1
|
Traba A, de Abreu A, Nevado C, Duran H, Gil A, Pérez Seoane M, Lopez-Gonzalez L, Ortega MA, Álvarez-Mon M, Martin P, San Roman J, Díaz-Pedrero R. Vagus Nerve Stimulation in the Carotid Triangle: An Effective Method for Monitoring the Recurrent Laryngeal Nerve in Thyroid and Parathyroid Surgery. J Clin Med 2023; 13:102. [PMID: 38202109 PMCID: PMC10780223 DOI: 10.3390/jcm13010102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE Our objective is the description of the technique of vagus nerve stimulation in carotid triangle in order to monitor the recurrent laryngeal nerve (RLN) during thyroid and parathyroid surgery. METHODS We stimulated the vagus nerve in the carotid triangle during 150 thyroid or parathyroid surgeries using a monopolar electromyography electrode inserted under the mastoid process towards the jugular foramen as a cathode, and using another subdermal electrode in the mastoid as an anode. Another complementary method of vagus stimulation was achieved with a pair of subdermal electrodes, placing the cathode at the mandibular angle and the anode at the mastoid. RESULTS In all patients, compound muscle action potential (CMAP) was recorded in the vocal cords with both stimulation techniques, allowing semi-continuous monitoring to be carried out. Intraoperative lesions were detected in 16 of the cases; 9 of them were transient with CMAP recovery achieved when modifying surgical maneuvers. CONCLUSIONS Vagus nerve stimulation in the carotid triangle is a reliable technique for monitoring the RLN in thyroid surgery. Vagus nerve stimulation in the carotid triangle is effective and safe for RLN monitoring, and it is a clear alternative to direct continuous stimulation of the nerve that by contrast requires its dissection in the carotid sheath.
Collapse
Affiliation(s)
- Alfredo Traba
- Neurology and Neurophysiology, Hospital Universitario HM Sanchinarro, C/de Oña 10, 28050 Madrid, Spain;
| | - Angela de Abreu
- Neurology and Neurophysiology, Hospital Universitario HM Sanchinarro, C/de Oña 10, 28050 Madrid, Spain;
| | - Clara Nevado
- Neurology and Neurophysiology, Hospital Fundación Alcorcón, C/Budapest 1, 28922 Madrid, Spain;
| | - Hipólito Duran
- General and Digestive Surgery Department, Hospital Universitario HM Sanchinarro, C/Oña 10, 28050 Madrid, Spain;
| | - Antonio Gil
- General and Digestive Surgery Department, Hospital Universitario HM Montepríncipe, Av. de Montepríncipe 25, 28660 Madrid, Spain; (A.G.); (M.P.S.); (P.M.)
| | - María Pérez Seoane
- General and Digestive Surgery Department, Hospital Universitario HM Montepríncipe, Av. de Montepríncipe 25, 28660 Madrid, Spain; (A.G.); (M.P.S.); (P.M.)
| | - Laura Lopez-Gonzalez
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (L.L.-G.); (M.A.O.); (R.D.-P.)
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain;
| | - Miguel A. Ortega
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (L.L.-G.); (M.A.O.); (R.D.-P.)
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Melchor Álvarez-Mon
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain;
- Immune System Diseases-Rheumatology and Internal Medicine Service, University Hospital Prince of Asturias, Networking Research Center on for Liver and Digestive Diseases (CIBEREHD), 28806 Alcalá de Henares, Spain
| | - Pedro Martin
- General and Digestive Surgery Department, Hospital Universitario HM Montepríncipe, Av. de Montepríncipe 25, 28660 Madrid, Spain; (A.G.); (M.P.S.); (P.M.)
| | - Juan San Roman
- General and Digestive Surgery Department, Hospital Universitario HM Torrelodones, Av. Castillo Olivares s/n, 28250 Madrid, Spain;
| | - Raul Díaz-Pedrero
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (L.L.-G.); (M.A.O.); (R.D.-P.)
