] [Accepted: 04/11/2024] [Indexed: 05/13/2024] Open
Abstract
Injury to the recurrent laryngeal nerve (RLN) can be a devastating complication of thyroid and parathyroid surgery. Intraoperative neuromonitoring (IONM) has been proposed as a method to reduce the number of RLN injuries but the data are inconsistent. We performed a meta-analysis to critically assess the data. After applying inclusion and exclusion criteria, 60 studies, including five randomized trials and eight non-randomized prospective trials, were included. A meta-analysis of all studies demonstrated an odds ratio (OR) of 0.66 (95% CI [0.56, 0.79], p < 0.00001) favoring IONM compared to the visual identification of the RLN in limiting permanent RLN injuries. A meta-analysis of studies employing contemporaneous controls and routine postoperative laryngoscopy to diagnose RLN injuries (considered to be the most reliable design) demonstrated an OR of 0.69 (95% CI [0.56, 0.84], p = 0.0003), favoring IONM. Strong consideration should be given to employing IONM when performing thyroid and parathyroid surgery.
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Affiliation(s)
- Andrew Saxe
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA; (M.I.); (J.G.)
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Ding Z, Sheng R, Zhang L, Han J, Chen M, Bi W, Zhao X, Zhang J, Nie C. Utility of video-assisted method for identifying and preserving the external branch of the superior laryngeal nerve during thyroidectomy. Front Surg 2023; 10:1118083. [PMID: 37143769 PMCID: PMC10151554 DOI: 10.3389/fsurg.2023.1118083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/03/2023] [Indexed: 05/06/2023] Open
Abstract
Background The EBSLN is vulnerable to damage during thyroidectomy, results in voice related complications, negatively affect patient quality of life, routine identification of the EBSLN prior to surgical manipulation is necessary for a complication-free thyroidectomy. We aimed to validate a video-assisted procedure for identifying and preserving the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy and analyze the EBSLN Cernea classification and the localization of the nerve entry point (NEP) from the insertion of the sternothyroid muscle. Methods A prospective descriptive study was performed; 134 patients, who scheduled for lobectomy with an intraglandular tumor max diameter ≤ 4 cm and without extrathyroidal extension, were randomly divided into the video-assisted surgery (VAS) and conventional open surgery (COS) groups. We used the video-assisted surgical procedure for visually identifying the EBSLN directly, and compared the differences in the visual identification rate and total identification rate of the two groups. We also measured the localization of the NEP using the insertion of the sternothyroid muscle as a reference. Results There was no statistically significant difference in clinical characteristics between the two groups. The visual identification rate and total identification rate were significantly higher in the VAS group than the COS group (91.04% vs. 77.61%, 100% vs. 89.6%). The EBSLN injury rate was 0 in both groups. The mean vertical distance (VD) of the NEP from the sternal thyroid insertion was 1.18 mm (SD 1.12 mm, range, 0-5 mm), with approximately 88.97% of the results occurring within the 0-2 mm range. The mean horizontal distance (HD) was 9.33 mm (SD 5.03 mm, range, 0-30 mm), with over 92.13% of the results occurring within the 5-15 mm range. Conclusion Both the visual and total identification rates of the EBSLN were significantly higher in the VAS group. This method provided a good visual exposure rate of the EBSLN, aiding in identifying and protecting the EBSLN during thyroidectomy.
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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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Optimization of Intraoperative Neural Monitoring of the Recurrent Laryngeal Nerve in Thyroid Surgery. Medicina (B Aires) 2022; 58:medicina58040495. [PMID: 35454334 PMCID: PMC9028259 DOI: 10.3390/medicina58040495] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/18/2022] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
The application of intraoperative neural monitoring (IONM) has been widely accepted to improve surgical outcomes after thyroid surgery. The malfunction of an IONM system might interfere with surgical procedures. Thus, the development of anesthesia modalities aimed at ensuring functional neuromonitoring is essential. Two key issues should be taken into consideration for anesthetic management. Firstly, most patients undergo recurrent laryngeal nerve monitoring via surface electrodes embedded in an endotracheal tube. Thus, advanced video-assisted devices might optimize surface electrode positioning for improved neuromonitoring signaling accuracy. Secondly, neuromuscular blocking agents are routinely used during thyroid surgery. The ideal neuromuscular block should be deep enough for surgical relaxation at excision and recovered enough for an adequate signal f nerve stimulation. Proper neuromuscular block management could be achieved by titration doses of muscle relaxants and reversal agents.
