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Chen H, Xu K, Peng X, Min X. Key points for protecting the external branch of the superior laryngeal nerve in open thyroidectomy: A possible exploration technique. Surg Oncol 2024; 53:102059. [PMID: 38461616 DOI: 10.1016/j.suronc.2024.102059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 01/29/2024] [Accepted: 02/28/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE Injury of the external branch of the superior laryngeal nerve (EBSLN) is easily overlooked in thyroidectomy, and voice changes caused by the injury have a negative effect on an increasing number of patients. This study aimed to reduce the injury rate of EBSLN by expanding the sternothyroid-laryngeal triangle and standardizing the exploration procedure. METHODS A total of 520 patients who had undergone thyroidectomy at the First Affiliated Hospital of Nanchang University between September 2021 and April 2022 were analyzed. During the operation, the exposure rate of the EBSLN before and after sternothyroid-laryngeal triangle expansion was compared, and all EBSLNs were anatomically classified. RESULTS The exposure rate of EBSLN after sternothyroid-laryngeal triangle expansion reached 82.7%, which is much higher than that before sternothyroid-laryngeal triangle expansion (33.7%), and voice change caused by injury of the EBSLN was reported in one case (the injury rate was 0.2%). The classification and proportion of the EBSLN were as follows: Type 1 (55.3%), the nerve ran within 1 cm above the STP, but no coincidence or crossover with blood vessels was observed in this region; Type 2 (14.7%), the nerve travelled within 1 cm above the STP and overlapped or intersected with blood vessels in this region; Type 3 (12.7%), the EBSLN ran below the level of the STP; and Type 4 (17.3%), no EBSLN was observed within 1 cm above the STP. CONCLUSION In thyroidectomy, injury to the EBSLN can be effectively reduced by expanding the sternothyroid-laryngeal triangle and exploring the upper pole area of the thyroid as far as possible, which has great clinical significance in reducing postoperative voice box injury.
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Affiliation(s)
- Hang Chen
- Department of Day Ward, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
| | - Keyi Xu
- Department of Day Ward, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
| | - Xueying Peng
- Department of Day Ward, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
| | - Xiang Min
- Department of Day Ward, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, China.
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2
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Yang X, Zhang Y, Liu Y, Wang Y, Zhou N. Fluorescence imaging of peripheral nerve function and structure. J Mater Chem B 2023; 11:10052-10071. [PMID: 37846619 DOI: 10.1039/d3tb01927f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
Peripheral nerve injuries are common and can cause catastrophic consequences. Although peripheral nerves have notable regenerative capacity, full functional recovery is often challenging due to a number of factors, including age, the type of injury, and delayed healing, resulting in chronic disorders that cause lifelong miseries and significant financial burdens. Fluorescence imaging, among the various techniques, may be the key to overcome these restrictions and improve the prognosis because of its feasibility and dynamic real-time imaging. Intraoperative dynamic fluorescence imaging allows the visualization of the morphological structure of the nerve so that surgeons can reduce the incidence of medically induced injury. Axoplasmic transport-based neuroimaging allows the visualization of the internal transport function of the nerve, facilitating early, objective, and accurate assessment of the degree of regenerative repair, allowing early intervention in patients with poor recovery, thereby improving prognosis. This review briefly discusses peripheral nerve fluorescent dyes that have been reported or could potentially be employed, with a focus on their role in visualizing the nerve's function and anatomy.
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Affiliation(s)
- Xiaoqi Yang
- Department of Orthopedics, The First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou 450052, Henan, China.
| | - Yumin Zhang
- Department of Geriatric Endocrinology, The First Hospital Affiliated to Nanjing Medical University, Nanjing, Jiangsu 210029, P. R. China
| | - Yadong Liu
- Department of Spinal Surgery, The First Hospital of Jilin University, Jilin Engineering Research Center For Spine and Spinal Cord Injury, 1 Xinmin St, Changchun, 130021, China.
| | - Yuanyi Wang
- Department of Spinal Surgery, The First Hospital of Jilin University, Jilin Engineering Research Center For Spine and Spinal Cord Injury, 1 Xinmin St, Changchun, 130021, China.
| | - Nan Zhou
- Department of Orthopedics, The First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou 450052, Henan, China.