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain;
- General and Digestive Surgery Department, Hospital Universitario HM Rivas Vaciamadrid, 28521 Madrid, Spain
| |
Collapse
|
2
|
Aygun N, Unlu MT, Kostek M, Caliskan O, Isgor A, Uludag M. Intraoperative cricothyroid muscle electromyography may contribute to the monitorization of the external branch of the superior laryngeal nerve during thyroidectomy. Front Endocrinol (Lausanne) 2023; 14:1303159. [PMID: 38130395 PMCID: PMC10733446 DOI: 10.3389/fendo.2023.1303159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Background In thyroid surgery, both the recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN) should be preserved for maintaining the vocal cord functions. We aimed to evaluate whether EMG of the CTM applied after the superior pole dissection provided additional informative data to the IONM via ETT or not, regarding the EBSLN function. Methods The prospectively collected data of the patients, who have undergone thyroidectomy with the use of IONM for the exploration of both the RLN and EBSLN between October 2016 and March 2017, were evaluated retrospectively. Patients over 18 years of age with primary thyroid surgery for malignant or benign thyroid disease, and whom were applied CTM EMG with a needle electrode after the completion of thyroidectomy were included in the study. In the study, each neck side was evaluated as a separate entity considering the EBSLN at risk. Results The data of 41 patients (32 female, 9 male) (mean age, 46.7 + 9.1; range, 22-71) were evaluated. Sixty seven EBSLNs out of 26 bilateral and 15 unilateral interventions were evaluated. With EBSLN stimulation after the superior pole dissection, positive glottic EMG waveforms via ETT were obtained in 45 (67.2%) out of 67, and the mean glottic amplitude value was 261 + 191 μV (min-max: 116-1086 μV). Positive EMG responses via the CTM EMG were achieved from all of the 67 EBSLNs (100%) with stimulation using a monopolar probe at the most cranial portion above the area of divided superior pole vessels. The mean value of CTM amplitudes via CTM EMG obtained with EBSLN stimulation was 5268 + 3916 μV (min-max:1215 -19726 μV). With EBSLN stimulation, the mean CTM EMG amplitude was detected significantly higher than the mean vocal cord amplitude (p<0.0001). The CTM EMG provided more objective quantifiable data regarding the EBSLN function (100% vs 67,2%, p<0.001). Conclusion In addition to the IONM via ETT, intraoperative post-dissection CTM EMG via needle electrode is a safe, simple and applicable method that may provide significant additional informative data to IONM with ETT by obtaining and recording objective quantitative data related to the EBSLN function.
Collapse
Affiliation(s)
- Nurcihan Aygun
- General Surgery Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Taner Unlu
- General Surgery Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Kostek
- General Surgery Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Ozan Caliskan
- General Surgery Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Adnan Isgor
- General Surgery Department, Memorial Sisli Hospital, Sisli, Istanbul, Türkiye
| | - Mehmet Uludag
- General Surgery Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| |
Collapse
|
3
|
Gurleyik E, Gurleyik G. Anatomical and functional identification of the external branch of the superior laryngeal nerve: classification based on morphology and electrophysiological monitoring. Acta Chir Belg 2022; 122:185-191. [PMID: 33729893 DOI: 10.1080/00015458.2021.1894733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Motor function of the external branch of superior laryngeal nerve (EBSLN) is vital for voice quality. We studied the rate of EBSLN identification and integrity in the era of intraoperative neuromonitoring (IONM). METHODS Anatomic and functional identification of 515 EBSLNs-at-risk was performed under the guidance of IONM that motor integrity was electrophysiologically checked. The functional integrity was assessed with crico-thyroid muscle (CTM) twitches and/or recordable waveform amplitude. We tried to establish the systematic classification of EBSLN identification and integrity. RESULTS Visual, electrophysiological and total identification rates were 64.3%, 31.6% and 95.9%, respectively. We could identify 4.1% of EBSLNs neither anatomically nor electrophysiologically. We recorded CTM twitches alone or both CTM twitches and wave amplitude in 203(39.4%) and 291(56.5%) branches respectively. Identification features of EBSLNs were systematically classified under three main types: Visualized-monitored (1), non-visualized-monitored (2), unidentified (3), and electrophysiological integrity of EBSLNs under two subtypes: CTM twitches alone (a) and CTM twitches and wave amplitude (b). CONCLUSION Dedicated thyroid surgeon could visually identify EBSLNs. IONM contribution significantly increases the identification rate. Systematic classification of identification and electrophysiological integrity of EBSLNs may increase comprehensive knowledge about its motor function that is crucial for complication-free thyroidectomy.
Collapse
Affiliation(s)
- Emin Gurleyik
- Department of Surgery, Medical Faculty, Duzce University, Duzce, Turkey
| | - Gunay Gurleyik
- Department of Surgery, Haydarpasa Numune Teaching Hospital, Health Sciences University, Istanbul, Turkey
| |
Collapse
|
4
|
Importance of Intraoperative Neuromonitoring Parameters in Predicting Temporary Recurrent Laryngeal Nerve Palsy Following Thyroid Surgery for Malignancy. Indian J Surg Oncol 2022; 13:218-224. [PMID: 35462654 PMCID: PMC8986907 DOI: 10.1007/s13193-021-01490-7] [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] [Accepted: 12/13/2021] [Indexed: 10/19/2022] Open
Abstract
Recurrent laryngeal nerve (RLN) palsy is one of the feared complications following thyroid surgery. Intraoperative neuromonitoring (IONM) has been used as an adjunct to reduce this complication. In the present study, we attempted to evaluate the IONM parameters such as latency, current requirement, and baseline amplitude that could predict temporary RLN palsy along with factors that could influence these parameters during thyroid surgery. This was a retrospective study of patients who underwent hemi, total, or completion thyroidectomy for cancer at our institute between June 1, 2017 to May 31, 2019 in whom IONM was used during surgery. The study consisted of 84 consecutive patients with 138 nerves at risk. The RLN palsy rate in our study was 5% (n = 7). Patients with low baseline amplitude and/or requiring higher current to maintain normal baseline amplitude were often associated with temporary RLN palsy. In the multivariate analysis, age > 40 years (p = 0.001, OR = 4.14) influenced the baseline EMG amplitude the most. The intraoperative current management was influenced by advanced pT stage (p = 0.001, OR = 2.87), and structural nerve injury (p = 0.001, OR = 3.15). Patients with low baseline amplitude and/or requiring higher current to maintain normal baseline amplitude were often associated with temporary RLN palsy. Factors such as age, pT stage, and structural nerve injury influenced the IONM stimulation and recording parameters.