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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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Gibson MM, Chen AY. Intermittent Neuromonitoring of the Recurrent Laryngeal and Vagus Nerves: the Ins and Outs. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00351-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Ling Y, Zhao J, Zhao Y, Li K, Wang Y, Kang H. Role of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid and parathyroid surgery. J Int Med Res 2021; 48:300060520952646. [PMID: 32961083 PMCID: PMC7513400 DOI: 10.1177/0300060520952646] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objective To investigate whether intraoperative neuromonitoring (IONM) has a
significant advantage in reducing the incidence of recurrent laryngeal nerve
(RLN) injury. Methods Patients who underwent thyroid and parathyroid surgery from October 2012 to
December 2017 at the Center for Thyroid and Breast Surgery of Xuanwu
Hospital were retrospectively analyzed. They were divided into the IONM
group and visualization alone group (VA group) according to whether IONM was
used. Results In total, 1696 nerves at risk of injury (IONM group, n = 1104; VA group,
n = 592) were included in the analysis. Among the high-risk nerves,
permanent damage occurred in no cases in the IONM group but in one case in
the VA group. Because the higher proportion of central lymph node metastasis
caused difficulties in central cervical lymph node dissection and
identification of the RLN, the patients undergoing lateral cervical lymph
node dissection in the VA group had a significantly higher risk of
postoperative RLN injury (11.76% vs. 0.00%). Conclusion IONM technology has advantages in protection of the RLN, especially in
high-risk nerves and patients with a high proportion of central lymph node
metastasis who require central and lateral cervical lymph node
dissection.
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Affiliation(s)
- Yuwei Ling
- Center for Thyroid and Breast Surgery, Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jing Zhao
- Center for Thyroid and Breast Surgery, Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ye Zhao
- Center for Thyroid and Breast Surgery, Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kaifu Li
- Center for Thyroid and Breast Surgery, Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yajun Wang
- Center for Thyroid and Breast Surgery, Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hua Kang
- Center for Thyroid and Breast Surgery, Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Kim JI, Kim SJ, Xu Z, Kwak J, Ahn JH, Yu HW, Chai YJ, Choi JY, Lee KE. Efficacy of Intraoperative Neuromonitoring in Reoperation for Recurrent Thyroid Cancer Patients. Endocrinol Metab (Seoul) 2020; 35:918-924. [PMID: 33397044 PMCID: PMC7803609 DOI: 10.3803/enm.2020.778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/04/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of intraoperative neuromonitoring (IONM) in thyroid surgery to preserve recurrent laryngeal nerve (RLN) function has been widely accepted. We aimed to evaluate the usefulness of IONM in reoperation for recurrent thyroid cancer patients to help identify the RLN and prevent vocal cord palsy (VCP). METHODS We analyzed 121 consecutive patients (with IONM group, 48 patients; without IONM group, 73 patients) who underwent reoperation for recurrent thyroid cancer after total thyroidectomy from January 2009 to March 2019 in our institution without VCP due to previous operations. Data including age, sex, number of previous operations, histologic subtype of the malignancy at the initial operation, operation time, RLNs at risk, difficulty of RLN identification, surgical procedure, VCP, and other postoperative complications were reviewed. Vocal cord movement evaluations were performed preoperatively and at 2 weeks postoperatively to evaluate RLN function. In patients with VCP, additional evaluations were performed. VCP exceeding 12 months after surgery was considered permanent VCP. RESULTS VCP was observed in six (12.5%) and 16 (21.9%) patients with and without IONM (P=0.189). Transient and permanent VCP were found in three (6.3%) and three (6.3%) patients with IONM (P=0.098 and P=0.982, respectively) versus in 12 (16.4%) and four (5.5%) patients without IONM. CONCLUSION The incidence of transient VCP seems to be lower in reoperations with IONM; however, there was no statistical significances. Further study will be needed to ascertain the efficacy of IONM in reoperation for recurrent thyroid cancer patients.
