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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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Lechien JR, Fisichella PM, Dapri G, Russell JO, Hans S. Facelift thyroid surgery: a systematic review of indications, surgical and functional outcomes. J Otolaryngol Head Neck Surg 2023; 52:25. [PMID: 37038204 PMCID: PMC10088190 DOI: 10.1186/s40463-023-00624-x] [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: 08/04/2022] [Accepted: 02/06/2023] [Indexed: 04/12/2023] Open
Abstract
OBJECTIVE To investigate indications, surgical and functional outcomes of robotic or endoscopic facelift thyroid surgery (FTS) and whether FTS reported comparable outcomes of other surgical approaches. DATA SOURCES PubMed, Cochrane Library, and Scopus. REVIEW METHODS A literature search was conducted about indications, clinical and surgical outcomes of patients who underwent FTS using PICOTS and PRISMA Statements. Outcomes reviewed included age; gender; indications; pathology; functional evaluations; surgical outcomes and complications. RESULTS Fifteen papers met our inclusion criteria, accounting for 394 patients. Endoscopic or robotic FTS was carried out for benign and malignant thyroid lesions, with or without central neck dissection. Nodule size and thyroid lobe volume did not exceed 6, 10 cm, respectively. FTS reported comparable outcome with transaxillary or oral approaches about operative time, complication rates or drainage features. The mean operative time ranged from 88 to 220 min, depending on the type of surgery (endoscopic vs robotic hemi- or total thyroidectomy). Conversion to open surgery was rare, occurring in 0-6.3% of cases. The most common complications were earlobe hypoesthesia, hematoma, seroma, transient hypocalcemia and transient recurrent nerve palsy. There was an important disparity between studies about the inclusion/exclusion criteria, surgical and functional outcomes. CONCLUSION FTS is a safe and effective approach for thyroid benign and malignant lesions. FTS reports similar complications to conventional thyroidectomy and excellent cosmetic satisfaction.
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Affiliation(s)
- Jérôme R Lechien
- Robotic Surgery Study Group of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), Paris, France.
- Department of Otolaryngology - Head & Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), Paris, France.
- Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium.
- Department of Otolaryngology, Elsan Hospital, Paris, France.
- Department of Otorhinolaryngology and Head and Neck Surgery, CHU Saint-Pierre, Brussels, Belgium.
| | | | - Giovanni Dapri
- Department of Minimally Invasive General and Oncologic Surgery, Humanitas Gavazzeni University Hospital, Bergamo, Italy
- International School Reduced Scar Laparoscopy, Bergamo, Italy
| | - Jonathon O Russell
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Stéphane Hans
- Robotic Surgery Study Group of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), Paris, France
- Department of Otolaryngology - Head & Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), Paris, France
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Ding Z, Sheng R, Zhang L, Han J, Chen M, Bi W, Zhao X, Zhang J, Nie C. Utility of video-assisted method for identifying and preserving the external branch of the superior laryngeal nerve during thyroidectomy. Front Surg 2023; 10:1118083. [PMID: 37143769 PMCID: PMC10151554 DOI: 10.3389/fsurg.2023.1118083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/03/2023] [Indexed: 05/06/2023] Open
Abstract
Background The EBSLN is vulnerable to damage during thyroidectomy, results in voice related complications, negatively affect patient quality of life, routine identification of the EBSLN prior to surgical manipulation is necessary for a complication-free thyroidectomy. We aimed to validate a video-assisted procedure for identifying and preserving the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy and analyze the EBSLN Cernea classification and the localization of the nerve entry point (NEP) from the insertion of the sternothyroid muscle. Methods A prospective descriptive study was performed; 134 patients, who scheduled for lobectomy with an intraglandular tumor max diameter ≤ 4 cm and without extrathyroidal extension, were randomly divided into the video-assisted surgery (VAS) and conventional open surgery (COS) groups. We used the video-assisted surgical procedure for visually identifying the EBSLN directly, and compared the differences in the visual identification rate and total identification rate of the two groups. We also measured the localization of the NEP using the insertion of the sternothyroid muscle as a reference. Results There was no statistically significant difference in clinical characteristics between the two groups. The visual identification rate and total identification rate were significantly higher in the VAS group than the COS group (91.04% vs. 77.61%, 100% vs. 89.6%). The EBSLN injury rate was 0 in both groups. The mean vertical distance (VD) of the NEP from the sternal thyroid insertion was 1.18 mm (SD 1.12 mm, range, 0-5 mm), with approximately 88.97% of the results occurring within the 0-2 mm range. The mean horizontal distance (HD) was 9.33 mm (SD 5.03 mm, range, 0-30 mm), with over 92.13% of the results occurring within the 5-15 mm range. Conclusion Both the visual and total identification rates of the EBSLN were significantly higher in the VAS group. This method provided a good visual exposure rate of the EBSLN, aiding in identifying and protecting the EBSLN during thyroidectomy.