Collapse
|
5
|
Can we routinely identify the external branch of the superior laryngeal nerves with neural monitoring?: a prospective report on 176 consecutive nerves at risk. Updates Surg 2021; 73:2275-2281. [PMID: 34041716 PMCID: PMC8606392 DOI: 10.1007/s13304-021-01084-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/05/2021] [Indexed: 01/15/2023]
Abstract
The external branch of the superior laryngeal nerve (EBSLN) provides motor function to the cricothyroid muscle (CTM). EBSLN damage produces changes in voice quality and projection. Intraoperative neuromonitoring (IONM) in thyroid surgery aims to optimize EBSLN control during dissection. We prospectively collected the data of 88 consecutive patients who underwent total thyroidectomy with IONM from July 2019 to December 2019. IONM was offered in the intermittent mode of application. We routinely searched for the EBSLN electromyographic (EMG) signal before (S1) and after (S2) dissection of the superior vascular peduncle. In the absence of the EMG signal, we observed the CTM twitch. We identified 141 (80%) S1 EMG signals, while we recorded the CTM twitch in 15 cases (8.5%). In 20 (11.3%) cases, we were unable to identify the EMG signal. Analysing the S2 results, we found loss of EBSLN signal in 11/141 cases (7.8%) identified with IONM in pre-dissection stimulation. Among the 20 cases without pre-dissection identification (we had not identified the external branch of the superior laryngeal nerve or the muscle twitch), in the post-dissection evaluation, we confirmed the loss of signal in 17 of 20 cases, equal to 85% (p < 0.001). Our data clearly show that intraoperative stimulation and recognition of EBSLN, performed before any dissection manoeuvre to the superior vascular thyroid pole, leads to a much higher rate of nerve conservation.
Collapse
|
6
|
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]
|
7
|
Scharpf J, Liu JC, Sinclair C, Singer M, Liddy W, Orloff L, Steward D, Bonilla Velez J, Randolph GW. Critical Review and Consensus Statement for Neural Monitoring in Otolaryngologic Head, Neck, and Endocrine Surgery. Otolaryngol Head Neck Surg 2021; 166:233-248. [PMID: 34000898 DOI: 10.1177/01945998211011062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Enhancing patient outcomes in an array of surgical procedures in the head and neck requires the maintenance of complex regional functions through the protection of cranial nerve integrity. This review and consensus statement cover the scope of cranial nerve monitoring of all cranial nerves that are of practical importance in head, neck, and endocrine surgery except for cranial nerves VII and VIII within the temporal bone. Complete and applied understanding of neurophysiologic principles facilitates the surgeon's ability to monitor the at-risk nerve. METHODS The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) identified the need for a consensus statement on cranial nerve monitoring. An AAO-HNS task force was created through soliciting experts on the subject. Relevant domains were identified, including residency education, neurophysiology, application, and various techniques for monitoring pertinent cranial nerves. A document was generated to incorporate and consolidate these domains. The panel used a modified Delphi method for consensus generation. RESULTS Consensus was achieved in the domains of education needs and anesthesia considerations, as well as setup, troubleshooting, and documentation. Specific cranial nerve monitoring was evaluated and reached consensus for all cranial nerves in statement 4 with the exception of the spinal accessory nerve. Although the spinal accessory nerve's value can never be marginalized, the task force did not feel that the existing literature was as robust to support a recommendation of routine monitoring of this nerve. In contrast, there is robust supporting literature cited and consensus for routine monitoring in certain procedures, such as thyroid surgery, to optimize patient outcomes. CONCLUSIONS The AAO-HNS Cranial Nerve Monitoring Task Force has provided a state-of-the-art review in neural monitoring in otolaryngologic head, neck, and endocrine surgery. The evidence-based review was complemented by consensus statements utilizing a modified Delphi method to prioritize key statements to enhance patient outcomes in an array of surgical procedures in the head and neck. A precise definition of what actually constitutes intraoperative nerve monitoring and its benefits have been provided.