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Al-Qahtani K, Shahrani MA, Zahrani FA, Ghamdi AA, Alghamdi FA, Alshaalan ZA, Al-Saif A, Bokhari A, Al-Abdulkarim AA, Islam T. Comparing Thyroidectomy Techniques, Surgical Loupe and Neuromonitoring Between ENT and Endocrine Surgeons-an Observational Study. Indian J Otolaryngol Head Neck Surg 2023; 75:1618-1624. [PMID: 37636681 PMCID: PMC10447852 DOI: 10.1007/s12070-023-03627-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 02/21/2023] [Indexed: 03/28/2023] Open
Abstract
Thyroid surgery is performed by ENT head and neck (ENT-HNS), endocrine (ES) and general surgeons (GS). Each modality adopts different surgical techniques causing difference in outcome, operative time and postoperative complication. A retrospective chart review of thyroid surgeries performed by two ENT-HNS, three ES of a single tertiary center was conducted. We compared the use of neuromonitoring and surgical loupe and subsequent patient outcomes between surgeries performed by ENT-HNS versus ES, focusing on parathyroid gland identification, operative duration, vocal cord paralysis and length of hospital stay. A total of 167 patients underwent thyroid surgery. Surgical loupes were used in all the surgeries performed by ENT-HNS vs. 85% by the ES. Parathyroid glands were identified in all the surgeries performed by ENT-HNS versus 95% by ES. Neuromonitoring was used in all the surgeries performed by ENT-HNS, and none by the ES. Vocal cord paralysis developed in two patients of ES versus none in the ENT-HNS. Mean operative duration for total thyroidectomy in ENT-HN surgeries, 183.7 min vs. 151 min in the ES. The mean hospital stay of patients was 3.6 ± 1.6 days for ENT-HNS, and 5.45 ± 3 days for ES. Identification of parathyroid gland and recurrent laryngeal nerve by neuromonitoring and surgical loupes may increase operative time but decrease the rate of vocal cord paralysis and increases the chance of parathyroid gland identification.
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Affiliation(s)
- Khalid Al-Qahtani
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Mohammad Al Shahrani
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Faisal Al Zahrani
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - AbdulAziz Al Ghamdi
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Fareed Al Alghamdi
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Zaid Al Alshaalan
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Abdulaziz Al-Saif
- Breast and Endocrine Surgery Unit, Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Areej Bokhari
- Breast and Endocrine Surgery Unit, Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Amal A. Al-Abdulkarim
- Breast and Endocrine Surgery Unit, Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Tahera Islam
- College of Medicine and Research Center, King Saud University, P.O. Box-245, Riyadh, 11461 Kingdom of Saudi Arabia
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Choi HW, Ji YB, Kim E, Kim KN, Tae K. Success rate and learning curve of intraoperative neural monitoring of the external branch of the superior laryngeal nerve in thyroidectomy. Head Neck 2021; 43:3946-3954. [PMID: 34632669 DOI: 10.1002/hed.26895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/14/2021] [Accepted: 09/21/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the success rate and learning curve of intraoperative neural monitoring (IONM) of the external branch of the superior laryngeal nerve (EBSLN) in thyroidectomy. METHODS We studied 130 consecutive patients (200 nerves at risk [NARs]) who had undergone conventional thyroidectomy with IONM of the recurrent laryngeal nerve (RLN) and EBSLN from January 2017 to March 2020. The learning curve was defined as the number of NARs required to achieve an effective and reliable neuromonitoring rate. RESULTS IONM of the EBSLN was successful in 136/200 (68%) NARs. The cutoff point of the learning curve was 45 NARs (28 patients). The neural identification rate of EBSLN was significantly higher in the post-learning 155 NARs group than the pre-learning group (82.6% vs. 17.8%, p < 0.001). CONCLUSIONS Approximately 45 NAR neuromonitoring attempts were required to reach a significant increase in the EBSLN identification rate and overcome the learning curve.
