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Schweitzer CL, Garcha I, Wiseman SM. Quality improvement lessons from Canadian thyroid and parathyroid surgery legal decisions. Am J Surg 2024; 235:115747. [PMID: 38734539 DOI: 10.1016/j.amjsurg.2024.04.018] [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: 11/14/2023] [Revised: 02/13/2024] [Accepted: 04/13/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND This is the first study of Canadian thyroid and parathyroid surgery legal decisions, and the first study of surgical malpractice using the Canadian Legal Information Institute (CanLII) database. The objective was to identify quality improvement opportunities in surgical practice, to increase patient safety and satisfaction. METHODS Legal decisions relating to thyroid and parathyroid surgery in the CanLII database were screened. Cases were included if a surgeon was listed as applicant or respondent; they related to pre-, intra-, or post-operative management of thyroid or parathyroid disease; and malpractice was alleged. Cases were excluded if surgery was mentioned incidentally or for non-surgical focus. RESULTS Of the 347 unique legal decisions screened, 14 met inclusion and exclusion criteria. Surgeries occurred between 1976 and 2012, with 13 thyroid surgeries, 1 parathyroidectomy, and 4 mortalities. CONCLUSIONS Quality improvement lessons include communication, pre-operative patient education and documentation of risks discussed, and in-person assessment of complications.
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Affiliation(s)
- Christina L Schweitzer
- University of British Columbia and St. Paul's Hospital, Department of Surgery, C303-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Ivneet Garcha
- Queen's University School of Medicine, 80 Barrie Street, Queen's University, Kingston, Ontario, K7L 3N6, Canada
| | - Sam M Wiseman
- University of British Columbia and St. Paul's Hospital, Department of Surgery, C303-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada.
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Karcioglu AS, Trinh LN, Mcllroy D, Okose OC, Wang B, Behr IJ, Cheung AY, Srikanthan A, Russell MD, Kamani D, Abdelhamid Ahmed AH, Randolph GW. Noninvasive monitoring of the vagus nerve during thyroid surgery using cutaneous adhesive and needle electrodes: What is the optimal configuration? Head Neck 2024; 46:1893-1901. [PMID: 38294128 DOI: 10.1002/hed.27669] [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: 04/01/2023] [Revised: 12/16/2023] [Accepted: 01/21/2024] [Indexed: 02/01/2024] Open
Abstract
OBJECTIVE Endotracheal tube (ETT) surface electrodes are used to monitor the vagus nerve (VN), recurrent laryngeal nerve (RLN), and external branch of the superior laryngeal nerve (EBSLN) during thyroid and parathyroid surgery. Alternative nerve monitoring methods are desirable when intubation under general anesthesia is not desirable or possible. In this pilot study, we compared the performance of standard ETT electrodes to four different noninvasive cutaneous recording electrode types (two adhesive electrodes and two needle electrodes) in three different orientations. METHODS The VN was stimulated directly during thyroid and parathyroid surgery using a Prass stimulator probe. Electromyographic (EMG) responses for each patient were recorded using an ETT plus one of the following four cutaneous electrode types: large-foot adhesive, small-foot adhesive, long-needle and short-needle. Each of the four electrode types was placed in three orientations: (1) bilateral, (2) ipsilateral mediolateral, and (3) ipsilateral craniocaudal. RESULTS Four surgical cases were utilized for data collection with the repetitive measures obtained in each subject. Bilateral electrode orientation was superior to ipsilateral craniocaudal and ipsilateral mediolateral orientations. Regardless of electrodes type, all amplitudes in the bilateral orientation were >100 μV. When placed bilaterally, the small-foot adhesive and the long-needle electrodes obtained the highest EMG amplitudes as a percentage of ETT amplitudes. CONCLUSION Cutaneous electrodes could potentially be used to monitor the VN during thyroid and parathyroid procedures. Different electrode types vary in their ability to record amplitudes and latencies. Bilateral orientation improves EMG responses in all electrode types. Additional validation of cutaneous electrodes as an alternative noninvasive method to monitor the VN is needed.
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Affiliation(s)
- Amanda Silver Karcioglu
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Lily N Trinh
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Dioan Mcllroy
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Okenwa C Okose
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Bo Wang
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
- Department of Thyroid Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ian J Behr
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony Y Cheung
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Adithya Srikanthan
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Marika D Russell
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Amr H Abdelhamid Ahmed
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Huang BL, Carneiro-Pla D. Intraoperative Adjuncts in Thyroid Surgery. Surg Clin North Am 2024; 104:767-777. [PMID: 38944497 DOI: 10.1016/j.suc.2024.02.006] [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] [Indexed: 07/01/2024]
Abstract
Thyroidectomy is relatively safe and often can be done as a minimally invasive procedure. Although they may be associated with a learning curve, thoughtful use of intraoperative adjuncts such as energy devices, recurrent laryngeal nerve monitoring, and parathyroid autofluorescence have the potential to make incremental improvements in the safety and efficiency of thyroid surgery. Perhaps many of these adjuncts may be of greatest benefit when used routinely by less experienced surgeons or selectively in higher-risk operations, although their adoption in practice continues to increase overall.
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Affiliation(s)
- Bernice Liying Huang
- Section of Endocrine Surgery, Division of Surgical Oncology, Department of Surgery at the Medical University of South Carolina, 30 Courtenay Drive, Suite 240, MSC 295, Charleston, SC 29425, USA
| | - Denise Carneiro-Pla
- Section of Endocrine Surgery, Division of Surgical Oncology, Department of Surgery at the Medical University of South Carolina, 30 Courtenay Drive, Suite 240, MSC 295, Charleston, SC 29425, USA.
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Durán Poveda M, Martos Martínez JM, Vidal Pérez O, Gluckmann Maldonado E, Quintana De la Basarrate A, Villar Del Moral J, Rodríguez-Caravaca G. Patterns and indications of intraoperative nerve monitoring usage during thyroidectomy and parathyroidectomy in Spain: results of a national survey of endocrine surgeons. Sci Rep 2024; 14:17680. [PMID: 39085408 PMCID: PMC11291499 DOI: 10.1038/s41598-024-68230-z] [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: 01/03/2024] [Accepted: 07/22/2024] [Indexed: 08/02/2024] Open
Abstract
We investigated the use patterns and indications of intraoperative neural monitoring (IONM) among endocrine surgeons in Spain. We sent an anonymous web-based survey to endocrine surgeons' members of the Spanish Association of Surgery by email. We analysed 79/ 269 surveys. Respondents had a median age of 52 years and 13 years of surgical experience. Only 32% of respondents performed routinely preoperative laryngoscopy in all thyroidectomies and 19% in all parathyroidectomies. Seventy-five percent of respondents used the intermittent-IONM, and 9.7% used the continuous-IONM. All respondents identified recurrent laryngeal nerve during surgery, and 40% of surgeons routinely identified external branch superior laryngeal nerve (EBSLN) during thyroidectomy. Seventy-eight percent of respondents used IONM always for all thyroidectomies. Only 11% stimulated EBSLN in all cases. Forty-nine percent used IONM always for all parathyroidectomies. The most frequent reasons for not using IONM were the unavailability of IONM, the high cost, and the lack of adding value to their clinical practice. Almost 10% declared not having IONM. The IONM is a reality in Spain, especially the intermittent mode. Its use is superior in thyroid surgery than in parathyroid. Its standardized use is not yet fully established, and routine adherence to standardized guidelines should increase.
