Single Dose Steroid Injection After Loss of Signal (LOS) During Thyroid Surgery is Effective to Recover Electric Signal Avoiding Vocal Cord Palsy and the Need of Staged Thyroidectomy: Prospective Evaluation on 702 Patients

Intraoperative neuromonitoring during thyroidectomy does not decrease vocal cord palsy risk, but the cumulative experience of the surgeon may

PURPOSE

To evaluate the influence of intraoperative neuromonitoring (IONM) on vocal cord palsy (VCP) rates and assess the temporal trends in VCP rates.

METHODS

The subjects of this retrospective study were patients who underwent thyroidectomy for thyroid cancer between March, 2014 and June, 2022, at a university hospital in Korea. We compared VCP rates between the non-IONM and IONM groups and analyzed the risk factors for VCP and VCP rates over time.

RESULTS

A total of 712 patients were included in the analysis. The rates of transient and permanent VCP did not differ significantly between the non-IONM and IONM groups. Transient VCP occurred in 4.6% and 4.3% patients (p = 0.878) and VCP was permanent in 0.7% and 0.4% patients (p = 0.607) in the non-IONM and IONM groups, respectively. Among the nerves at risk, transient damage occurred in 2.8% and 3.0% patients (p = 0.901), and permanent damage occurred in 0.4% and 0.3% (p = 0.688), respectively. Multivariate analysis revealed no significant risk factors for VCP. There was a significant decreasing trend in VCP rates over time as the cumulative number of cases increased (p = 0.017).

CONCLUSIONS

IONM did not reduce the risk of VCP significantly. However, the declining trend of VCP rates suggests that the surgeon's experience may mitigate VCP risk.

The Utility of Intraoperative Neuromonitoring in Pediatric Surgical Oncology

BACKGROUND

Intraoperative nerve monitoring (IONM) is a technique used to decrease the possibility of nerve-associated morbidity and damage to nearby neural structures during complex surgical procedures. The use and potential benefits of IONM in pediatric surgical oncology are not well-described.

METHODS

An overview of the current literature was performed to elucidate the various techniques that may be useful to pediatric surgeons for resection of solid tumors in children.

RESULTS

The physiology and common types of IONM relevant to the pediatric surgeon are described. Important anesthetic considerations are reviewed. Specific applications for IONM that may be useful in pediatric surgical oncology are then summarized, including its use for monitoring the recurrent laryngeal nerve, the facial nerve, the brachial plexus, spinal nerves, and lower extremity nerves. Troubleshooting techniques regarding common pitfalls are then proposed.

CONCLUSION

IONM is a technique that may be beneficial in pediatric surgical oncology to minimize nerve injury during extensive tumor resections. This review aimed to elucidate the various techniques available. IONM should be considered as an adjunct for the safe resection of solid tumors in children in the proper setting with the appropriate level of expertise. A multidisciplinary approach is advised. Additional studies are necessary to further clarify the optimal use and outcomes in this patient population.

LEVELS OF EVIDENCE

Level III.

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)

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.

A novel computer based risk prediction model for vocal cord palsy before thyroidectomy

BACKGROUND

Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts suspicious findings on fine needle aspiration (FNA) biopsy, dyspnea from airway compression or dysphagia from cervical esophageal compression, etc. The incidences of vocal cord palsy (VCP) caused by thyroid surgery were reported to range from 3.4% to 7.2% and 0.2% to 0.9% for temporary and permanent vocal fold palsy respectively which is a serious complication of thyroidectomy that is worrisome for patients.

OBJECTIVE

Therefore, it is aimed to determine the patients who have the risk of developing vocal cord palsy before thyroidectomy by using machine learning methods in the study. In this way, the possibility of developing palsy can be reduced by applying appropriate surgical techniques to individuals in the high-risk group.

METHOD

For this aim, 1039 patients with thyroidectomy, between the years 2015 and 2018, have been used from Karadeniz Technical University Medical Faculty Farabi Hospital at the department of general surgery. The clinical risk prediction model was developed using the proposed sampling and random forest classification method on the dataset.

CONCLUSION

As a result, a novel quite a satisfactory prediction model with 100% accuracy was developed for VCP before thyroidectomy. Using this clinical risk prediction model, physicians can be helped to identify patients at high risk of developing post-operative palsy before the operation.

