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Stahl A, Bitton E, Katz M, Guttman D. Is trans-thyroid cartilage monitoring as good as endotracheal tube monitoring during thyroidectomy? Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08760-4. [PMID: 38914816 DOI: 10.1007/s00405-024-08760-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/26/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE To evaluate whether trans-thyroid cartilage nerve monitoring for thyroid surgeries is as effective and safe as endotracheal tube monitoring. METHODS Fifty-one thyroidectomies (38 hemithyroidectomies and 13 total thyroidectomies, analyzed as two separate hemi-thyroidectomies) were included. Patients undergoing surgery from 6/2020 to 8/2021 were monitored simultaneously with the NIM® Nerve Monitoring System TriVantage™ Electromyography (EMG) endotracheal tube and EMG trans-thyroid cartilage. Electrophysiological responses of 64 vagus and recurrent laryngeal nerves were obtained. Peri-operative evaluation and 12-month post-operative follow-up were conducted to examine nerve function. Wilcoxon signed-rank and Spearman coefficient tests were used to determine whether there were differences between the methods. RESULTS The average initial amplitude measured with the trans-thyroid cartilage method was higher in the recurrent laryngeal and vagus nerves (p = 0.002, p = 0.003, respectively). The mean difference in EMG amplitude from start to end of surgery for 10 damaged nerves (7 temporary and 3 permanent) differed from intact nerves in both methods and nerves (p < 0.05 for all). Among intact recurrent laryngeal nerves, 20.4% had 20-80% decrease in amplitude in endotracheal tube electrodes and 16.7% in trans-thyroid cartilage electrodes (p = 0.92). All cases with stable EMG signals or with increased EMG amplitude (with both types of electrodes and with both nerves) had normal post-operative vocal function. No significant difference was found between the two methods when measuring the vagus and recurrent laryngeal nerves. No complications occurred when using trans-thyroid cartilage electrodes. CONCLUSIONS Trans-thyroid cartilage nerve monitoring for thyroid surgeries is as effective and safe as the current standard monitoring using an endotracheal tube. During thyroid surgery, patients are monitored to avoid damaging nerves near the vocal cords. This study compared monitoring through a throat tube with the easier method of monitoring outside of the throat to see if it is as effective and safe. No major difference was found between the two methods and there were no problems.
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Affiliation(s)
- Avishai Stahl
- Department of Otolaryngology, Head and Neck Surgery, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba, 4428164, Israel.
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Eden Bitton
- Department of Otolaryngology, Head and Neck Surgery, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba, 4428164, Israel
| | - Matan Katz
- Department of Otolaryngology, Head and Neck Surgery, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba, 4428164, Israel
| | - Dan Guttman
- Department of Otolaryngology, Head and Neck Surgery, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba, 4428164, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Won D, Lee JM, Lee J, Chai YJ, Hwang JY, Kim TK, Chang JE, Kim H, Kim MJ, Min SW. Usefulness of video laryngoscopy in tracheal intubation at thyroid surgical position for intraoperative neuromonitoring. Sci Rep 2024; 14:4980. [PMID: 38424153 PMCID: PMC10904775 DOI: 10.1038/s41598-024-55537-0] [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: 10/17/2023] [Accepted: 02/24/2024] [Indexed: 03/02/2024] Open
Abstract
This observational study aimed to compare the glottic view between video and direct laryngoscopy for tracheal intubation in the surgical position for thyroid surgery with intraoperative neuromonitoring. Patients scheduled for elective thyroid surgery with intraoperative neuromonitoring were enrolled. After the induction of anesthesia, patients were positioned in the thyroid surgical posture with a standard inclined pillow under their head and back. An investigator assessed the glottic view using the percentage of glottic opening (POGO) scale and the modified Cormack-Lehane grade in direct laryngoscopy and then video laryngoscopy sequentially while using the same McGRATH™ MAC video laryngoscope at once, with or without external laryngeal manipulation, at the surgical position. A total of thirty-nine patients were participated in this study. Without external laryngeal manipulation, the POGO scale significantly improved during video laryngoscopy compared to direct laryngoscopy in the thyroid surgical position (60.0 ± 38.2% vs. 22.4 ± 23.8%; mean difference (MD) 37.6%, 95% confidence interval (CI) = [29.1, 46.0], P < 0.001). Additionally, with external laryngeal manipulation, the POGO scale showed a significant improvement during video laryngoscopy compared to direct laryngoscopy (84.6 ± 22.9% vs. 58.0 ± 36.3%; MD 26.7%, 95% CI = [18.4, 35.0] (P < 0.001). The superiority of video laryngoscopy was also observed for the modified Cormack-Lehane grade. In conclusion, video laryngoscopy with the McGRATH™ MAC video laryngoscope, when compared to direct laryngoscopy with it, improved the glottic view during tracheal intubation in the thyroid surgical position. This enhancement may potentially facilitate the proper placement of the electromyography tracheal tube and prevent tube displacement due to positional change for thyroid surgery.