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Affiliation(s)
- Manuel Durán Poveda
- Departamento de Cirugía General y del Aparato Digestivo, Hospital Universitario Rey Juan Carlos, Calle Gladiolo s/n, 28933, Móstoles, Madrid, Spain.
- Departamento de Especialidades Médicas y Salud Pública, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.
| | - Juan Manuel Martos Martínez
- Departamento de Cirugía General, Hospital Universitario Virgen del Rocío, Sevilla, Spain
- Departamento de Cirugía, Universidad de Sevilla, Sevilla, Spain
| | - Oscar Vidal Pérez
- Departamento de Cirugía General, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Departamento de Cirurgia y Especialidades Medicoquirúrgicas, Universidad de Barcelona, Barcelona, Spain
| | | | - Aitor Quintana De la Basarrate
- Departamento de Cirugía General, Hospital de Cruces, Barakaldo, Bizkaia, Spain
- Departamento Cirugía, Radiología y Medicina Física, Universidad del País Vasco, Leioa, Vizcaya, Spain
| | - Jesús Villar Del Moral
- Departamento de Cirugía General, Hospital Virgen de Las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
- Departamento de Cirugía, Universidad de Granada, Granada, Spain
| | - Gil Rodríguez-Caravaca
- Departamento de Especialidades Médicas y Salud Pública, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
- Unidad de Medicina Preventiva, Hospital Universitario Fundación Alcorcón, Madrid, Spain
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Velayutham P, Thiagarajan S, Dhar H, Chidambaranathan N, Vaidya A, Teja K. A Nationwide Survey to Assess the Practices and Patterns of Use of Intraoperative Nerve Monitoring During Thyroid Surgery Among Surgeons in India. Indian J Surg Oncol 2024; 15:18-24. [PMID: 38511027 PMCID: PMC10948657 DOI: 10.1007/s13193-023-01818-5] [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: 07/02/2023] [Accepted: 09/06/2023] [Indexed: 03/22/2024] Open
Abstract
There is still equipoise for the routine use of intraoperative nerve monitoring (IONM) for thyroid surgeries; however, some surgeons tend to use it for various reasons. In our study, we did a national survey to assess the patterns and practice of the use of IONM among surgeons during thyroid surgery in India. A questionnaire survey was sent to surgeons (head and neck surgical oncologists, general surgical oncologists, endocrine surgeons and otolaryngologists) in different zones in India via email, and their responses were analysed. One hundred and one responses were received. The majority of the respondents were head and neck surgical oncologists (n = 56, 55.4%). Forty-three (42.6%) respondents used IONM during thyroid surgeries in this survey. Surgeons with ≤ 15 years of experience performing thyroid surgeries (p = 0.02) and surgeons performing > 50 thyroid surgeries also tended to use IONM. Mostly IONM was used for surgeries on thyroid malignancies (p = 0.016). The respondents used IONM for more than one reason such as medicolegal purposes and surgeon comfort among others. IONM was most often used during redo surgeries (n = 46, 45.5%) and in patients with already one fixed cord (n = 39, 38.6%). The majority felt IONM was not cost-effective (n = 53, 52.5%). The use of IONM during thyroid surgery in our survey was nearly 43%. It was used mostly for surgery for thyroid malignancies, and it was found to be used for more than one reason and indications such as redo surgeries (most commonly). Supplementary Information The online version contains supplementary material available at 10.1007/s13193-023-01818-5.
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Affiliation(s)
- Parthiban Velayutham
- Department of Neurosurgery, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra India
| | - Shivakumar Thiagarajan
- Department of Head & Neck Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra 400012 India
| | - Harsh Dhar
- Medica Super Speciality Hospital, Kolkata, Mumbai, India
| | | | - Abhishek Vaidya
- National Cancer Institute, Nagpur, Maharashtra India
- NKPSIMS, Nagpur, Maharashtra India
| | - Kantamani Teja
- Department of Head & Neck Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra 400012 India
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Peckham M, Rose T, King D, Moreno M, Stack BC, Vural E. Subjective Voice Outcomes in Surgeon Versus Technician-Monitored Recurrent Laryngeal Nerves in Thyroidectomy. EAR, NOSE & THROAT JOURNAL 2024; 103:105-109. [PMID: 34427116 DOI: 10.1177/01455613211037635] [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] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To compare subjective voice outcomes and postoperative laryngoscopic examination findings of patients with subjective voice complaints between surgeon-monitored and certified technician-monitored thyroidectomies. METHODS Patients who underwent hemithyroidectomy, total thyroidectomy, and completion thyroidectomy using a nerve monitoring system between November 2015 and June 2018 were included in the study. Retrospective chart review was carried out to assess how often patients reported voice changes and to record postoperative flexible laryngoscopic findings of patients when that examination was performed. Data were analyzed using the χ2 test to identify significant differences in outcomes for the 2 groups. RESULTS A total of 293 procedures was performed among 3 surgeons. Surgeons monitored the nerves in 147 cases and a certified technician monitored the nerves in 146 cases. Subjective voice changes were identified in 11 (7.48%) cases in the surgeon-monitored group and in 20 (13.70%) cases in the technician-monitored group (P = .084). Among the patients who expressed subjective voice changes, 7 patients were identified with vocal cord hypomobility or immobility in the surgeon-monitored group and 13 patients had an abnormal examination in the technician-monitored group (P = .234). CONCLUSIONS Subjective voice changes or proven vocal cord mobility problems were not different between surgeon-monitored patients and technician-monitored patients in thyroidectomies.