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Affiliation(s)
- Jang-il Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul,
Korea
| | - Su-jin Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul,
Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul,
Korea
- Division of Surgery, Thyroid Center, Seoul National University Cancer Hospital, Seoul,
Korea
- Medical Big Data Research Center, Institute of Medical and Biological Engineering, Seoul National University, Seoul,
Korea
| | - Zhen Xu
- Department of Surgery, Seoul National University College of Medicine, Seoul,
Korea
| | - JungHak Kwak
- Department of Surgery, Seoul National University College of Medicine, Seoul,
Korea
| | - Jong-hyuk Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul,
Korea
| | - Hyeong Won Yu
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Seoul,
Korea
| | - Young Jun Chai
- Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul,
Korea
| | - June Young Choi
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Seoul,
Korea
| | - Kyu Eun Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul,
Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul,
Korea
- Division of Surgery, Thyroid Center, Seoul National University Cancer Hospital, Seoul,
Korea
- Medical Big Data Research Center, Institute of Medical and Biological Engineering, Seoul National University, Seoul,
Korea
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Seoul,
Korea
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Zhou B, Zhai Y, Hei H, Zhang S, Li C, Wang C, Gong W, Zhang R, Zheng C, Qin J. The strap intermuscular approach can significantly increase the exposure rate of the external branch of the superior laryngeal nerve during thyroid surgery. Surg Oncol 2020; 35:56-61. [DOI: 10.1016/j.suronc.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/29/2020] [Accepted: 08/02/2020] [Indexed: 11/15/2022]
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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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Jiang X, Fang G, Guo D, Xu X, Chen B, Jiang J, Dong Z, Fu W. Surgical Management of Carotid Body Tumor and Risk Factors of Postoperative Cranial Nerve Injury. World J Surg 2020; 44:4254-4260. [PMID: 32804251 DOI: 10.1007/s00268-020-05723-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND To identify risk factors of postoperative cranial nerve injury (CNI) following surgical treatment of a carotid body tumor (CBT) by retrospective analysis of the data during the past decade in our center. METHODS From May 2008 to September 2018, patients who underwent CBT resections at the Department of Vascular Surgery, Zhongshan Hospital, Fudan University, were included in the study. Demographic, preoperative, intraoperative, and postoperative data of patients were collected and analyzed. Univariate and multivariate logistic regression analyses were performed to identify the independent risk factors of CNI. RESULTS A total of 203 CBTs were excised in 196 patients; 17.7% was classified as Shamblin I, 59.1% as Shamblin II, and 23.2% as Shamblin III. CNI after surgery occurred in 57 (28.1%) patients. Postoperative CNI, external carotid artery (ECA) ligation, internal carotid artery (ICA) reconstruction, tumor volume, and established blood loss (EBL) were significantly correlated with Shamblin classification. On univariate analysis, there were statistically significant differences in Shamblin classification (p = 0.002), tumor volume (p = 0.014), number of lymph nodes removed (NOLNR) (p < 0.001), and EBL (p = 0.019) between two groups (with and without CNI after surgery). Multivariate logistic regression analysis revealed a significant positive correlation between CNI and Shamblin III (AOR, 4.744; 95% CI, 1.21-18.56; p = 0.025) and NOLNR (AOR, 0.25; 95% CI, 1.23-1.46 for each three-interval increase, p < 0.001). CONCLUSIONS Shamblin III and NOLNR are independent risk factors of CNI for patients who undergo CBT resections.