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Affiliation(s)
- Hae Won Choi
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Yong Bae Ji
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Eugene Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Kyu Nam Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Kyung Tae
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
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Park JS, Frank E, Simental A, Perez HA, Park JJ, Filho PA, Murry T. Incidence of Dysphonia and Dysphagia Exceeds Recurrent Laryngeal Nerve Injury During Thyroid Surgery. J Voice 2021:S0892-1997(21)00093-X. [PMID: 34053823 DOI: 10.1016/j.jvoice.2021.02.030] [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: 12/21/2020] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To determine the prevalence of separate and combined voice and swallowing impairments before and after total thyroidectomy and to delineate risk factors for these symptoms. METHODS Retrospective review of 592 consecutive patients who underwent total thyroidectomy from July 2003 to August 2015. RESULTS Combined voice and swallowing problems occurred preoperatively in 4.7% (11/234), 3.3% (3/92), and 6.0% (16/266) of patients with malignancy, hyperthyroidism, and benign euthyroid disease, respectively. Postoperatively, prevalence was 5.1%, 2.2%, and 1.9%, respectively. Benign euthyroid disease (20.7%) had the greatest risk of preoperative dysphagia (P = 0.003) and the largest glands (P < 0.001). Comparing before and after surgery, the cancer and benign euthyroid groups had decreased dysphagia (cancer: 11.5% vs. 6.0%, P = 0.034; benign: 20.7% vs. 3.8%, P < 0.001) but increased dysphonia (cancer: 19.2% vs. 28.6%, P = 0.017; benign: 15.8% vs. 27.1%, P = 0.002). Overall, 23/592 (3.9%) developed new dysphagia and 122/592 (20.6%) developed new dysphonia after surgery. Intraoperative recurrent laryngeal nerve transection occurred in 12 cases (2.0%). CONCLUSIONS Total thyroidectomy resolved dysphagia but increased dysphonia in benign and malignant euthyroid patients. Voice and swallowing problems following thyroidectomy occurred more frequently than intraoperative recurrent laryngeal nerve transection, confirming symptoms often occur in the absence of suspected nerve injury.
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Affiliation(s)
- Joshua S Park
- Loma Linda University Health, Department of Otolaryngology, Loma Linda, California.
| | - Ethan Frank
- Loma Linda University Health, Department of Otolaryngology, Loma Linda, California
| | - Alfred Simental
- Loma Linda University Health, Department of Otolaryngology, Loma Linda, California
| | - Hector A Perez
- Loma Linda University Health, Department of Otolaryngology, Loma Linda, California
| | - Jaimie J Park
- Loma Linda University School of Medicine, Loma Linda, California
| | - Pedro Andrade Filho
- Loma Linda University Health, Department of Otolaryngology, Loma Linda, California
| | - Thomas Murry
- Loma Linda University Health, Department of Otolaryngology, Loma Linda, California
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6
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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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Wang Z, Yu J, Rao S, Lin Z, Pan Z, Shen X. Analysis of Risk Factors for Surgical Complications of Endoscopic Thyroidectomy via Total Areola Approach. Cancer Manag Res 2021; 13:4003-4012. [PMID: 34040441 PMCID: PMC8140881 DOI: 10.2147/cmar.s293328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/04/2021] [Indexed: 11/23/2022] Open
Abstract
Background Increased surgical technology has led broad acceptance endoscopic thyroidectomy and its application in the treatment of thyroid diseases, including thyroid carcinoma. Although the incidence of complications and mortality of thyroid surgery has been significantly reduced, serious complications still occur from time to time. The purpose of this retrospective study is to identify the factors that influence the complications of endoscopic thyroidectomy. Methods This study was carried out between January 2012 and December 2019, where a total of 630 patients undergoing endoscopic thyroidectomy via the total areola approach were retrospectively evaluated to identify the key influencing factors of complications. Results The study established that the common complications included recurrent laryngeal nerve injury (3.33%), superior laryngeal nerve injury (2.54%), hypocalcemia (8.57%), and the incidence of complications was acceptable. Both univariate and multivariate analysis showed that thyroid carcinoma (P = 0.041), operation time lasting more than 150 minutes (P = 0.034) and operation before 2017 (P = 0.001) were risk factors of recurrent laryngeal nerve injury. We established that operation after 2017 (P < 0.005) was the only protective factor of superior laryngeal nerve injury. Thyroid carcinoma (P=0.04), operation mode (P=0.001), and surgery before 2017 (P<0.001) are risk factors for parathyroid injury. Among the clinical groups, operation before 2017 was an independent risk factor for all complications. Conclusion For thyroid specialists, after the early learning curve, with the continuous improvement of endoscopic operation technology, high-definition equipment and more sophisticated operation equipment can be used in clinical practice, which can prevent and reduce the occurrence of complications.