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Affiliation(s)
- Merry Peckham
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Tyler Rose
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Deanne King
- Otolaryngology-Head & Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mauricio Moreno
- Otolaryngology-Head & Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Brendan C Stack
- Otolaryngology-Head & Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Emre Vural
- Otolaryngology-Head & Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Kirke DN, Sinclair CF. Recurrent Laryngeal Nerve Monitoring: Nuts and Bolts. Otolaryngol Clin North Am 2024; 57:53-61. [PMID: 37684153 DOI: 10.1016/j.otc.2023.08.002] [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] [Indexed: 09/10/2023]
Abstract
Intraoperative neuromonitoring (IONM) of the laryngeal nerves has become an important tool for neck endocrine surgery. In this article, the authors review the current evidence behind its use in neck endocrine procedures. The subtypes of IONM, including intermittent IONM, continuous vagal IONM (vagal-CIONM), and laryngeal adductor reflex CIONM, will be discussed. Finally, the authors review recent advances in IONM, and how standardization of outcomes reporting will help minimise conjecture regarding the usefulness of IONM.
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Affiliation(s)
- Diana N Kirke
- Department of Otolaryngology - Head & Neck Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1189, Annenberg 10-40, New York, NY 10029, USA
| | - Catherine F Sinclair
- Department of Surgery, Monash University, Melbourne, Victoria, Australia; Department of Otolaryngology - Head & Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Melbourne Thyroid Surgery, 159 Wattletree Road, Malvern, Victoria 3144, Australia.
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Huang TY, Tseng HY, Frattini F, Russell MD, Ahmed AHA, Weber F, Wierzbicka P, Lu IC, Jung KY, Makay Ö, Chai YJ, Chiang FY, Schneider R, Barczyński M, Dralle H, Randolph GW, Wu CW, Dionigi G. The INMSG Survey on the Loss of Signal Management on the First Side During Planned Bilateral Thyroid Surgery. J Otolaryngol Head Neck Surg 2024; 53:19160216241265684. [PMID: 39092609 DOI: 10.1177/19160216241265684] [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] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND The aim of this study is to describe the management and associated follow-up strategies adopted by thyroid surgeons with different surgical volumes when loss of signal (LOS) occurred on the first side of planned bilateral thyroid surgery, and to further define the consensus on intraoperative neuromonitoring (IONM) applications. METHODS The International Neural Monitoring Study Group (INMSG) web-based survey was sent to 950 thyroid surgeons worldwide. The survey included information on the participants, IONM team/equipment/procedure, intraoperative/postoperative management of LOS, and management of LOS on the first side of thyroidectomy for benign and malignant disease. RESULTS Out of 950, 318 (33.5%) respondents completed the survey. Subgroup analyses were performed based on thyroid surgery volume: <50 cases/year (n = 108, 34%); 50 to 100 cases/year (n = 69, 22%); and >100 cases/year (n = 141, 44.3%). High-volume surgeons were significantly (P < .05) more likely to perform the standard procedures (L1-V1-R1-S1-S2-R2-V2-L2), to differentiate true/false LOS, and to verify the LOS lesion/injury type. When LOS occurs, most surgeons arrange otolaryngologists or speech consultation. When first-side LOS occurs, not all respondents decided to perform stage contralateral surgery, especially for malignant patients with severe disease (eg, extrathyroid invasion and poorly differentiated thyroid cancer). CONCLUSIONS Respondents felt that IONM was optimized when conducted under a collaborative team-based approach, and completed IONM standard procedures and management algorithm for LOS, especially those with high volume. In cases of first-site LOS, surgeons can determine the optimal management of disease-related, patient-related, and surgical factors. Surgeons need additional education on LOS management standards and guidelines to master their decision-making process involving the application of IONM.
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Affiliation(s)
- Tzu-Yen Huang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology, School of Post-Baccalaureate Medicine and School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology, Kaohsiung Medical University Gangshan Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Yi Tseng
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Francesco Frattini
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS (Istituto di ricovero e cura a carattere scientifico), Piazzale Brescia, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Marika D Russell
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Amr H Abdelhamid Ahmed
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Frank Weber
- Division of Endocrine Surgery, Department of General, Visceral, and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Paulina Wierzbicka
- Department of Endocrine Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kwang Yoon Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Özer Makay
- Özel Sağlık Hospital, Centre for Endocrine Surgery, Izmir, Turkey
- Aristotle University, School of Medicine, Thessaloniki, Greece
| | - Young Jun Chai
- Department of Surgery, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Rick Schneider
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University of Halle-Wittenberg, Halle (Saale), Germany
| | - Marcin Barczyński
- Department of Endocrine Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Henning Dralle
- Department of General, Visceral, and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - 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
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS (Istituto di ricovero e cura a carattere scientifico), Piazzale Brescia, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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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.
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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
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10
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Wong A, Ahsanuddin S, Teng M, Abdelhamid Ahmed AH, Randolph GW, Sinclair C. US residents experiences with intraoperative nerve monitoring in thyroid and parathyroid surgery. Head Neck 2023; 45:2009-2016. [PMID: 37293876 DOI: 10.1002/hed.27427] [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: 01/22/2023] [Revised: 04/21/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Understanding the patterns of IONM use and training among resident otolaryngologists is essential to ensure that the IONM skills and knowledge gained in residency are optimized for successful future practice of IONM. METHOD An electronic survey was distributed to US-based OHNS residents. Questions evaluated resident experience, implementation, knowledge and understanding of IONM for endocrine surgeries. RESULTS One hundred and seven OHNS residents participated, spanning all training levels and US geographic locations. The majority of residents received no didactic teaching on IONM (74.5%) nor had a clear troubleshooting algorithm in the event of a loss of signal (69.8%). The majority of residents were uncertain regarding the advantages/disadvantages of continuous versus intermittent IONM. CONCLUSION The knowledge gap found in our survey study suggests that greater teaching of IONM principles for endocrine head and neck surgeries in OHNS residency programs would help to ensure successful utilization in future practice.
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Affiliation(s)
- Anni Wong
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Salma Ahsanuddin
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Marita Teng
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amr H Abdelhamid Ahmed
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine Sinclair
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Ali KM, Wolfe SA, Nagururu NV, Seo S, Han SM, Kim Y, Oh E, Kim DY, Ning B, Lee SY, Cha RJ, Tufano RP, Russell JO. Parathyroid gland detection using an intraoperative autofluorescence handheld imager - early feasibility study. Front Endocrinol (Lausanne) 2023; 14:1190282. [PMID: 37554762 PMCID: PMC10405624 DOI: 10.3389/fendo.2023.1190282] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/30/2023] [Indexed: 08/10/2023] Open
Abstract
Introduction Parathyroid glands may be compromised during thyroid surgery which can lead to hypoparathyroidism and hypocalcemia. Identifying the parathyroid glands relies on the surgeon's experience and the only way to confirm their presence was through tissue biopsy. Near infrared autofluorescence technology offers an opportunity for real-time, non-invasive identification of the parathyroid glands. Methods We used a new research prototype (hANDY-I) developed by Optosurgical, LLC. It offers coaxial excitation light and a dual-Red Green Blue/Near Infrared sensor that guides anatomical landmarks and can aid in identification of parathyroid glands by showing a combined autofluorescence and colored image simultaneously. Results We tested the imager during 23 thyroid surgery cases, where initial clinical feasibility data showed that out of 75 parathyroid glands inspected, 71 showed strong autofluorescence signal and were correctly identified (95% accuracy) by the imager. Conclusions The hANDY-I prototype demonstrated promising results in this feasibility study by aiding in real-time visualization of the parathyroid glands. However, further testing by conducting randomized clinical trials with a bigger sample size is required to study the effect on levels of hypoparathyroidism and hypocalcemia.