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Affiliation(s)
- Xiaolang Jiang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Gang Fang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Daqiao Guo
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Xin Xu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Bin Chen
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Junhao Jiang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Zhihui Dong
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| | - Weiguo Fu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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Gurleyik E, Dogan S, Cetin F, Gurleyik G. Visual and electrophysiological identification of the external branch of superior laryngeal nerve in redo thyroid surgery compared with primary thyroid surgery. Ann Surg Treat Res 2019; 96:269-274. [PMID: 31183330 PMCID: PMC6543049 DOI: 10.4174/astr.2019.96.6.269] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 04/04/2019] [Accepted: 04/12/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Thyroid reoperations are surgically challenging because of significant anatomical variance. Visual and functional identification of the external branch of the superior laryngeal nerve (EBSLN) were studied in 2 groups of patients who underwent primary and redo thyroid surgery. Methods This study was conducted on 200 patients: 100 patients with redo and 100 patients with primary thyroid surgery. In addition to visual identification, nerve branches were functionally identified by intraoperative nerve monitoring (IONM). Visual, functional, and total identification rates of the EBSLN in both primary and redo surgery were determined and compared between the 2 groups. Results We attempted to identify 138 and 170 EBSLNs at risk in redo and primary surgery, respectively. Visual identification rates were 65.3% and 30.4% (P < 0.001) in primary and redo surgery groups, respectively. In total, 164 (96.5%) and 97 EBSLNs (70.3%) were identified in primary and redo surgery, respectively (P < 0.001), including the use of IONM. In primary surgery group, 53 nonvisualized EBSLNs of 164 identified nerves (32.3%) were determined by IONM alone. In redo surgery group, 55 of 97 identified nerves (56.7%) were determined by IONM alone (P < 0.001). Conclusion Both visual and total identification rates of the EBSLN are significantly decreased in reoperative thyroidectomy. IONM increases the total identification rate of the EBSLN in primary and redo thyroid surgery. Electrophysiological monitoring makes a substantial contribution to the identification of the EBSLN both in primary and especially in redo thyroid surgery.
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Affiliation(s)
- Emin Gurleyik
- Department of Surgery, Duzce University, Medical Faculty, Duzce, Turkey
| | - Sami Dogan
- Department of Surgery, Duzce University, Medical Faculty, Duzce, Turkey
| | - Fuat Cetin
- Department of Surgery, Duzce University, Medical Faculty, Duzce, Turkey
| | - Gunay Gurleyik
- Department of Surgery, Health Sciences University, Haydarpasa Numune Hospital, Istanbul, Turkey
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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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16
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Mizuno K, Takeuchi M, Kanazawa Y, Kitamura M, Ide K, Omori K, Kawakami K. Recurrent laryngeal nerve paralysis after thyroid cancer surgery and intraoperative nerve monitoring. Laryngoscope 2018; 129:1954-1960. [DOI: 10.1002/lary.27698] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Kayoko Mizuno
- Department of Otolaryngology-Head and Neck Surgery; Kyoto Japan
- Department of Pharmacoepidemiology; Graduate School of Medicine and Graduate School of Medicine and Pubic Health, Kyoto University; Kyoto Japan
| | - Masato Takeuchi
- Department of Pharmacoepidemiology; Graduate School of Medicine and Graduate School of Medicine and Pubic Health, Kyoto University; Kyoto Japan
| | - Yuji Kanazawa
- Department of Otolaryngology; Shiga Medical Center for Children; Shiga Japan
| | | | - Kazuki Ide
- Department of Pharmacoepidemiology; Graduate School of Medicine and Graduate School of Medicine and Pubic Health, Kyoto University; Kyoto Japan
| | - Koichi Omori
- Department of Otolaryngology-Head and Neck Surgery; Kyoto Japan
| | - Koji Kawakami
- Department of Otolaryngology-Head and Neck Surgery; Kyoto Japan
- Department of Pharmacoepidemiology; Graduate School of Medicine and Graduate School of Medicine and Pubic Health, Kyoto University; Kyoto Japan
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17
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Masood MM, Hackman TG. Disparity between Preoperative and Pre-Excisional Intraoperative Parathyroid Hormone in Parathyroid Surgery. Int Arch Otorhinolaryngol 2018; 22:382-386. [PMID: 30357058 PMCID: PMC6197976 DOI: 10.1055/s-0038-1635574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/19/2018] [Indexed: 11/29/2022] Open
Abstract
Introduction Intraoperative parathyroid hormone (ioPTH) testing is a widely accepted standard for assessing the parathyroid gland function. A decline of preoperative parathyroid hormone (PTH) levels by more than 50% is one accepted measure of parathyroid surgery adequacy. However, there may be a variation between preoperative PTH levels obtained at a clinic visit and pre-excisional ioPTH. Objective Our study explores the differences between preoperative PTH and pre-excisional ioPTH levels, and the potential impact this difference has on determining the adequacy of parathyroid surgery. Methods A retrospective study that consisted of 33 patients that had undergone parathyroid resection between September 2009 and March 2016 at a tertiary academic center was performed. Each subject's preoperative PTH levels were obtained from clinic visits and pre-excisional ioPTH levels were recorded along with the time interval between the measurements. Results There was a significant difference between the mean preoperative PTH and the pre-excisional ioPTH levels of 147 pg/mL (95% confidence interval [CI] 11.43 to 284.47; p = 0.0396). The exclusion of four outliers revealed a further significant difference with a mean of 35.09 pg/mL (95% CI 20.27 to 49.92; p < 0.0001). The average time interval between blood draws was 48 days + 32 days. A weak correlation between the change in PTH values and the time interval between preoperative and pre-excision blood draws was noted (r2 = 0.15). Conclusion Our study reveals a significant difference between the preoperative PTH levels obtained at clinic visits and the pre-excisional intraoperative PTH levels. We recommend routine pre-excisional intraoperative PTH levels, despite evidence of elevated preoperative PTH levels, in order to more accurately assess the adequacy of surgical resection.