Collapse
Affiliation(s)
- Joseph Scharpf
- Cleveland Clinic Foundation Head and Neck Institute, Cleveland, Ohio, USA
| | - Jeffrey C Liu
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | | | | | | | - Lisa Orloff
- Stanford University, Palo Alto, California, USA
| | | | | | | |
Collapse
|
8
|
Iwata AJ, Liddy W, Barczyński M, Wu CW, Huang TY, Van Slycke S, Schneider R, Dionigi G, Dralle H, Cernea CR, Kamani D, Ahmed AH, Okose OC, Wang B, Randolph GW. Superior Laryngeal Nerve Signal Attenuation Influences Voice Outcomes in Thyroid Surgery. Laryngoscope 2021; 131:1436-1442. [PMID: 33521945 DOI: 10.1002/lary.29413] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/06/2021] [Accepted: 01/10/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVES/HYPOTHESIS The objective was to identify whether injury of the external branch of the superior laryngeal nerve (EBSLN) or changes in EBSLN parameters after dissection during thyroidectomies correlate with changes in voice quality postoperatively. STUDY DESIGN Prospective multicenter case series. METHODS A prospective multicenter study was conducted on patients undergoing thyroidectomies with intraoperative nerve monitoring. Electromyography waveforms of EBSLN stimulation before (S1) and after superior pole dissection (S2) were evaluated using endotracheal tube (ETT) and cricothyroid intramuscular (CTM) electrodes. Voice outcomes were assessed using Voice-Related Quality of Life Surveys and Voice Handicap Index. RESULTS A total of 131 at-risk EBSLNs were evaluated in 80 patients. Two nerves showed loss of CTM twitch coupled with an absent S2 signal response. Complete EBSLN loss of signal was more likely with: 1) Cernea EBSLN anatomic classification Type 2B; 2) with a longer distance from the sternothyroid muscle insertion site; and 3) with larger lobar volumes (P < .05). Patients who experienced a more than 50% decrement in CTM amplitudes of S2 (n = 7) by CTM electrodes had a statistically significant decline in their voice outcomes compared to those who did not (n = 69) (P < .05). CONCLUSIONS Patients experienced worse voice outcomes when at least one EBSLN response amplitude decreased by more than 50% after dissection when measured by CTM needle electrodes. CTM needle electrodes have an ability to measure finer amplitude changes compared to ETT electrodes, may represent a safe method to deduce subtle EBSLN injuries, and may serve to optimize voice outcomes during thyroidectomy. CTM needle electrodes are safe and tolerated well. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1436-1442, 2021.
Collapse
Affiliation(s)
- Ayaka J Iwata
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Whitney Liddy
- Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Che-Wei Wu
- Department of Otolaryngology - Head and Neck Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- Department of Otolaryngology - Head and Neck Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Sam Van Slycke
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Ziekenhuis Aalst, Aalst, Belgium
| | - Rick Schneider
- Department of Surgery, University Hospital Halle, Martin-Luther-University, Haller-Wittenberg, Germany
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery. Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Claudio R Cernea
- Department of Surgery, Head and Neck Surgery Service of the Hospital das Clínicas, University of Sao Paulo, Sao Paulo, Brazil
| | - Dipti Kamani
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Amr H Ahmed
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Okenwa C Okose
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Bo Wang
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.,Department of Thyroid Surgery, Fujian Medical University Union Hospital, Fujian, China
| | - Gregory W Randolph
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.,Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| |
Collapse
|
9
|
Wu CW, Randolph GW, Barczyński M, Schneider R, Chiang FY, Huang TY, Karcioglu AS, Konturek A, Frattini F, Weber F, Liu CH, Dralle H, Dionigi G. Training Courses in Laryngeal Nerve Monitoring in Thyroid and Parathyroid Surgery- The INMSG Consensus Statement. Front Endocrinol (Lausanne) 2021; 12:705346. [PMID: 34220726 PMCID: PMC8253252 DOI: 10.3389/fendo.2021.705346] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/26/2021] [Indexed: 01/04/2023] Open
Abstract
Intraoperative neural monitoring (IONM) is now an integral aspect of thyroid surgery in many centers. Interest in IONM and the number of institutions that perform monitored thyroidectomies have increased throughout the world in recent years. For surgeons considering the introduction of IONM in their practice, specific training in IONM devices and procedures can substantially shorten the learning curve. The International Neural Monitoring Study Group (INMSG) has been at the forefront of IONM technology and procedural adoption since the introduction of neural monitoring in thyroid and parathyroid surgery. The purpose of this document is to define the INMSG consensus on essential elements of IONM training courses. Specifically, this document describes the minimum training required for teaching practical application of IONM and consensus views on key issues that must be addressed for the safe and reliable introduction of IONM in surgical practice. The intent of this publication is to provide societies, course directors, teaching institutions, and national organizations with a practical reference for developing IONM training programs. With these guidelines, IONM will be implemented optimally, to the ultimate benefit of the thyroid and parathyroid surgical patients.