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Affiliation(s)
- Khalid Mohamed Ali
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Samantha A. Wolfe
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Nimesh V. Nagururu
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Stefanie Seo
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | | | - Yoseph Kim
- Department of Research and Development, Optosurgical, LLC, Columbia, MD, United States
| | - Eugene Oh
- Department of Research and Development, Optosurgical, LLC, Columbia, MD, United States
| | - Dong-Yun Kim
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Bo Ning
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, United States
| | - Seung Yup Lee
- Department of Electrical and Computer Engineering, Kennesaw State University, Marietta, GA, United States
| | - Richard Jaepyeong Cha
- Department of Research and Development, Optosurgical, LLC, Columbia, MD, United States
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, United States
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Ralph P. Tufano
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
- Head and Neck Endocrine Surgery, Sarasota Memorial Health Care System, Sarasota, FL, United States
| | - Jonathon O. Russell
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
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12
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Najah H, Donatini G, Van Slycke S, Bizard JP, Triponez F, Sebag F. Place of laryngoscopy and neuromonitoring in thyroid surgery. Recommendations of the AFCE (Association francophone de chirurgie endocrinienne) with the SFE (Société française d'endocrinologie) and the SFMN (Société française de médecine nucléaire). J Visc Surg 2023:S1878-7886(23)00069-3. [PMID: 37210345 DOI: 10.1016/j.jviscsurg.2023.04.004] [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: 05/22/2023]
Abstract
Preoperative laryngoscopy is mandatory when there is a history of cervical or thoracic surgery, dysphonia, posteriorly developed thyroid carcinoma, or significant lymph node involvement in the central compartment. Postoperative laryngoscopy should be performed for any postoperative dysphonia, swallowing difficulties, respiratory symptoms, or loss of signal during neuromonitoring of the recurrent and/or vagus nerve. Neuromonitoring can be useful in thyroid surgery because it lowers the rate of transient recurrent palsy (RP), although no impact on permanent RP has been demonstrated. It facilitates location of the recurrent nerve. Continuous neuromonitoring of the vagus nerve can, in some situations, allow early detection of a signal drop during dissection near the recurrent nerve.
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Affiliation(s)
- Haythem Najah
- Department of Digestive and Endocrine Surgery, Haut Lévêque Hospital, University Hospital Center of Bordeaux, Bordeaux France.
| | - Gianluca Donatini
- Digestive and endocrine surgery department, University Hospital Center of Poitiers, Poitiers, France
| | - Sam Van Slycke
- Digestive and endocrine surgery department, OLV Alost, Alost, Belgium
| | | | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery, University Hospital of Genève and Faculty of Medicine, Genève, Switzerland
| | - Frédéric Sebag
- General and Endocrine Surgery Department, University Hospital of Marseille Conception, Marseille, France
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13
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Intra-operative nerve monitoring and recurrent laryngeal nerve injury during thyroid surgery: a network meta-analysis of prospective studies. Langenbecks Arch Surg 2022; 407:3209-3219. [PMID: 35953619 DOI: 10.1007/s00423-022-02651-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE Recurrent laryngeal nerve (RLN) injury is a feared complication of thyroid surgery occurring in 1-5% of cases. The present approaches to RLN preservation include RLN visualization with no nerve monitoring (No-NM), intermittent intra-operative nerve monitoring (I-IONM) and continuous intra-operative nerve monitoring (C-IONM). There is ambiguity as to which of these strategies should be the preferred method of RLN preservation. METHODS A systematic review of the PubMed, Embase and the Cochrane Collaboration databases was undertaken with network meta-analysis (NMA) performed according to the PRISMA and Cochrane Collaboration guidelines. A Bayesian NMA was conducted using R packages netmeta with outcomes expressed as odds ratios (ORs) with 95% credible intervals (CrI). Only prospective studies were included. RESULTS Eighteen studies met inclusion criteria, including 22,080 patients and 40,642 nerves at risk (NAR). Overall, 23,364 NARs (57.5%) underwent I-IONM, 17,176 (42.3%) No-NM and 98 (0.2%) underwent C-IONM. There were no significant differences between groups regarding the incidence of permanent RLN injury following thyroid surgery (I-IONM vs.No-NM, OR 0.84, 95% CrI 0.55-1.19; C-IONM vs. No-NM, OR 0.44, 95% CrI 0.02-5.00). Pooled analysis showed that IONM (I-IONM or C-IONM) demonstrated a protective effect versus No-NM in reducing the incidence of transient RLN injury (OR 0.75, 95% CI 0.59-0.97, p = 0.03). CONCLUSIONS IONM strategies did not significantly reduce the incidence of permanent RLN injury following thyroid surgery. However, the small number of C-IONM NARs limits conclusions that may be drawn. Further well-designed prospective studies will be required to definitively assess the utility of C-IONM.