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Affiliation(s)
- Zhonglin Wang
- Department of General Surgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Jian Yu
- Department of General Surgery, Wenzhou Central Hospital, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Shangrui Rao
- Department of General Surgery, Wenzhou Central Hospital, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Zhe Lin
- Department of General Surgery, Wenzhou Central Hospital, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Zhongliang Pan
- Department of General Surgery, Wenzhou Central Hospital, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Xian Shen
- Department of General Surgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
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Dhillon VK, Randolph GW, Stack BC, Lindeman B, Bloom G, Sinclair CF, Woodson G, Brooks JA, Childs LF, Esfandiari NH, Evangelista L, Guardiani E, Quintanilla-Dieck L, Naunheim MR, Shindo M, Singer M, Tolley N, Angelos P, Kupfer R, Banuchi V, Liddy W, Tufano RP. Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment. Head Neck 2020; 42:3779-3794. [PMID: 32954575 DOI: 10.1002/hed.26472] [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: 08/26/2020] [Accepted: 09/08/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Laryngeal dysfunction after thyroid and parathyroid surgery requires early recognition and a standardized approach for patients that present with voice, swallowing, and breathing issues. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to define the terms "immediate vocal fold paralysis" and "partial neural dysfunction" and to provide clinical consensus statements based on review of the literature, integrated with expert opinion of the group. METHODS A multidisciplinary expert panel constructed the manuscript and recommendations for laryngeal dysfunction after thyroid and parathyroid surgery. A meta-analysis was performed using the literature and published guidelines. Consensus was achieved using polling and a modified Delphi approach. RESULTS Twenty-two panelists achieved consensus on five statements regarding the role of early identification and standardization of evaluation for patients with "immediate vocal fold paralysis" and "partial neural dysfunction" after thyroid and parathyroid surgery. CONCLUSION After endorsement by the AHNS Endocrine Section and Quality of Care Committee, it received final approval from the AHNS Council.
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Affiliation(s)
- Vaninder K Dhillon
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University National Capital Region, Bethesda, Maryland, USA
| | - Gregory W Randolph
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Brendan C Stack
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Brenessa Lindeman
- Department of General Surgery, Surgical Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Gary Bloom
- ThyCa: Thyroid Cancer Survivors' Association, Inc., Olney, Maryland, USA
| | - Catherine F Sinclair
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai West Hospital, New York, New York, USA
| | - Gayle Woodson
- Department of Otolaryngology-Head and Neck Surgery, Drexel University, Philadelphia, Pennsylvania, USA
| | - Jennifer A Brooks
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lesley F Childs
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nazanene H Esfandiari
- Department of Internal Medicine, Metabolism, Endocrinology & Diabetes (MEND), University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa Evangelista
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, California, USA
| | - Elizabeth Guardiani
- Department of Otolaryngology-Head and Neck Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Lourdes Quintanilla-Dieck
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Oregon, Portland, USA
| | - Matthew R Naunheim
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Maisie Shindo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Oregon, Portland, USA
| | - Michael Singer
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Neil Tolley
- Department of Otolaryngology-Head and Neck Surgery, Imperial College NHS Trust, London, UK
| | - Peter Angelos
- Department of Surgery, University of Chicago School of Medicine, Chicago, Illinois, USA
| | - Robbi Kupfer
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Victoria Banuchi
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell School of Medicine, New York, New York, USA
| | - Whitney Liddy
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, Illinois, USA
| | - Ralph P Tufano
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