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Affiliation(s)
- Maheer M. Masood
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States
| | - Trevor G. Hackman
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States
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18
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Displacement of the Recurrent Laryngeal Nerve in Patients with Recurrent Goiter Undergoing Redo Thyroid Surgery. J Thyroid Res 2018; 2018:4763712. [PMID: 29682274 PMCID: PMC5851157 DOI: 10.1155/2018/4763712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/29/2018] [Indexed: 11/17/2022] Open
Abstract
Thyroid reoperations are surgically challenging because of scarring and disturbances in the anatomy of the recurrent laryngeal nerve (RLN). This study was conducted on 49 patients who underwent redo surgery. 61 RLNs were identified and completely exposed. Their functional integrity was evaluated using intraoperative nerve monitoring (IONM). Indications for secondary surgery, anatomical changes secondary to recurrent goiter mass and prior surgery, and results of IONM were studied. Frequent indications for redo surgery were multinodular goiter (MNG) in 19 (38.8%) and results of cytology in 14 (28.5%) patients. The mean time interval between primary and redo thyroid surgery was 23.4 years. We laterally approached 41 (67.2%) thyroid lobes between the sternocleidomastoid and sternohyoid muscles. 16 (26.2%) RLNs were found to be adherent to the lateral surface of the corresponding thyroid lobe. The functional integrity of all RLNs was confirmed by IONM. The remnant thyroid tissue can then lead to goiter recurrence requiring secondary surgery after a long period of time. The indications for redo surgery were similar to primary cases. Lateral displacement of the RLN which is adherent to the lateral surface of recurrent goiter mass is common anatomic variation. Thyroid reoperations based on awareness of anatomical disturbances can be performed safely by an experienced surgeon with support of ancillary electrophysiological technology.
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19
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Sun W, Liu J, Zhang H, Zhang P, Wang Z, Dong W, He L, Zhang T. A meta-analysis of intraoperative neuromonitoring of recurrent laryngeal nerve palsy during thyroid reoperations. Clin Endocrinol (Oxf) 2017; 87:572-580. [PMID: 28585717 DOI: 10.1111/cen.13379] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/19/2017] [Accepted: 05/05/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND The rate of recurrent laryngeal nerve (RLN) palsy, a common complication of thyroid surgery, is especially high in thyroid reoperations. The present meta-analysis assesses whether intraoperative neuromonitoring (IONM) reduces the prevalence of RLN palsy in thyroid reoperations. DESIGN AND METHODS A systematic literature search was conducted in the PubMed, SCIE and Wan Fang databases for studies published up to 31 August 2016. All data were analysed using STATA (version 11) software. Publication bias was assessed using Begg's funnel plot and Egger's test, and sensitivity analysis was performed. RESULTS Nine studies including 2436 at-risk nerves met the inclusion criteria. The results were presented as pooled relative risks (RRs) with 95% confidence intervals (CI). The overall RLN palsy rate was significantly lower in reoperations conducted with IONM than in those conducted without IONM (RR=0.434, 95% CI=0.206-0.916, P=.029). High heterogeneity was found (I2 =70.2%, P=.001). The rates of transient RLN palsy with and without IONM did not differ significantly (RR=0.607, 95% CI=0.270-1.366, P=.227). The heterogeneity was high (I2 =67.4%, P=.005). However, IONM was significantly associated with a reduction in permanent RLN palsy (RR=0.426, 95% CI=0.196-0.925, P=.031). No significant heterogeneity was found (I2 =13.7%, P=.325). Funnel plots for overall and transient RLN palsy showed a possible publication bias. CONCLUSIONS Intraoperative neuromonitoring (IONM) is associated with a reduction in overall and permanent RLN palsy in thyroid reoperations. However, given the limited sample size and heterogeneity in this meta-analysis, further studies are required to confirm our preliminary findings.