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Aygun N, Kostek M, Unlu MT, Isgor A, Uludag M. Clinical and Anatomical Factors Affecting Recurrent Laryngeal Nerve Paralysis During Thyroidectomy via Intraoperative Nerve Monitorization. Front Surg 2022; 9:867948. [PMID: 35574531 PMCID: PMC9095935 DOI: 10.3389/fsurg.2022.867948] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background Despite all the technical developments in thyroidectomy and the use of intraoperative nerve monitorization (IONM), recurrent laryngeal nerve (RLN) paralysis may still occur. We aimed to evaluate the effects of anatomical variations, clinical features, and intervention type on RLN paralysis. Method The RLNs identified till the laryngeal entry point, between January 2016 and September 2021 were included in the study. The effects of RLN anatomical features considering the International RLN Anatomical Classification System, intervention and monitoring types on RLN paralysis were evaluated. Results A total of 1,412 neck sides of 871 patients (672 F, 199 M) with a mean age of 49.17 + 13.42 years (range, 18–99) were evaluated. Eighty-three nerves (5.9%) including 78 nerves with transient (5.5%) and 5 (0.4%) with permanent vocal cord paralysis (VCP) were detected. The factors that may increase the risk of VCP were evaluated with binary logistic regression analysis. While the secondary thyroidectomy (OR: 2.809, 95%CI: 1.302–6.061, p = 0.008) and Berry entrapment of RLN (OR: 2.347, 95%CI: 1.425–3.876, p = 0.001) were detected as the independent risk factors for total VCP, the use of intermittent-IONM (OR: 2.217, 95% CI: 1.299–3.788, 0.004), secondary thyroidectomy (OR: 3.257, 95%CI: 1.340–7.937, p = 0.009), and nerve branching (OR: 1.739, 95%CI: 1.049–2.882, p = 0.032) were detected as independent risk factors for transient VCP. Conclusion Preference of continuous-IONM particularly in secondary thyroidectomies would reduce the risk of VCP. Anatomical variations of the RLN cannot be predicted preoperatively. Revealing anatomical features with careful dissection may contribute to risk reduction by minimizing actions causing traction trauma or compression on the nerve.
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Affiliation(s)
- Nurcihan Aygun
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
- *Correspondence: Nurcihan Aygun
| | - Mehmet Kostek
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Taner Unlu
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Adnan Isgor
- Department of General Surgery, Sisli Memorial Hospital, Istanbul, Turkey
| | - Mehmet Uludag
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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15
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Seeing Is Not Believing: Intraoperative Nerve Monitoring (IONM) in the Thyroid Surgery. Indian J Surg Oncol 2022; 13:121-132. [PMID: 35462673 PMCID: PMC8986933 DOI: 10.1007/s13193-021-01348-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/12/2021] [Indexed: 10/21/2022] Open
Abstract
Ensuring the integrity of the recurrent laryngeal nerve (RLN), the external branch of superior laryngeal nerve (EBSLN) and preservation of normal voice are the prime 'functional' goals of thyroid surgery. More in-depth knowledge of neuronal mechanisms has revealed that anatomical integrity does not always translate into functional integrity. Despite meticulous dissection, neural injuries are not always predictable or visually evident. Intraoperative nerve monitoring (IONM) is designed to aid in nerve identification and early detection of functional impairment. With the evolution of technique, intermittent monitoring has given way to continuous-IONM. Over the years, IONM gathered both support and flak. Despite numerous randomised studies, systematic reviews, and meta-analyses, there still prevails a state of clinical equipoise concerning the utility of IONM and its cost-effectiveness. This article inspects the true usefulness of IONM, elaborates on the optimal way to practice it, and presents a critical literature review.
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16
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Lu IC, Hsu CD, Chang PY, Wu SH, Huang TY, Lin YC, Ko HY, Dionigi G, Chai YJ, Chiang FY, Kuo YW, Wu CW. A Surgeon-Centered Neuromuscular Block Protocol Improving Intraoperative Neuromonitoring Outcome of Thyroid Surgery. Front Endocrinol (Lausanne) 2022; 13:817476. [PMID: 35222277 PMCID: PMC8867063 DOI: 10.3389/fendo.2022.817476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/11/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Neuromuscular blocking agents provide muscular relaxation for tracheal intubation and surgery. However, the degree of neuromuscular block may disturb neuromuscular transmission and lead to weak electromyography during intraoperative neuromonitoring. This study aimed to investigate a surgeon-friendly neuromuscular block degree titrated sugammadex protocol to maintain both intraoperative neuromonitoring quality and surgical relaxation during thyroid surgery. METHODS A total of 116 patients were enrolled into two groups and underwent elective thyroid surgery with intraoperative neuromonitoring. All patients followed a standardized intraoperative neuromonitoring protocol with continuous neuromuscular transmission monitoring and received 0.6 mg/kg rocuronium for tracheal intubation. Patients were allocated into two groups according to the degree of neuromuscular block when the anterior surface of the thyroid gland was exposed. The neuromuscular block degree was assessed by the train-of-four (TOF) count and ratio. Patients in group I received sugammadex 0.25 mg/kg for non-deep neuromuscular block degree (TOF count = 1~4). Patients in group II were administered sugammadex 0.5 mg/kg for deep neuromuscular block degree (TOF count = 0). The quality of the intraoperative neuromonitoring was measured using the V1 electromyography (EMG) amplitude. An amplitude less than 500 μV and greater than 500 μV was defined as weak and satisfactory, respectively. RESULTS The quality of the intraoperative neuromonitoring was not different between groups I and II (satisfactory/weak: 75/1 vs. 38/2, P = 0.14). The quality of surgical relaxation was acceptable after sugammadex injection and showed no difference between groups [55/76 (72.3%) in group I vs. 33/40 (82.5%) in group II, P = 0.23]. CONCLUSIONS This surgeon-centered sugammadex protocol guided by neuromuscular block degree (0.5 mg/kg for deep block and 0.25 mg/kg for others) showed comparably high intraoperative neuromonitoring quality and adequate surgical relaxation. The results expanded the practicality of sugammadex for precise neuromuscular block management during monitored thyroidectomy.
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Affiliation(s)
- I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chiung-Dan Hsu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Sheng-Hua Wu
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chu Lin
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - How-Yun Ko
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS (Istituto di ricovero e cura a carattere scientifico), Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Young Jun Chai
- Department of Surgery, Seoul National University College of Medicine, Seoul Metropolitan Government—Seoul National University Boramae Medical Center, Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, South Korea
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yi-Wei Kuo
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Yi-Wei Kuo, ; Che-Wei Wu,
| | - Che-Wei Wu
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Yi-Wei Kuo, ; Che-Wei Wu,
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Abstract
Background: The field of surgical and interventional thyroidology is rapidly evolving. In the past few years, we have seen the introduction and establishment of many novel surgical adjuncts, techniques, and disruptive ablative technologies that have impacted the field. Methods: We identified the most influential articles on technological developments in surgical and interventional thyroidology that were published from September 1, 2020, to August 1, 2021. We searched three electronic databases and consulted experts. Results: Major findings are summarized. Continuous intraoperative nerve monitoring (cIONM) lowered the risk of early postoperative vocal cord palsy 1.8-fold and permanent palsy 29 · 4-fold compared with intermittent intraoperative nerve monitoring. Parathyroid autofluorescence yielded a diagnostic odds ratio (OR) of 228.9 for detection of parathyroid glands over visualization, with 96% sensitivity and 92% specificity. There was no significant difference in the incidence of major complications between the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transcervical thyroidectomy (1.5% vs. 2.1%, p = 0.75), and a higher body mass index did not lead to a significant increase in the odds of cumulative complication with TOETVA for the overweight (OR = 0.52 [95% confidence interval {CI} 0.17-1.58]) and obese groups (OR = 1.69 [CI 0.74-3.88]). Radiofrequency ablation (RFA) for benign thyroid nodules typically resulted in a 50-85% volume reduction with faster recovery times, less pain levels, and higher social and psychological well-being compared with conventional thyroidectomy at 15 months post-treatment, although physical well-being levels were higher in the conventional thyroidectomy group at this time. RFA for papillary thyroid microcarcinoma showed no significant difference in local tumor progression (1.8% vs. 3.3%, p = 0.209), lymph node metastasis (0.6% vs. 0.6%, p = 1.000), recurrence (1.2% vs. 2.4%, p = 0.244), and 4-year recurrence-free survival rates (98.2% vs. 97.0%, p = 0.223) when compared with transcervical lobectomy. Conclusions: cIONM, parathyroid autofluorescence, transoral vestibular approach thyroid surgery, and RFA for benign and malignant thyroid nodules are some of the latest additions to the surgeon's and interventionalist's armamentarium to manage thyroid disease. These technological advancements demonstrate promise to improve outcomes, decrease complications, and enhance a patient's quality of life, but further rigorous studies are needed to define their utility and value.