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Prades JM, Lelonge Y, Farizon B, Dubois MD, Gavid M. Intraoperative neuromonitoring by vagus nerve stimulation in thyroid surgery: Clinical assessment of recurrent and superior laryngeal nerves. Eur Ann Otorhinolaryngol Head Neck Dis 2020; 137:227-230. [DOI: 10.1016/j.anorl.2020.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
OBJECTIVE This review details the agents for fluorescence-guided nerve imaging in both preclinical and clinical use to identify factors important in selecting nerve-specific fluorescent agents for surgical procedures. BACKGROUND Iatrogenic nerve injury remains a significant cause of morbidity in patients undergoing surgical procedures. Current real-time identification of nerves during surgery involves neurophysiologic nerve stimulation, which has practical limitations. Intraoperative fluorescence-guided imaging provides a complimentary means of differentiating tissue types and pathology. Recent advances in fluorescence-guided nerve imaging have shown promise, but the ideal agent remains elusive. METHODS In February 2018, PubMed was searched for articles investigating peripheral nerve fluorescence. Key terms used in this search include: "intraoperative, nerve, fluorescence, peripheral nerve, visualization, near infrared, and myelin." Limits were set to exclude articles exclusively dealing with central nervous system targets or written in languages other than English. References were cross-checked for articles not otherwise identified. RESULTS Of the nonspecific agents, tracers that rely on axonal transport showed the greatest tissue specificity; however, neurovascular dyes already enjoy wide clinical use. Fluorophores specific to nerve moieties result in excellent nerve to background ratios. Although noteworthy findings on tissue specificity, toxicity, and route of administration specific to each fluorescent agent were reported, significant data objectively quantifying nerve-specific fluorescence and toxicity are lacking. CONCLUSIONS Fluorescence-based nerve enhancement has advanced rapidly over the past 10 years with potential for continued utilization and progression in translational research. An ideal agent would be easily administered perioperatively, would not cross the blood-brain barrier, and would fluoresce in the near-infrared spectrum. Agents administered systemically that target nerve-specific moieties have shown the greatest promise. Based on the heterogeneity of published studies and methods for reporting outcomes, it appears that the development of an optimal nerve imaging agent remains challenging.
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Minuto MN, Reina S, Monti E, Ansaldo GL, Varaldo E. Morbidity following thyroid surgery: acceptable rates and how to manage complicated patients. J Endocrinol Invest 2019; 42:1291-1297. [PMID: 31124043 DOI: 10.1007/s40618-019-01064-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 05/14/2019] [Indexed: 12/01/2022]
Abstract
PURPOSE The endocrine surgeon and the endocrinologist should standardize how they deal with patients with an indication for thyroidectomy, as the road to surgery starts well before the operation itself. The patient should be thoroughly informed about where and how surgery will be performed, the postoperative improvements that can be expected, and the possibility and incidence of relevant complications. This short review aims at identifying the most common postoperative issues after thyroidectomy, with the relevant therapeutic suggestions. METHODS A revision of studies reporting the morbidity of thyroid surgery, involving the largest numbers of patients. RESULTS It has been clearly demonstrated that the outcome of thyroid surgery is significantly better when the procedure is performed by an experienced surgeon. Thus, the number of thyroidectomies performed by a surgeon should drive the endocrinologist when referring a patient. CONCLUSIONS Despite the surgeon's experience, thyroidectomy is burdened by a relatively high rate of postoperative issues ranging from less severe ones to others causing significant changes in the patient's quality of life. Minor, non-invalidating symptoms have been described in 40% of patients after thyroidectomy (e.g. hoarseness, mild dysphagia, some degree of voice alteration); however, these symptoms usually resolve within a few months of surgery, with or without early treatment. On the other hand, major postoperative complications are observed in a limited number of patients, but in these cases early diagnosis is important to provide the most appropriate postoperative treatment, and thus hasten full recovery or at least achieve the greatest possible improvement.
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Affiliation(s)
- M N Minuto
- Dipartimento di Scienze Chirurgiche (DISC), Università degli Studi di Genova, V.le Benedetto XV 6, 16132, Genoa, Italy.