Collapse
Affiliation(s)
- Che-Wei Wu
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gregory W. Randolph
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Rick Schneider
- Department of Surgery, University Hospital Halle, Martin-Luther-University, Halle-Wittenberg, Germany
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Amanda Silver Karcioglu
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States
| | - Aleksander Konturek
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Francesco Frattini
- Department of Surgery, Ospedale di Circolo, ASST Settelaghi, Varese, Italy
| | - Frank Weber
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Cheng-Hsin Liu
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Gianlorenzo Dionigi
- Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Messina, Italy
- *Correspondence: Gianlorenzo Dionigi,
| |
Collapse
|
10
|
Wu CW, Huang TY, Randolph GW, Barczyński M, Schneider R, Chiang FY, Silver Karcioglu A, Wojtczak B, Frattini F, Gualniera P, Sun H, Weber F, Angelos P, Dralle H, Dionigi G. Informed Consent for Intraoperative Neural Monitoring in Thyroid and Parathyroid Surgery - Consensus Statement of the International Neural Monitoring Study Group. Front Endocrinol (Lausanne) 2021; 12:795281. [PMID: 34950109 PMCID: PMC8689131 DOI: 10.3389/fendo.2021.795281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
In the past decade, the use of intraoperative neural monitoring (IONM) in thyroid and parathyroid surgery has been widely accepted by surgeons as a useful technology for improving laryngeal nerve identification and voice outcomes, facilitating neurophysiological research, educating and training surgeons, and reducing surgical complications and malpractice litigation. Informing patients about IONM is not only good practice and helpful in promoting the efficient use of IONM resources but is indispensable for effective shared decision making between the patient and surgeon. The International Neural Monitoring Study Group (INMSG) feels complete discussion of IONM in the preoperative planning and patient consent process is important in all patients undergoing thyroid and parathyroid surgery. The purpose of this publication is to evaluate the impact of IONM on the informed consent process before thyroid and parathyroid surgery and to review the current INMSG consensus on evidence-based consent. The objective of this consensus statement, which outlines general and specific considerations as well as recommended criteria for informed consent for the use of IONM, is to assist surgeons and patients in the processes of informed consent and shared decision making before thyroid and parathyroid surgery.
Collapse
Affiliation(s)
- Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gregory W. Randolph
- Department of Otolaryngology, Harvard Medical School, Boston, MA, United States
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Rick Schneider
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle, Martin-Luther-University, Halle-Wittenberg, Germany
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | | | - Beata Wojtczak
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Francesco Frattini
- Department of Surgery, Ospedale di Circolo, ASST, Settelaghi, Varese, Italy
| | - Patrizia Gualniera
- Forensics Division, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Frank Weber
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Peter Angelos
- Department of Surgery and MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL, United States
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Gianlorenzo Dionigi
- Division of Surgery, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- *Correspondence: Gianlorenzo Dionigi,
| |
Collapse
|
11
|
Cossa A, Castagnola G, Romeo G, Bellucci M, Nigri G, Bellotti C. Utility of intraoperative neuromonitoring in detecting recurrent nerve's anatomical anomalies during thyroidectomy. Endocrine 2020; 70:194-197. [PMID: 32430794 DOI: 10.1007/s12020-020-02345-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022]
Abstract
Anatomical variations such as a non-recurrent laryngeal nerve (NRLN) are very rare (reported rates within 0.6-1% to the right side and only four cases to the left side) but they can lead to serious risk of nerve lesion during thyroidectomy. It is known that to prevent inferior laryngeal nerve lesions, it is mandatory to obtain a correct and wide exposure of the nerve during all kind of thyroid surgeries but in case of laryngeal nerve position anomalies, it is hard to achieve a safe nerve identification. Continuous intraoperative neuromonitoring (C-IONM) technology can detect the presence of NRLN. In this study we present seven cases of NRLN incidentally found during our last 10-year experience, in a total of 1074 procedures, including total thyroidectomy and lobectomy. Three out of seven cases were identified with the help of C-IONM. On the other hand, the other four cases of non-recurrent laryngeal nerve were identified during an extensive dissection of the thyroid lodge. We registered no nerve palsy in the group of patients who underwent surgery with the help of C-IONM, while we had two nerve palsies (out of four cases) in the group of patients without the help of C-IONM. In our experience we also registered a reduction of surgery time when we used the C-IONM. In our opinion C-IONM is a safe method to discover anatomical anomalies such as a non-recurrent laryngeal nerve and may help to reduce nerve palsy rate.
Collapse
Affiliation(s)
- Alessandra Cossa
- Facolta di Farmacia e Medicina, Universita degli Studi di Roma La Sapienza, Roma, RM, Italy.