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Affiliation(s)
- Ralph P Tufano
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Director of the FPG Thyroid and Parathyroid Center, Department of Otolaryngology-Head and Neck Surgery, Sarasota Memorial Health Care System, Sarasota, Florida, USA
| | - Khalid Mohamed Ali
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Pace-Asciak P, Russell JO, Dhillon VK. Intraoperative Neuromonitoring: Evaluating the Role of Continuous IONM and IONM Techniques for Emerging Surgical and Percutaneous Procedures. Front Endocrinol (Lausanne) 2022; 13:823117. [PMID: 35273568 PMCID: PMC8902817 DOI: 10.3389/fendo.2022.823117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Continuous and intermittent intraoperative nerve monitoring (IONM) has become an important asset for endocrine surgeons over the past few decades. The ability to determine neurophysiologic integrity of the recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN) on top of identification and meticulous dissection of the nerve in the surgical field, has allowed for advances in technology and improved outcomes when it comes to prevention of vocal fold immobility. This article aims to compare in review continuous and intermittent nerve monitoring (CIONM, IIONM), as well as review the current paradigms of their use. This article will also discuss the future of intraoperative nerve monitoring technologies in scarless thyroid surgery and percutaneous approaches to thyroid pathology in form of radiofrequency ablation (RFA).
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Affiliation(s)
- Pia Pace-Asciak
- Department of Otolaryngology – Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Jonathon O. Russell
- Division of Endocrine Head and Neck Surgery, Johns Hopkins Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Vaninder K. Dhillon
- Division of Endocrine Head and Neck Surgery, Johns Hopkins Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
- *Correspondence: Vaninder K. Dhillon,
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19
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Wang JJ, Huang TY, Wu CW, Lin YC, Tseng HY, Liu CH, Lu IC, Chang PY, Chen HC, Chen HY, Dionigi G, Chiang FY, Wang LF. Improving Voice Outcomes After Thyroid Surgery - Review of Safety Parameters for Using Energy-Based Devices Near the Recurrent Laryngeal Nerve. Front Endocrinol (Lausanne) 2021; 12:793431. [PMID: 34899616 PMCID: PMC8662988 DOI: 10.3389/fendo.2021.793431] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Technological advances in thyroid surgery have rapidly increased in recent decades. Specifically, recently developed energy-based devices (EBDs) enable simultaneous dissection and sealing tissue. EBDs have many advantages in thyroid surgery, such as reduced blood loss, lower rate of post-operative hypocalcemia, and shorter operation time. However, the rate of recurrent laryngeal nerve (RLN) injury during EBD use has shown statistically inconsistent. EBDs generate high temperature that can cause iatrogenic thermal injury to the RLN by direct or indirect thermal spread. This article reviews relevant medical literatures of conventional electrocauteries and different mechanisms of current EBDs, and compares two safety parameters: safe distance and cooling time. In general, conventional electrocautery generates higher temperature and wider thermal spread range, but when applying EBDs near the RLN adequate activation distance and cooling time are still required to avoid inadvertent thermal injury. To improve voice outcomes in the quality-of-life era, surgeons should observe safety parameters and follow the standard procedures when using EBDs near the RLN in thyroid surgery.
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Affiliation(s)
- Jia Joanna Wang
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, 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
| | - Tzu-Yen Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, 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
| | - Yi-Chu Lin
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Yi Tseng
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Hsin Liu
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, 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
| | - I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hui-Chun Chen
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Hsiu-Ya Chen
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Ling-Feng Wang
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Schneider R, Machens A, Sekulla C, Lorenz K, Elwerr M, Dralle H. Superiority of continuous over intermittent intraoperative nerve monitoring in preventing vocal cord palsy. Br J Surg 2021; 108:566-573. [PMID: 34043775 DOI: 10.1002/bjs.11901] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/20/2020] [Accepted: 06/14/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Continuous intraoperative nerve stimulation (IONM) with uninterrupted monitoring is likely better than intermittent IONM in preventing vocal cord palsy after thyroid surgery. METHODS This was a comparative study of intermittent versus continuous IONM in patients with benign and malignant thyroid disease treated at a tertiary centre over 10 years. Early postoperative and permanent vocal cord palsy rates were estimated. Multivariable logistic regression analysis was used to quantify the contributions of clinical and histopathological variables to early postoperative and permanent vocal cord palsy. RESULTS A total of 6029 patients were included, of whom 3139 underwent continuous and 2890 intermittent IONM. Based on nerves at risk (5208 versus 5024 nerves), continuous IONM had a 1·7-fold lower early postoperative vocal cord palsy rate than intermittent monitoring (1·5 versus 2·5 per cent). This translated into a 30-fold lower permanent vocal cord palsy rate (0·02 versus 0·6 per cent). In multivariable logistic regression analysis, continuous IONM independently reduced early postoperative vocal cord palsy 1·8-fold (odds ratio (OR) 0·56) and permanent vocal cord palsy 29·4-fold (OR 0·034) compared with intermittent IONM. One permanent vocal cord palsy per 75·0 early vocal cord palsies was observed with continuous IONM, compared with one per 4·2 after intermittent IONM. Early postoperative vocal cord palsies were 17·9-fold less likely to become permanent with continuous than intermittent IONM. CONCLUSION Continuous IONM is superior to intermittent IONM in preventing vocal cord palsy.