Intraoperative Neuromonitoring and Optical Magnification in the Prevention of Recurrent Laryngeal Nerve Injuries during Total Thyroidectomy

Background and Objectives: Recurrent laryngeal nerve (RLN) paralysis is a fearful complication during thyroidectomy. Intraoperative neuromonitoring (IONM) and optical magnification (OM) facilitate RLN identification and dissection. The purpose of our study was to evaluate the influence of the two techniques on the incidence of RLN paralysis and determine correlations regarding common outcomes in thyroid surgery. Materials and Methods: Two equally sized groups of 50 patients who underwent total thyroidectomies were examined. In the first group (OM), only surgical binocular loupes (2.5×−4.5×) were used during surgery, while in the second group (IONM), the intermittent NIM was applied. Results: Both the operative time and the length of hospitalization were shorter in the OM group than in the IONM group (median 80 versus 100 min and median 2 versus 4 days, respectively) (p < 0.05). The male patients were found to have a five-fold higher risk of developing transient dysphonia than the females (adjusted OR 5.19, 95% IC 0.99−27.18, p = 0.05). The OM group reported a four-fold higher risk of developing transient hypocalcemia than the IONM group (OR 3.78, adjusted OR 4.11, p = 0.01). Despite two cases of temporary bilateral RLN paralysis in the IONM group versus none in the OM group, no statistically significant difference was found (p > 0.05). No permanent RLN paralysis or hypoparathyroidism have been reported. Conclusions: Despite some limitations, our study is the first to compare the use of IONM with OM alone in the prevention of RLN injuries. The risk of recurrent complications remains comparable and both techniques can be considered valid instruments, especially if applied simultaneously by surgeons.

Abu Dhabi Neural Mapping (ADNM) during Minimally Invasive Thyroidectomy Enables the Early Identification of Non-Recurrent Laryngeal Nerve and Prevents Voice Dysfunction

The aim of this study was to evaluate the diagnostic accuracy of a neuromonitoring protocol—the Abu Dhabi Neural Mapping protocol (ADNM)—using a new device, Nim-Vital™, during minimally invasive thyroidectomy in the early identification of non-recurrent laryngeal nerve (n-RLN) problems and the preservation of its function. Method: Patients with thyroid disorders that required thyroid resection, who were admitted to the Department of Surgery at Burjeel Hospital, Abu Dhabi, between January and July 2022, were included in the study. The data were extracted from a prospective database and were analyzed retrospectively. All nerves at risk were identified and exposed at seven precisely defined anatomical points, with strict adherence to the intraoperative technical steps of neuromonitoring. These were sequentially applied to the vagal nerve (VN), the superior laryngeal nerve (SLN), and the recurrent laryngeal nerve (RLN). In the next step after the creation of the skin-platysma flap, the strap muscle’s lateral border was moved from the medial limb of the sternocleidomastoid without using any electrical device and without any manipulation of the thyroid gland. The VN was exposed in the carotid sheath and then stimulated using a monopolar probe at a precisely defined point above the clavicle, using anatomical landmarks. Results: In total, 136 women with a mean age of 40 years (range 18–74) and 36 men with a mean age of 42 (range 21–66), demonstrating 270 nerves at risk, were included in the analysis. Indications for surgery were malignancy in 70 cases, toxic goiter/Graves in 23 cases, retrosternal goiter in 21, and symptomatic multinodular goiter in 64 cases. Of these, 100 patients received a total thyroidectomy, 46 received a right lobectomy, and 24 received a left lobectomy only. For a total thyroidectomy, the median skin-to-skin surgery duration was 52 min (range 24–104 min) and the median hospital stay was 2 days (range 1–4 days). In 4 cases (4/146; 2.74%) the pre-dissection stimulation of the vagal nerve (VN1) at the ADNM’s precisely defined point did not create any signal or proper EMG-curve that indicated the existence of the non-RLN. Proximal dissection of the right VN at a precisely defined point by the ADNM’s level of incisura of the larynx created a positive signal. The separation point of the right non-RLN from the VN was discovered in all four patients. The postoperative video-laryngoscopy confirmed bilateral mobile vocal cords in all cases. Conclusions: Following the ADNM protocol during thyroid surgery minimizes the risk of a non-laryngeal nerve injury and prevents voice dysfunction.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism.

BACKGROUND

Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT.

METHODS

Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.

Recurrent Laryngeal Nerve Paralysis Following Thyroidectomy: Analysis of Factors Affecting Nerve Recovery

OBJECTIVES

Paralysis of the recurrent laryngeal nerves (RLNs), albeit decreased over the years, leaves the surgeon helpless as there is not much that can be done once it occurs. Nimodipine has been suggested as a remedy that could accelerate the recovery of the nerve. Our study aimed to examine the factors that affect the recovery rate (RR) and time to recovery (TTR) of post-thyroidectomy RLN paralysis, with an emphasis on the use of nimodipine.

METHODS

A total of 197 patients who had undergone thyroid and parathyroid surgeries were retrospectively reviewed from October 2016 to August 2019. Patients who had RLN paralysis following surgery were assessed. The medical records were retrospectively analyzed to look for possible factors that may influence RLN recovery.