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Affiliation(s)
- Wei Sun
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Jinhao Liu
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Hao Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ping Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Zhihong Wang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Wenwu Dong
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Liang He
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ting Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
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20
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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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21
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Wojtczak B, Barczyński M. Intermittent neural monitoring of the recurrent laryngeal nerve in surgery for recurrent goiter. Gland Surg 2016; 5:481-489. [PMID: 27867862 DOI: 10.21037/gs.2016.09.07] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Reoperative thyroid surgery is still challenging even for skilled surgeons, and is associated with a higher incidence of complications, such as hypoparathyroidism and recurrent laryngeal nerve (RLN) palsy. Displacement of the RLN, scar tissue from previous neck surgery and difficulty in maintaining good hemostasis are risk factors in reoperations. The prevalence of RLN injury in reoperative thyroid surgery ranges as high as 12.5% for transient injury and up to 3.8% for permanent injury. Bilateral paresis can also occur during reoperations, and is a dangerous complication influencing the quality of life, sometimes requiring tracheostomy. RLN identification is the gold standard during thyroidectomy, and the use of intraoperative neuromonitoring (IONM) can be a valuable adjunct to visual identification. This technique can be used to identify the RLN and the external branch of the superior laryngeal nerve (EBSLN), both of which are standardized procedures. The aim of this review was to evaluate the use of intermittent neural monitoring of the RLN in surgery for recurrent goiter, and to assess the prevalence of RLN injury while using IONM reported in the current literature.
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Affiliation(s)
- Beata Wojtczak
- 1st Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Marcin Barczyński
- Department of Endocrine Surgery, 3rd Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
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Morphology and Functional Anatomy of the Recurrent Laryngeal Nerve with Extralaryngeal Terminal Bifurcation. ANATOMY RESEARCH INTERNATIONAL 2016; 2016:9503170. [PMID: 27493803 PMCID: PMC4963538 DOI: 10.1155/2016/9503170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/20/2016] [Indexed: 11/20/2022]
Abstract
Anatomical variations of the recurrent laryngeal nerve (RLN), such as an extralaryngeal terminal bifurcation (ETB), threaten the safety of thyroid surgery. Besides the morphology of the nerve branches, intraoperative evaluation of their functional anatomy may be useful to preserve motor activity. We exposed 67 RLNs in 36 patients. The main trunk, bifurcation point, and terminal branches of bifid nerves were macroscopically determined and exposed during thyroid surgery. The functional anatomy of the nerve branches was evaluated by intraoperative nerve monitoring (IONM). Forty-six RLNs with an ETB were intraoperatively exposed. The bifurcation point was located along the prearterial, arterial, and postarterial segments in 11%, 39%, and 50% of bifid RLNs, respectively. Motor activity was determined in all anterior branches. The functional anatomy of terminal branches detected motor activity in 4 (8.7%) posterior branches of 46 bifid RLNs. The motor activity in posterior branches created a wave amplitude at 25–69% of that in the corresponding anterior branches. The functional anatomy of bifid RLNs demonstrated that anterior branches always contained motor fibres while posterior branches seldom contained motor fibres. The motor activity of the posterior branch was weaker than that of the anterior branch. IONM may help to differentiate between motor and sensory functions of nerve branches. The morphology and functional anatomy of all nerve branches must be preserved to ensure a safer surgery.
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