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Affiliation(s)
- R Schneider
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - A Machens
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - C Sekulla
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - K Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - M Elwerr
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - H Dralle
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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Kong DK, Kong AM, Chai RL. Comparison of a Handheld Device vs Endotracheal Tube-Based Neuromonitoring for Recurrent Laryngeal Nerve Stimulation. Otolaryngol Head Neck Surg 2021; 166:260-266. [PMID: 34030499 DOI: 10.1177/01945998211013753] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To measure the effect of thyroidectomy difficulty on intraoperative neuromonitoring false loss of signal (LOS) and to compare intraoperative endotracheal tube-based neuromonitoring (ETNM) and Checkpoint palpation-based direct stimulation (pDS) signals with postoperative laryngoscopy. We hypothesized that pDS has higher a positive predictive value for postdissection confirmation of recurrent laryngeal nerve function than ETNM and that this difference is accentuated with increasing thyroidectomy difficulty. STUDY DESIGN Prospective single-arm cross-sectional study comparing ETNM and pDS for patients undergoing hemi-, total, or completion thyroidectomy from July 2018 to March 2020. SETTING Single-surgeon series at a tertiary care hospital. METHODS Percentage concordance and positive and negative predictive values were measured. Each thyroidectomy was assigned a validated thyroidectomy difficulty score, and recorded recurrent laryngeal nerve signals were compared with postoperative vocal fold mobility. RESULTS Percentage concordance was 90.09%. Positive and negative predictive values were 0.19 (95% CI, 0.09-0.31) and 1.0 for ETNM and 0.59 (95% CI, 0.35-0.82) and 1.0 for pDS. The difference in positive predictive value was significant (0.40 [95% CI, 0.33-0.47], P < .001). False LOS rates for ETNM and pDS were 13.19% versus 3.30% (9.89% [95% CI, 1.80%-18.62%], P = .0155), 44.11% versus 0% (44.11% [95% CI, 25.80%-60.54%], P < .001), and 73.33% versus 13.33% (60% [95% CI, 24.76%-78.46%], P = .001) for the second through fourth thyroidectomy difficulty score quartiles, respectively. False LOS with ETNM was linearly correlated with increasing difficulty (R2 = 0.97). CONCLUSION ETNM was subject to high rates of postdissection false LOS that increased with thyroidectomy difficulty score. pDS is a reliable alternative that has higher positive predictive value than ETNM, particularly in more challenging cases such as those with posteriorly fixed thyroid cancers and fibrotic glands. EVIDENCE LEVEL 2.
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Affiliation(s)
- Derek Kai Kong
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Raymond L Chai
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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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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Intraoperative Nerve Monitoring Setup and Data Interpretation: How Do I Augment My IONM Experience? CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00347-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Maneeprasopchoke P, Chongkolwatana C, Pongsapich W, Iwata AJ, Kamani D, Randolph GW. Intraoperative nerve monitoring in thyroid surgery: Analysis of recurrent laryngeal nerve identification and operative time. Laryngoscope Investig Otolaryngol 2021; 6:354-361. [PMID: 33869769 PMCID: PMC8035947 DOI: 10.1002/lio2.543] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/12/2021] [Accepted: 02/16/2021] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To evaluate the clinical value of intraoperative nerve monitoring (IONM) by comparing the procedure times for thyroidectomies performed with and without IONM. METHODS A prospective, randomized, controlled study was conducted on 32 patients (representing 41 nerves at risk) undergoing thyroidectomies carried out by two experienced head and neck surgeons (CC & WP). Sixteen thyroidectomies were performed without IONM (the "non-IONM group"), while 16 thyroidectomies were performed with IONM (the "IONM group"). The measured datapoints were setup time, time to visual identification of the recurrent laryngeal nerve (RLN), time to confirm the RLN electrophysiologically, dissection time, and total operative time. RESULTS With both surgeons, the IONM group had shorter visual times to RLN identification than the non-IONM group (CC: 3.7 minutes vs 5.3 minutes; WP: 3.4 minutes vs 9.7 minutes). Additionally, the electrophysiological identification time for the IONM group was shorter than the visual identification time for the non-IONM group. The setup times, dissection times, and total operative times of the 2 groups did not significantly differ (P > .05). No RLN injuries were observed. CONCLUSIONS IONM reduces the time needed for RLN identification in thyroidectomies. Functional RLN confirmation can reassure surgeons of the operative results. Moreover, use of IONM does not significantly impact setup and total operative times. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Prachya Maneeprasopchoke
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Cheerasook Chongkolwatana
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Warut Pongsapich
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Ayaka J. Iwata
- Division of Thyroid and Parathyroid Surgery, Department of OtolaryngologyMassachusetts Eye and Ear Infirmary, Harvard Medical SchoolBostonMassachusettsUSA
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Surgery, Department of OtolaryngologyMassachusetts Eye and Ear Infirmary, Harvard Medical SchoolBostonMassachusettsUSA
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Surgery, Department of OtolaryngologyMassachusetts Eye and Ear Infirmary, Harvard Medical SchoolBostonMassachusettsUSA
- Division of Surgical Oncology, Department of SurgeryMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Schweitzer CL, Wiseman SM. Adoption of intraoperative nerve monitoring for thyroidectomy: Supported by real-world NSQIP data. Am J Surg 2021; 221:1285-1290. [PMID: 33838865 DOI: 10.1016/j.amjsurg.2021.03.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/12/2021] [Accepted: 03/21/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Christina L Schweitzer
- Department of Surgery, St. Paul's Hospital & University of British Columbia, C303-1081 Burrard St, Vancouver, British Columbia, V6Z 1Y6, Canada.
| | - Sam M Wiseman
- Department of Surgery, St. Paul's Hospital & University of British Columbia, C303-1081 Burrard St, Vancouver, British Columbia, V6Z 1Y6, Canada.