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Khafif AH, Cohen O, Dionigi G. Editorial: Improving quality of life in patients with differentiated thyroid cancer. Front Oncol 2023; 13:1154569. [PMID: 36890817 PMCID: PMC9987244 DOI: 10.3389/fonc.2023.1154569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/07/2023] [Indexed: 02/22/2023] Open
Affiliation(s)
- Avi Hefetz Khafif
- Department of Otolaryngology, Soroka Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Oded Cohen
- Department of Otolaryngology, Soroka Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Gianlorenzo Dionigi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Division of Surgery, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
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Wu CW, Dionigi G, Tae K. Editorial: Improving voice outcomes after thyroid surgery and ultrasound-guided ablation procedures. Front Surg 2022; 9:1064768. [PMID: 36578971 PMCID: PMC9791206 DOI: 10.3389/fsurg.2022.1064768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery,Kaohsiung Medical University Hospital, College of Medicine, Faculty of Medicine and Post-Baccalaureate Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy,Division of Surgery, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy,Correspondence: Gianlorenzo Dionigi
| | - Kyung Tae
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, South Korea
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Tincani A, Lehn C, Cernea C, Queiroz E, Dias F, Walder F, Hojaij F, Monteiro F, Kligerman J, Podesta J, Brandão L, de Mello LEB, Medina L, Abrahao M, Tavares M, Barbosa M, Cervantes O, Demétrio P, Curioso R, Lima R, Arap S, Vasconcellos S. Transoral thyroidectomy: A reflexive opinion on the technique. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:396-399. [PMID: 34191418 PMCID: PMC10065330 DOI: 10.20945/2359-3997000000383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Alfio Tincani
- Universidade Estadual de Campinas, Campinas, SP, Brasil
| | - Carlos Lehn
- Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brasil
| | - Cláudio Cernea
- Departamento de Cirurgia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | | | - Fernando Dias
- Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brasil
| | - Fernando Walder
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
| | - Flávio Hojaij
- Departamento de Cirurgia, Laboratório de Investigação Médica (LIM-02), Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil,
| | | | | | - José Podesta
- Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brasil
| | - Lenine Brandão
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Luiz Eduardo Barbalho de Mello
- Universidade Federal do Rio Grande do Norte, Centro de Ciências da Saúde, Programa de Pós-graduação em Ciências da Saúde, Natal, RN, Brasil
| | - Luiz Medina
- Departamento de Cirurgia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Márcio Abrahao
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
| | - Marcos Tavares
- Departamento de Cirurgia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Mauro Barbosa
- Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brasil
| | - Onivaldo Cervantes
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
| | - Paula Demétrio
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
| | | | - Roberto Lima
- Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brasil
| | - Sérgio Arap
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
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Anatomical, Functional, and Dynamic Evidences Obtained by Intraoperative Neuromonitoring Improving the Standards of Thyroidectomy. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2021; 55:146-155. [PMID: 34349588 PMCID: PMC8298074 DOI: 10.14744/semb.2021.45548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022]
Abstract
The use of intraoperative neuromonitoring (IONM) is getting more common in thyroidectomy. The data obtained by the usage of IONM regarding the laryngeal nerves’ anatomy and function have provided important contributions for improving the standards of the thyroidectomy. These evidences obtained through IONM increase the rate of detection and visual identification of recurrent laryngeal nerve (RLN) as well as the detection rate of extralaryngeal branches which are the most common anatomic variations of RLN. IONM helps early identification and preservation of the non-recurrent laryngeal nerve. Crucial knowledge has been acquired regarding the complex innervation pattern of the larynx. Extralaryngeal branches of the RLN may contribute to the motor innervation of the cricothyroid muscle (CTM). Anterior branch of the extralaryngeal branching RLN has always motor function and gives motor branches both to the abductor and adductor muscles. In addition, up to 18% of posterior branches may have adductor and/or abductor motor fibers. In 70–80% of cases, external branch of superior laryngeal nerve (EBSLN) provides motor innervation to the anterior 1/3 of the thyroarytenoid muscle which is the main adductor of the vocal cord through the human communicating nerve. Furthermore, approximately 1/3 of the cases, EBSLN may contribute to the innervation of posterior cricoarytenoid muscle which is the main abductor of ipsilateral vocal cord. RLN and/or EBSLN together with pharyngeal plexus usually contribute to the motor innervation of cricopharyngeal muscle that is the main component of upper esophageal sphincter. Traction trauma is the most common reason of RLN injuries and constitutes of 67–93% of cases. More than 50% of EBSLN injuries are caused by nerve transection. A specific point of injury on RLN can be detected in Type 1 (segmental) injury, however, Type 2 (global) injury is the loss of signal (LOS) throughout ipsilateral vagus-RLN axis and there is no electrophysiologically detectable point of injury. Vocal cord paralysis (VCP) develops in 70–80% of cases when LOS persists or incomplete recovery of signal occurs after waiting for 20 min. In case of complete recovery of signal, VCP is not expected. VCP is temporary in patients with incomplete recovery of signal and permanent VCP is not anticipated. Visual changes may be seen in only 15% of RLN injuries, on the other hand, IONM detects 100% of RLN injuries. IONM can prevent bilateral VCP. Continuous IONM (C-IONM) is a method in which functional integrity of vagus-RLN axis is evaluated in real time and C-IONM is superior to intermittent IONM (I-IONM). During upper pole dissection, IONM makes significant contributions to the visual and functional identification of EBSLN. Routine use of IONM may minimalize the risk of nerve injury. Reduction of amplitude more than 50% on CTM is related with poor voice outcome.
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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.
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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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11
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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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12
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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.
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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,
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