| | - Giorgio Castagnola
- Facolta di Farmacia e Medicina, Universita degli Studi di Roma La Sapienza, Roma, RM, Italy
| | - Gherardo Romeo
- Facolta di Farmacia e Medicina, Universita degli Studi di Roma La Sapienza, Roma, RM, Italy
| | - Marco Bellucci
- Facolta di Farmacia e Medicina, Universita degli Studi di Roma La Sapienza, Roma, RM, Italy
| | - Giuseppe Nigri
- Facolta di Farmacia e Medicina, Universita degli Studi di Roma La Sapienza, Roma, RM, Italy
| | - Carlo Bellotti
- Facolta di Farmacia e Medicina, Universita degli Studi di Roma La Sapienza, Roma, RM, Italy
| |
Collapse
|
12
|
Ji YB, Jeong JH, Wu CW, Chiang FY, Tae K. Neural Monitoring of the External Branch of the Superior Laryngeal Nerve During Transoral Thyroidectomy. Laryngoscope 2020; 131:E671-E676. [PMID: 32820531 DOI: 10.1002/lary.28883] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/24/2020] [Accepted: 06/03/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS There is no study regarding intraoperative neural monitoring (IONM) of the external branch of the superior laryngeal nerve (EBSLN) during transoral thyroidectomy. The objective of this study was to evaluate the feasibility and success rate of electrical identification of the EBSLN during transoral robotic or endoscopic thyroidectomy. STUDY DESIGN Case series study. METHODS We studied a cohort of 76 patients (87 nerves at risk, (NARs)) who underwent transoral robotic or endoscopic thyroidectomy and simultaneous intermittent IONM between July 2017 and May 2019. We performed the standard IONM procedure plus routine neural monitoring of the EBSLN. IONM and surgical outcome data were prospectively collected. RESULTS Sixty-one patients underwent the robotic procedure, and 15 patients underwent the endoscopic procedure. Thirty-seven external branches of the superior laryngeal nerves at risk (42.5%) were electrically identified using electromyography signals (31 NARs, 35.6%) or cricothyroid muscle twitches (6 NARs, 6.9%). The mean pre-(S1) and post-dissection (S2) amplitudes of the EBSLN were 372 ± 147 and 351 ± 159 μV, respectively. The identification rates were not different between the robotic and endoscopic procedures. In comparing the early 20 NARs (18 patients) and the later 67 NARs (58 patients), the identification rate was higher in the later cases, although the difference was not statistically significant (25.0% vs. 47.8%, P = .079). CONCLUSION IONM of the EBSLN is feasible and useful in identifying and preserving the nerve during transoral thyroidectomy, although the identification rate of the nerve is relatively low. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E671-E676, 2021.
Collapse
Affiliation(s)
- Yong Bae Ji
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Jin Hyeok Jeong
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, I-Shou University, School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Kyung Tae
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| |
Collapse
|
13
|
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]
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Huang TY, Yu WHV, Chiang FY, Wu CW. Regarding: Cricothyroid muscle twitch could be a preventive tool for EBSLN injury in thyroid surgery. Laryngoscope 2019; 129:E263. [PMID: 31046148 DOI: 10.1002/lary.28033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 03/25/2019] [Indexed: 01/15/2023]
Affiliation(s)
- Tzu-Yen Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wing-Hei Viola Yu
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital and Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| |
Collapse
|
16
|
Sung ES, Chang JH, Kim J, Cha W. In Response to Letter to the Editor Regarding: Is Cricothyroid Muscle Twitch Predictive of the Integrity of the EBSLN in Thyroid Surgery? Laryngoscope 2019; 129:E264. [PMID: 31046150 DOI: 10.1002/lary.28032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/11/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Eui-Suk Sung
- Department of Otorhinolaryngology-Head and Neck Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Jae Hyeok Chang
- Department of Rehabilitation Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Jia Kim
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Wonjae Cha
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| |
Collapse
|
17
|
Liddy W, Lawson BR, Barber SR, Kamani D, Shama M, Soylu S, Wu CW, Chiang FY, Scharpf J, Barczynski M, Dralle H, Van Slycke S, Schneider R, Dionigi G, Randolph GW. Anterior laryngeal electrodes for recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: New expanded options for neural monitoring. Laryngoscope 2018; 128:2910-2915. [PMID: 30417384 DOI: 10.1002/lary.27362] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 05/25/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Intraoperative neural monitoring is a useful adjunct for the laryngeal nerve function assessment during thyroid and parathyroid surgery. Typically, monitoring is performed by measurement of electromyographic responses recorded by endotracheal tube (ETT) surface electrodes. Tube position alterations during surgery can cause displacement of the electrodes relative to the vocal cords, leading to false positive loss of signal. Numerous reports have denoted monitoring equipment-related issues, especially endotracheal tube displacement, as the dominant source of false positive error. The false positive error may result in inappropriate decisions by the surgeon. This study tests the hypothesis that anterior laryngeal electrodes (ALEs) can help reduce this error. Placement of ALEs directly onto the thyroid cartilage represent an adjunctive and possible alternative method to standard ETT surface electrodes. STUDY DESIGN Retrospective review. METHODS Fifteen consecutive patients undergoing thyroid and parathyroid surgery with intraoperative neuromonitoring using both ETT electrodes and ALEs were studied. Data collected included site of neural stimulation, laterality, and electromyographic parameters. RESULTS With vagal and recurrent laryngeal nerve stimulation, the ALEs recorded mean vocalis muscle waveform amplitude within 83% of that recorded with standard ETT electrodes. The latency measurements with the anterior laryngeal and endotracheal electrodes were similar, with both electrodes recording significantly longer latency for the left vagus nerve as compared to the right vagus nerve. With superior laryngeal nerve stimulation, the ALEs recorded a 800% greater mean amplitude than the ETT electrodes. The ALEs demonstrated similar sensitivity to stimulation at low current as ETT electrodes and provided stable intraoperative monitoring information. CONCLUSIONS Compared to ETT surface electrodes, the ALEs provide similar and stable electromyographic responses with equal sensitivity for recording evoked responses during neural monitoring in thyroid and parathyroid surgery. The ALEs offer significantly more robust monitoring of the external branch of the superior laryngeal nerve. Furthermore, ALEs are contained within the operative field, are totally surgeon controlled, and are unaffected by the potential vicissitudes of ETT position during surgery. LEVEL OF EVIDENCE 4 Laryngoscope, 128:2910-2915, 2018.