- U.O. Chirurgia 1, Dipartimento di Chirurgia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - S Reina
- Dipartimento di Scienze Chirurgiche (DISC), Università degli Studi di Genova, V.le Benedetto XV 6, 16132, Genoa, Italy
- U.O. Chirurgia 1, Dipartimento di Chirurgia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - E Monti
- Dipartimento di Medicina Interna (DIMI), Università degli Studi di Genova, Genoa, Italy
| | - G L Ansaldo
- U.O. Chirurgia 1, Dipartimento di Chirurgia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - E Varaldo
- Dipartimento di Scienze Chirurgiche (DISC), Università degli Studi di Genova, V.le Benedetto XV 6, 16132, Genoa, Italy
- U.O. Chirurgia 1, Dipartimento di Chirurgia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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13
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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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Chen HC, Pei YC, Fang TJ. Risk factors for thyroid surgery-related unilateral vocal fold paralysis. Laryngoscope 2018; 129:275-283. [PMID: 30284255 PMCID: PMC6585753 DOI: 10.1002/lary.27336] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2018] [Indexed: 01/02/2023]
Abstract
Objectives/Hypothesis We aimed to identify the risk factors for iatrogenic unilateral vocal fold paralysis (UVFP) caused by thyroid surgery, to allow the identification of patients requiring nerve‐protection procedures and monitoring technologies. Study Design Retrospective case study in a medical center. Methods Patients who underwent thyroid surgery from April 2011 to February 2016 and who were diagnosed with UVFP by laryngoscopy and laryngeal electromyography were included. Patient demographics, types of surgery, and characteristics of the thyroid lesions were analyzed. Results Sixty (2.1%) of 2,815 patients who received thyroid surgery developed UVFP. The risk of UVFP was higher in patients over 60 years old (odds ratio, 1.89; 95% confidence interval, 1.01‐3.26; P = .01). Involvement of the external branch of superior laryngeal nerve (EBSLN) occurred in 19 (31.7%) of the 60 UVFP patients, and was more likely to occurr in patients with diabetes mellitus (odds ratio, 14.19; 95% confidence interval, 3.80‐52.94; P < .001). The incidence of UVFP and involvement of the EBSLN differed among surgery types, and was the highest among patients undergoing total thyroidectomy with neck dissection (TTND) (10/158, 6.3% and 5/158, 3.2%, respectively). Conclusions The risk of thyroid surgery–related UVFP is higher in older patients. EBSLN involvement is more likely in patients with diabetes mellitus. TTND is associated with higher risks of UVFP and EBSLN injury than other types of surgery, implying the need of intraoperative nerve monitoring in these high‐risk characteristics. Level of Evidence 4 Laryngoscope, 129:275–283, 2019
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Affiliation(s)
- Hung-Chun Chen
- From the Department of Otolaryngology-Head and Neck Surgery, Taoyuan, Taiwan
| | - Yu-Cheng Pei
- Department of Physical Medicine and Rehabilitation, Taoyuan, Taiwan.,Center of Vascularized Tissue Allograft, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,the Healthy Aging Research Center.,the School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tuan-Jen Fang
- From the Department of Otolaryngology-Head and Neck Surgery, Taoyuan, Taiwan.,the School of Medicine, Chang Gung University, Taoyuan, Taiwan
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Schneider R, Machens A, Randolph GW, Kamani D, Lorenz K, Dralle H. Opportunities and challenges of intermittent and continuous intraoperative neural monitoring in thyroid surgery. Gland Surg 2017; 6:537-545. [PMID: 29142846 DOI: 10.21037/gs.2017.06.08] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The number of thyroid operations and there radically continues to rise in the western hemisphere, bringing prevention of recurrent laryngeal nerve (RLN) palsy to the fore. Overall, the incidence of RLN palsy is fairly low but continues to prompt litigation for malpractice. In an effort to diminish transient, and more importantly permanent, RLN palsy rates, intraoperative neuromonitoring (IONM) has been advocated as a risk minimization tool. Recent meta-analyses of studies, many of which were limited by poor study design and the sole use of intermittent nerve stimulation, were unable to demonstrate superiority of IONM over mere anatomic RLN dissection. This is where continuous IONM (CIONM) comes into play: this technology enables the surgeon to (I) identify impending nerve injury as it unfolds; (II) release distressed nerves by reversing causative surgical maneuvers; and (III) verify functional nerve recovery after intraoperative loss of the electromyographic signal. Despite this superiority, CIONM is not devoid of methodological limitations, which need to be accounted for. This review summarizes the current key achievements of IONM; outlines opportunities for improvement regarding clinical implementation; and suggests areas of future research in this rapidly evolving field.