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Kim J, Graves CE, Jin C, Duh QY, Gosnell JE, Shen WT, Suh I, Sosa JA, Roman SA. Intraoperative nerve monitoring is associated with a lower risk of recurrent laryngeal nerve injury: A national analysis of 17,610 patients. Am J Surg 2021; 221:472-477. [DOI: 10.1016/j.amjsurg.2020.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 09/21/2020] [Accepted: 10/08/2020] [Indexed: 01/21/2023]
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Liu CH, Huang TY, Wu CW, Wang JJ, Wang LF, Chan LP, Dionigi G, Chiang FY, Tseng HY, Lin YC. New Developments in Anterior Laryngeal Recording Technique During Neuromonitored Thyroid and Parathyroid Surgery. Front Endocrinol (Lausanne) 2021; 12:763170. [PMID: 34777256 PMCID: PMC8586463 DOI: 10.3389/fendo.2021.763170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/14/2021] [Indexed: 11/13/2022] Open
Abstract
A recurrent laryngeal nerve (RLN) injury resulting in vocal fold paralysis and dysphonia remains a major source of morbidity after thyroid and parathyroid surgeries. Intraoperative neural monitoring (IONM) is increasingly accepted as an adjunct to the standard practice of visual RLN identification. Endotracheal tube (ET) surface recording electrode systems are now widely used for IONM; however, the major limitation of the clinical use of ET-based surface electrodes is the need to maintain constant contact between the electrodes and vocal folds during surgery to obtain a high-quality recording. An ET that is malpositioned during intubation or displaced during surgical manipulation can cause a false decrease or loss of electromyography (EMG) signal. Since it may be difficult to distinguish from an EMG change caused by a true RLN injury, a false loss or decrease in EMG signal may contribute to inappropriate surgical decision making. Therefore, researchers have investigated alternative electrode systems that circumvent common causes of poor accuracy in ET-based neuromonitoring. Recent experimental and clinical studies have confirmed the hypothesis that needle or adhesive surface recording electrodes attached to the thyroid cartilage (transcartilage and percutaneous recording) or attached to the overlying neck skin (transcutaneous recording) can provide functionality similar to that of ET-based electrodes, and these recording methods enable access to the EMG response of the vocalis muscle that originates from the inner surface of the thyroid cartilage. Studies also indicate that, during surgical manipulation of the trachea, transcartilage, percutaneous, and transcutaneous anterior laryngeal (AL) recording electrodes could be more stable than ET-based surface electrodes and could be equally accurate in depicting RLN stress during IONM. These findings show that these AL electrodes have potential applications in future designs of recording electrodes and support the use of IONM as a high-quality quantitative tool in thyroid and parathyroid surgery. This article reviews the major recent developments of newly emerging transcartilage, percutaneous, and transcutaneous AL recording techniques used in IONM and evaluates their contribution to improved voice outcomes in modern thyroid surgery.
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Affiliation(s)
- Cheng-Hsin Liu
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, 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 Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Che-Wei Wu
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jia Joanna Wang
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, 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 Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ling-Feng Wang
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Leong-Perng Chan
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division of Surgery, Istituto Auxologico Italiano IRCCS, Piazzale Brescia, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Hsin-Yi Tseng
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Hsin-Yi Tseng, ; Yi-Chu Lin,
| | - Yi-Chu Lin
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Hsin-Yi Tseng, ; Yi-Chu Lin,
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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.
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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,
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Casano K, Cannon CR, Didlake R, Replogle WR, Cannon R. Use of GlideScope in Patients Undergoing NIM Thyroidectomy. EAR, NOSE & THROAT JOURNAL 2020; 101:650-653. [PMID: 33314961 DOI: 10.1177/0145561320974829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Thyroidectomy and parathyroidectomy using the nerve integrity monitor (NIM) require proper placement of the endotracheal tube with electrodes aligned correctly within the larynx. The purpose of this study is to determine the percentage of patients who require positional adjustments of the endotracheal tube prior to beginning surgery and to understand the value of using the GlideScope to assure proper NIM tube placement within the larynx. METHODS This prospective study examines operative data from 297 patients who underwent NIM thyroidectomy and parathyroidectomy. After routine orotracheal intubation by an anesthesiologist and positioning of the patient for surgery, a GlideScope was used to check the position of the tube in 2 planes: depth of tube placement and rotation of the tube within the larynx assuring proper placement of the electromyogram electrodes within the glottis. RESULTS Tube adjustment was required for 66.5% of patients. In 48.1% of cases, tube retraction or advancement to a proper depth was needed. Tube rotation was required for 30.1% of patients, and 11.8% of patients required both adjustment of tube depth and tube rotation to properly align electrodes. CONCLUSIONS After the anesthesiologist places the NIM endotracheal tube, and the patient is positioned for surgery, additional tube adjustment is often needed prior to the start of surgery. The GlideScope is readily available in the operating suite, its use adds little time to the procedure, and assures proper NIM tube placement. The use of the GlideScope is recommended.
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Affiliation(s)
- Kelsey Casano
- 12258Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | | | - Ralph Didlake
- 21693University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Robert Cannon
- 21693University of Mississippi Medical Center, Jackson, MS, USA
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Abt NB, Puram SV, Kamani D, Modi R, Randolph GW. Neuromonitored Thyroid Surgery: Optimal Stimulation Based on Intraoperative EMG Response Features. Laryngoscope 2020; 130:E970-E975. [DOI: 10.1002/lary.28613] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/10/2020] [Accepted: 02/19/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Nicholas B. Abt
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
| | - Sidharth V. Puram
- Department of Otolaryngology‐Head and Neck Surgery and Department of Genetics Washington University School of Medicine St. Louis Missouri U.S.A
| | - Dipti Kamani
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
| | - Rahul Modi
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
| | - Gregory W. Randolph
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
- Division of Surgical Oncology, Department of Surgery Massachusetts General Hospital, Harvard Medical School Boston Massachusetts U.S.A
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Schneider R, Machens A, Lorenz K, Dralle H. Intraoperative nerve monitoring in thyroid surgery-shifting current paradigms. Gland Surg 2020; 9:S120-S128. [PMID: 32175252 DOI: 10.21037/gs.2019.11.04] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Over the past two decades, intraoperative neural monitoring (IONM) has matured into a powerful risk minimization tool. Meta-analyses of studies, most of which were limited by poor study designs and the sole use of intermittent nerve stimulation, failed to demonstrate superiority of IONM over anatomic recurrent laryngeal nerve (RLN) dissection in the absence of IONM. With the advent of continuous IONM (CIONM), intraoperative nerve electromyographic tracings, registered almost in real time during the operation, accurately predict postoperative vocal fold function when International Neural Monitoring Study Group quality standards are adhered to. CIONM aids in avoiding permanent traction-related nerve injury by urging surgeons to reverse harmful surgical maneuvers. CIONM also forms an integral part in the surgical concept of staged thyroidectomy. Delaying completion surgery on the other side until nerve function has recovered mitigates the risk of bilateral vocal fold palsy. CIONM has greatly furthered our understanding of functional RLN injury, enabling conception of effective risk minimization strategies tailored to the individual patient. The review summarizes the advances of continuous IONM technology that caused a quantum leap in risk minimization for thyroid surgery, shifting current paradigms.
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Affiliation(s)
- Rick Schneider
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Andreas Machens
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kerstin Lorenz
- Medical Faculty, 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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