Collapse
Affiliation(s)
- Whitney Liddy
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Bradley R Lawson
- Department of Otolaryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Samuel R Barber
- Department of Otolaryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Dipti Kamani
- Department of Otolaryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mohamed Shama
- Department of Otolaryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Selen Soylu
- Department of Otolaryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Che Wei Wu
- Department of Otorhinolaryngology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Joseph Scharpf
- Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Marcin Barczynski
- Department of Endocrine Surgery, Jagiellonian University Medical College, Third Chair of General Surgery, Krakow, Poland
| | - Henning Dralle
- Department of General Surgery, University Hospital Halle, Halle/Saale, Germany
| | | | - Rick Schneider
- Department of General, Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Gianlorenzo Dionigi
- Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Gregory W Randolph
- Department of Otolaryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A.,Division of Surgical Oncology, Endocrine Surgery Service, Department of Surgery, Massachusetts General Hospital, Division of Surgical Oncology, Endocrine Surgery Service, Boston, Massachusetts, U.S.A
| |
Collapse
|
18
|
Wu CW, Chiang FY, Randolph GW, Dionigi G, Kim HY, Lin YC, Chen HC, Chen HY, Kamani D, Tsai TY, Lu IC, Chang PY. Feasibility of Intraoperative Neuromonitoring During Thyroid Surgery Using Transcartilage Surface Recording Electrodes. Thyroid 2018; 28:1508-1516. [PMID: 30255736 DOI: 10.1089/thy.2017.0680] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Intraoperative neural monitoring (IONM) has gained widespread acceptance as an adjunct to the gold standard of visual identification of the recurrent laryngeal nerve (RLN) during thyroid surgery. Currently, laryngeal electromyography (EMG) recording during IONM is almost always performed using endotracheal tube (ETT) surface electrodes placed adjacent to vocal folds originating from the inner surface of the thyroid cartilage (TC). Therefore, it was hypothesized that surface recording electrodes placed on the outer surface of the TC should enable access to the EMG response of the vocal folds during IONM. The aim of this experimental study was to evaluate the feasibility of the transcartilage approach for laryngeal EMG recording during IONM. METHODS A porcine model (12 pigs and 24 RLN sides) with well established applicability in IONM research was used for the experiments. Both ETT electrodes adjacent to vocal folds and adhesive pre-gelled electrodes on the TC were used for EMG recording during IONM. Electrically evoked EMG signals detected by both electrode types were recorded and analyzed. EMG changes during tracheal displacement and RLN traction injury were compared. RESULTS Both the ETT and TC recording electrodes recorded typical laryngeal EMG waveforms evoked by a 1 mA stimulus current applied on both sides of the RLNs and vagus nerves (VNs). Under RLN stimulation, the mean EMG amplitudes recorded with the ETT and TC electrodes were 973 ± 79 μV and 695 ± 150 μV, respectively. Under VN stimulation, the mean amplitudes were 841 ± 163 μV and 607 ± 162 μV, respectively. When upward displacement of the trachea was experimentally induced, the TC electrodes showed less variation in recorded EMG signals compared to ETT electrodes. When RLN traction stress was experimentally induced, both the ETT and TC electrodes accurately recorded the typical EMG pattern of progressively degrading amplitude and gradual recovery after release of traction. CONCLUSIONS This study confirms the feasibility of using transcartilage surface electrodes for recording laryngeal EMG signals evoked during IONM in an animal model. However, before practical application of this approach in clinical thyroid surgery, further studies are needed to improve electrode designs by optimizing their shapes and sizes, and increasing their adhesive stability and sensitivity.