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Affiliation(s)
- Rick Schneider
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Andreas Machens
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Kerstin Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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Gurleyik E, Gurleyik G. Intraoperative Monitoring of External Branch of the Superior Laryngeal Nerve: Functional Identification, Motor Integrity, and its Role on Vocal Cord Function. J INVEST SURG 2017; 31:509-514. [PMID: 28952819 DOI: 10.1080/08941939.2017.1362489] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Beside recurrent laryngeal nerve (RLN), protection of the external branch of the superior laryngeal nerve (EBSLN) is required for complication-free thyroid surgery. This study investigates the contribution of intraoperative neuromonitoring (IONM) to identification and motor integrity of the EBSLN. METHODS This prospective study was performed on 245 EBSLNs in 147 patients with thyroid surgery. The rate of visual identification, contribution of IONM to functional localization, the rate and levels of recordable waveform amplitude from vocal cord (VC) movement were determined during surgery. RESULTS 164 (66.9%) EBSLNs were visually identified and additional 74 branches were functionally identified by IONM. Additional identification rate of IONM was 30.2%. Seven (2.9%) EBSLNs could not be identified during surgery. Cricothyroid muscle (CTM) twitch established functional integrity in 97.1% of EBSLNs. Electrophysiological stimulation of 151 (63.4%) EBSLNs created waveform amplitude >100 µV that mean amplitude level was calculated as 186 µV, and an amplitude >300 µV was recorded in 19 of 151 (12.6%) EBSLNs. CONCLUSIONS In addition to visual identification, surgeons can functionally localize the EBSLN with the assistance of IONM that CTM twitch is a reliable evience for functional integrity of the EBSLN. In the majority of patients, stimulation of the EBSLN creates recordable waveform amplitude thus the EBSLN appears to be a second source of motor innervations for intrinsic laryngeal muscles.
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Affiliation(s)
- Emin Gurleyik
- a Department of Surgery , Duzce University, Medical Faculty , Duzce
| | - Gunay Gurleyik
- b Department of Surgery , Haydarpasa Numune Hospital , Istanbul , 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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Chávez KV, Ramírez J, Pantoja JP, Sierra M, Velázquez-Fernández D, Herrera MF. Continuous intraoperative neural monitoring in thyroid surgery: a Mexican experience. Updates Surg 2017; 69:505-508. [PMID: 28493220 DOI: 10.1007/s13304-017-0455-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 04/24/2017] [Indexed: 11/28/2022]
Abstract
Intraoperative continuous neural monitoring (C-IONM) during thyroid surgery has been recognized as a useful tool to identify and confirm recurrent laryngeal nerve integrity. The aim of the present study is to analyze electromyographic features and thresholds for normal vocal fold function in our initial experience with C-IONM in thyroid surgery. C-IONM was utilized in 57 patients who underwent thyroid surgery between July 2012 and December 2015. EMG parameters were analyzed looking for potential predictors of postoperative vocal fold dismotility. There were 54 females (94.7%) and 3 males (5.3%) with a mean age of 46.7 ± 11.6 years. C-IONM was successfully registered in 89 of 107 nerves at risk (83.1%). Mean basal amplitude was 727.31 ± 471.25 μV and mean final amplitude was 650.27 ± 526.87 μV (P = 0.095, CI 95% 13.83-167.91). Mean basal latency was 5.23 ± 1.42 mS and mean final latency was 5.18 ± 1.50 mS (P = 0.594, CI 95% 0.39-0.24). Four patients had transient postoperative vocal fold paresis. None of these four patients had loss of signal (LOS), three had transient decrease in amplitude, and one had a normal registry throughout the operation. C-IONM is a useful tool to identify patients in whom intraoperative RLN is at risk during surgery. Final amplitude above 500 μV and no LOS is associated with RLN integrity and normal postoperative vocal fold function.