RESULTS

A total of 289 nerves were at risk. Temporary RLN paralysis rate was 7.9% while 1.7% was permanent. Age (odds ratio [OR] = 4.8) and intra-operative extra-thyroid extension (OR = 9.0) were independent risk factors for RLN paralysis. The rate of recovery was 82.1%. Loss of signal (LOS; P = .066) was a factor trending for an impact on RR but not nimodipine (P > .05). The mean TTR was 32 days. LOS, nimodipine, and steroid use, among others, were factors trending for an impact on the TTR.

CONCLUSION

Although not reaching statistical significance, nimodipine and steroids might influence TTR but not the RR. Larger studies are warranted to address the effect of nimodipine on the outcome of RLN paralysis.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Effectiveness of early administration of a single dose of steroids and escin after loss of signal on electromyographic signal recovery during neuromonitored thyroidectomy

BACKGROUND

The aim of this study was to evaluate the effect of a single early administration of dexamethasone and escin after loss of signal (LOS) during a neuromonitored total thyroidectomy.

METHODS

A retrospective analysis of results concerning consecutive patients undergoing total thyroidectomy was performed. Patients included in the study were divided into two groups: Group 1 for which a "wait and see" strategy was used; Group 2, receiving dexamethasone and escin immediately after LOS detection.

RESULTS

Overall 37 patients were included in Group 1 and 35 in Group 2. LOS recovery occurring in 29.7% of cases (n. 11) versus 65.7% (n. 23) respectively (p < 0.001). Postoperative fibrolayngoscopy for patients without LOS recovery showed normal cord function in 4 out of 26 cases (15.4%) in Group 1 and in 7 out of 12 (58.3%) in Group 2 (p < 0.001).

CONCLUSIONS

The early administration of dexamethasone and escin after LOS detection may achieve greater EMG signal recovery than a "wait and see" strategy.

Use of Prophylactic Steroids to Prevent Hypocalcemia and Voice Dysfunction in Patients Undergoing Thyroidectomy: A Randomized Clinical Trial

Importance

Total thyroidectomy is associated with risks related to temporary hypocalcemia and vocal quality dysfunction. Dexamethasone has been proposed to have a physiological effect on hypocalcemia and voice quality.

Objective

To assess the effect of preoperative dexamethasone used to improve hypocalcemia and postthyroidectomy voice dysfunction.

Design, Setting, and Participants

This double-blind, parallel-group, placebo-controlled randomized clinical trial was conducted from January 15, 2014, to December 31, 2019, at the Department of Surgery, Holy Family Hospital in Rawalpindi, Pakistan. All patients with a benign thyroid condition and no preoperative corrected hypocalcemia and voice or vocal quality dysfunction were included. Patients were excluded if they had previous thyroid or neck surgery, known vocal cord dysfunction on laryngoscopy, hearing or voice problems, a history of gastroesophageal reflux, stomach ulcer disease, or contraindications to steroid use.

Interventions

Corrected serum calcium levels and Voice Analog Score defined and measured preoperatively. The dexamethasone group received a 2-mL intravenous dose of 8 mg of dexamethasone 60 minutes before the induction of anesthesia. In contrast, the placebo group received 2 mL of intravenous normal saline (0.9%) 60 minutes before the induction of anesthesia.

Main Outcomes and Measures

Evidence of hypocalcemia and voice dysfunction. Voice dysfunction was defined as a subjective score of less than 50 on a Voice Analog Score scale of 0 to 100 points.

Results

A total of 192 patients (mean [SD] age, 38.9 [12.4] years; 156 women [81.2%]) were included in the study, with 96 patients randomized to each study group (dexamethasone group, mean [SD] age, 39.2 [12.1] years; 75 women [78.1%]; placebo group, mean [SD] age, 38.5 [12.9] years; 81 women [84.5%]). In the first 24 hours after undergoing thyroidectomy, 47 patients (24.4%) developed hypocalcemia and 18 (9.4%) were symptomatic. At 3 days postthyroidectomy, 4 of 96 patients (4.2%) in the placebo group had hypocalcemia compared with no patients in the dexamethasone group. At 24 hours postthyroidectomy, 8 of 96 patients (8.3%) in the dexamethasone group had voice dysfunction compared with 32 of 96 patients (33.3%) in the placebo group. A total of 40 patients (20.8%) reported voice dysfunction. The absolute reduction in the rate of hypocalcemia at 24 hours was 24% (95% CI, 11.9%-35.2%) and at 3 days was 4.2% (-0.44% to 10.0%). The rate of symptomatic hypocalcemia was 19% lower in the dexamethasone group than in the placebo group (95% CI, 11.1%-27.7%). The rate of voice dysfunction was 25% lower in the dexamethasone group than in the placebo group (95% CI, 13.7%-35.7%).

Conclusions and Relevance

In this randomized clinical trial, a single preoperative dose of dexamethasone was safe and effective in reducing postoperative hypocalcemia and voice dysfunction rates in patients undergoing thyroidectomy.

Trial Registration

ClinicalTrials.gov identifier: NCT04752852.