Collapse
Affiliation(s)
- Che-Wei Wu
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Gregory W Randolph
- 2 Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School , Boston, Massachusetts
- 3 Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital , Harvard Medical School, Boston, Massachusetts
| | - Gianlorenzo Dionigi
- 4 Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi," University Hospital G. Martino, University of Messina , Sicily, Italy
| | - Hoon Yub Kim
- 5 Department of Surgery, Korea University College of Medicine , Seoul, Korea
| | - Yi-Chu Lin
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Hui-Chun Chen
- 6 Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Hsiu-Ya Chen
- 7 Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Dipti Kamani
- 2 Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School , Boston, Massachusetts
| | - Tsung-Yi Tsai
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - I-Cheng Lu
- 7 Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Pi-Ying Chang
- 7 Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| |
Collapse
|
19
|
Abstract
Introduction Anatomical studies on human cadavers have established anastomoses between laryngeal nerves. However, we need to functionally identify motor communication via these anastomoses between the recurrent laryngeal nerve (RLN) and the external branch of the superior laryngeal nerve (EBSLN) in living bodies. We aim to establish motor interconnections using intraoperative nerve monitoring (IONM). Methods IONM of 112 EBSLNs and RLNs in 62 thyroidectomy cases was used to establish motor functions of laryngeal nerves. Electrophysiological parameters were recorded, and cricothyroid muscle (CTM) contraction was observed after stimulation of laryngeal nerves. Results Eighty (71.4%) EBSLNs were visually identified, and 109 (97.3%) EBSLNs were functionally identified with CTM contraction. Stimulation of 74 (67.9%) EBSLNs induced contraction of laryngeal muscles and generated wave amplitude from intrinsic laryngeal musculature. The stimulation of the RLN induced CTM contraction in 65 (58%) of the 112 muscles. The mean conductivity powers of the EBSLN and of the RLN to intrinsic laryngeal musculature were calculated as 231.3 µV and 1354.5 µV, respectively. Conclusion Recordable waveform amplitude with EBSLN stimulation yielded motor relations between laryngeal nerves. CTM contraction after stimulation of the RLN confirmed these relations. These results of IONM established motor interconnections between superior and inferior laryngeal nerves in the majority of patients. The EBSLN may have an effect on motor innervations for intrinsic laryngeal muscles via motor interconnections.
Collapse
Affiliation(s)
- Emin Gurleyik
- Department of Surgery, Duzce University Medical Faculty
| |
Collapse
|
20
|
Périé S, Santini J, Kim H, Dralle H, Randolph G. International consensus (ICON) on comprehensive management of the laryngeal nerves risks during thyroid surgery. Eur Ann Otorhinolaryngol Head Neck Dis 2018; 135:S7-S10. [DOI: 10.1016/j.anorl.2017.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 11/20/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022]
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
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.
Collapse
Affiliation(s)
- Emin Gurleyik
- a Department of Surgery , Duzce University, Medical Faculty , Duzce
| | - Gunay Gurleyik
- b Department of Surgery , Haydarpasa Numune Hospital , Istanbul , Turkey
| |
Collapse
|
23
|
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]
|
24
|
Dionigi G, Kim HY, Wu CW, Lavazza M, Materazzi G, Lombardi CP, Anuwong A, Tufano RP. Neuromonitoring in endoscopic and robotic thyroidectomy. Updates Surg 2017; 69:171-179. [DOI: 10.1007/s13304-017-0442-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 04/01/2017] [Indexed: 12/01/2022]
|
25
|
Liddy W, Barber SR, Lin BM, Kamani D, Kyriazidis N, Lawson B, Randolph GW. Monitoring of the posterior cricoarytenoid muscle represents another option for neural monitoring during thyroid surgery: Normative vagal and recurrent laryngeal nerve posterior cricoarytenoid muscle electromyographic data. Laryngoscope 2017; 128:283-289. [DOI: 10.1002/lary.26456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/10/2016] [Accepted: 11/15/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Whitney Liddy
- Division of Thyroid and Parathyroid Endocrine Surgery; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
- Department of Otology and Laryngology, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
| | - Samuel R. Barber
- Division of Thyroid and Parathyroid Endocrine Surgery; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
| | - Brian M. Lin
- Division of Thyroid and Parathyroid Endocrine Surgery; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
- Department of Otology and Laryngology, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Endocrine Surgery; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
- Department of Otology and Laryngology, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
| | - Natalia Kyriazidis
- Division of Thyroid and Parathyroid Endocrine Surgery; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
| | - Bradley Lawson
- Division of Thyroid and Parathyroid Endocrine Surgery; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
- Department of Otology and Laryngology, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
- Department of Otology and Laryngology, Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
- Division of Surgical Oncology Endocrine Surgical Service; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
| |
Collapse
|
26
|
Barber SR, Liddy W, Kyriazidis N, Cinquepalmi M, Lin BM, Modi R, Patricio S, Kamani D, Belotti C, Mahamad S, Lawson B, Randolph GW. Changes in electromyographic amplitudes but not latencies occur with endotracheal tube malpositioning during intraoperative monitoring for thyroid surgery: Implications for guidelines. Laryngoscope 2016; 127:2182-2188. [DOI: 10.1002/lary.26392] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 08/26/2016] [Accepted: 09/22/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Samuel R. Barber
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Whitney Liddy
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Natalia Kyriazidis
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Matteo Cinquepalmi
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Operative Unit Surgery of Thyroid and Parathyroid; Sapienza University of Rome, Sant'Andrea Hospital; Rome Italy
| | - Brian M. Lin
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Rahul Modi
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Stephanie Patricio
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Carlo Belotti
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Operative Unit Surgery of Thyroid and Parathyroid; Sapienza University of Rome, Sant'Andrea Hospital; Rome Italy
| | - Sadhana Mahamad
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Bradley Lawson
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| |
Collapse
|