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Affiliation(s)
- Karla Verónica Chávez
- Service of Endocrine Surgery, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga #15, Tlalpan, PO Box 14000, Mexico City, Mexico
| | - Jackeline Ramírez
- Service of Otolaryngology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan Pablo Pantoja
- Service of Endocrine Surgery, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga #15, Tlalpan, PO Box 14000, Mexico City, Mexico
| | - Mauricio Sierra
- Service of Endocrine Surgery, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga #15, Tlalpan, PO Box 14000, Mexico City, Mexico
| | - David Velázquez-Fernández
- Service of Endocrine Surgery, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga #15, Tlalpan, PO Box 14000, Mexico City, Mexico
| | - Miguel F Herrera
- Service of Endocrine Surgery, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga #15, Tlalpan, PO Box 14000, Mexico City, Mexico.
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Abstract
PURPOSE OF REVIEW Laryngeal nerve injury, resulting in speech and swallowing dysfunction, is a feared complication of thyroid operations. Routine visualization of the recurrent laryngeal nerve (RLN) has decreased the likelihood of nerve injury, and intraoperative nerve monitoring has been applied in the hope of further enhancing safety. RECENT FINDINGS There is conflicting evidence about the value of nerve monitoring during thyroid operations, despite ample research. The data favor nerve monitoring in certain situations, such as neck re-explorations, contralateral RLN injury, extensive or challenging dissections, invasive tumors or large goiters, and nonrecurrent or branching recurrent laryngeal nerves. Continuous intraoperative nerve monitoring may reduce the chances of excessive traction, which is the most common mechanism of injury. Nerve monitoring may also identify and protect the external branches of the superior laryngeal nerve. SUMMARY Surgeons should routinely identify recurrent laryngeal nerves during thyroid operations, and intraoperative nerve monitoring might be a useful adjunct to prevent injury. As a result of the relatively low probability of permanent recurrent laryngeal nerve injury, it is difficult to establish the absolute value of nerve monitoring. Further research may focus on continuous nerve monitoring and intraoperative monitoring of the external branches of the superior laryngeal nerves.
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Affiliation(s)
- Ivy H Gardner
- aBoston University School of MedicinebDepartment of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
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Lv B, Zhang B, Zeng QD. Total Endoscopic Thyroidectomy with Intraoperative Laryngeal Nerve Monitoring. Int J Endocrinol 2016; 2016:7381792. [PMID: 27413372 PMCID: PMC4931063 DOI: 10.1155/2016/7381792] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 05/24/2016] [Indexed: 11/22/2022] Open
Abstract
Objective. To evaluate the clinical efficacy of laryngeal nerve (LN) monitoring (LNM) during total endoscopic thyroidectomy via breast approach, with emphasis on the identification rates for RLN and EBSLN and the incidence of RLN paralysis. Materials and Methods. This retrospective study included 280 patients who underwent endoscopic thyroidectomy with or without LNM. RLN and EBSLN were identified using endoscopic magnification in the control group, while they were localized additionally by LNM in the LNM group. Demographic parameters and surgical outcomes were analyzed by statistical methods. Patients in the control group were also stratified by the side of thyroidectomy to determine difference in left and right RLN injury rates. Results. All procedures were successfully conducted without permanent LN damage. The identification rates for RLN and EBSLN were high in the LNM group compared to those of the control group, and the risk difference (RD) of temporary RLN injury between two groups was 6.3%. The risk of damage was slightly higher for the left RLN than for the right RLN in the control group, which was performed by a right-hand surgeon. Conclusion. The joint application of LNM and endoscopic magnified view endows total endoscopic thyroidectomy with ease, safety, and efficiency.
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Affiliation(s)
- Bin Lv
- Qilu Hospital of Shandong University, Department of General Surgery, Jinan 250012, Shandong, China
| | - Bin Zhang
- Qilu Hospital of Shandong University, Department of General Surgery, Jinan 250012, Shandong, China
| | - Qing-Dong Zeng
- Qilu Hospital of Shandong University, Department of General Surgery, Jinan 250012, Shandong, China
- *Qing-Dong Zeng:
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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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