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Affiliation(s)
- Dongwook Won
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Jung-Man Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea.
| | - Jiwon Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, 211, Eonju-ro, Gangnam-gu, Seoul, Republic of Korea.
| | - Young Jun Chai
- Department of Surgery, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Jin-Young Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Tae Kyong Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Jee-Eun Chang
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Hyerim Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Min Jong Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seong-Won Min
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
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Chiang FY, Shih YC, Lien CF, Wang CC, Wang CC, Hwang TZ, Huang YC, Wu CW, Yeh TH, Huang TY. Comparison of EMG amplitudes recorded by ipsilateral and contralateral electrodes placement during using trans-thyroid cartilage recording method in thyroid surgery. Front Endocrinol (Lausanne) 2024; 14:1305629. [PMID: 38292768 PMCID: PMC10826414 DOI: 10.3389/fendo.2023.1305629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/28/2023] [Indexed: 02/01/2024] Open
Abstract
Objectives The feasibility and reliability of trans-thyroid cartilage EMG recording method (TCERM) during intraoperative monitoring (IONM) of the recurrent laryngeal nerve (RLN) in thyroid surgery have been established. This study compared two different recording electrode placements on the ipsi-lateral and contra-lateral lamina of the thyroid cartilage (TC). Methods Fifty consecutive patients undergoing total thyroidectomy with 100 RLNs at risk were enrolled. Two paired subdermal needle electrodes were inserted into the subperichondrium of the bilateral TC lamina to record electromyography (EMG) signals. The channel leads from the TC electrodes were connected to the patient interface with two different modes. In A-mode, the electrode leads were placed ipsi-laterally, and channel 1 monitored the left RLN and channel 2 monitored the right RLN respectively. In B-mode, the electrode leads were placed contra-laterally, and channels 1 and 2 simultaneously monitored the same side of the RLN. The amplitudes of four EMG signals (V1-R1-R2-V2) recorded by A-mode and B-mode were compared. Results All EMG amplitudes of V1-R1-R2-V2 signals recorded with B-mode were all above 500μV and significantly higher than those with A-mode (p<0.001). No false loss of signal, electrode dislodgement, or needle-related complications were noted during IONM. Postoperatively, all patients had symmetrical vocal cord movement. Lower EMG amplitudes were observed in older and male patients. Histopathology and laterality showed no significant differences in EMG amplitude. Conclusion During using TCERM in thyroid surgery, the recording electrodes should be placed contra-laterally on the TC lamina. This approach ensures high and stable EMG signals, which are important for high-quality IONM of the RLN.
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Affiliation(s)
- 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
| | - Yu-Chen Shih
- Department of Otolaryngology, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Ching-Feng Lien
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chih-Chun Wang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chien-Chung Wang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Tzer-Zen Hwang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yaw-Chang Huang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tai-Hung Yeh
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, 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 Otorhinolaryngology, School of Post-Baccalaureate Medicine and School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Lian T, Leong D, Ng K, Bajenov S, Sywak M. A Prospective Study of Electromyographic Amplitude Changes During Intraoperative Neural Monitoring for Open Thyroidectomy. World J Surg 2023; 47:1971-1977. [PMID: 37005926 PMCID: PMC10310560 DOI: 10.1007/s00268-023-07000-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Intraoperative nerve monitoring (IONM) of the vagus and recurrent laryngeal nerve (RLN) enables prediction of postoperative nerve function. The underlying mechanism for loss of signal (LOS) in a visually intact nerve is poorly understood. The correlation of intraoperative electromyographic amplitude changes (EMG) with surgical manoeuvres could help identify mechanisms of LOS during conventional thyroidectomy. METHODS A prospective study of consecutive patients undergoing thyroidectomy was performed with intermittent IONM using the NIM Vital nerve monitoring system. The ipsilateral vagus and RLN was stimulated, and vagus nerve signal amplitude recorded at five time points during thyroidectomy (baseline, after mobilisation of superior pole, medialisation of the thyroid lobe, before release at Ligament of Berry, end of case). RLN signal amplitude was recorded at two time points; after medialisation of the thyroid lobe (R1), and end of case (R2). RESULTS A total of 100 consecutive patients undergoing thyroidectomy were studied with 126 RLN at risk. The overall rate of LOS was 4.0%. Cases without LOS demonstrated a highly significant vagus nerve median percentage amplitude drop at medialisation of the thyroid lobe (- 17.9 ± 53.1%, P < 0.001), and end of case (- 16.0 ± 47.2%, P < 0.001) compared to baseline. RLN had no significant amplitude drop at R2 compared to R1 (P = 0.207). CONCLUSIONS A significant reduction in vagus nerve EMG amplitude at medialisation of the thyroid and the end of case compared to baseline indicates that stretch injury or traction forces during thyroid mobilisation are the most likely mechanism of RLN impairment during conventional thyroidectomy.
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Affiliation(s)
- Tony Lian
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia.
- Department of Endocrine Surgery, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia.
| | - David Leong
- Department of Endocrine Surgery, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
| | - Karl Ng
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia
- Department of Neurology, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
| | - Sonya Bajenov
- Department of Anaesthesia and Pain Management, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
| | - Mark Sywak
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia
- Department of Endocrine Surgery, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
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Mathieson T, Jimaja W, Triponez F, Licker M, Karenovics W, Makovac P, Muradbegovic M, Belfontali V, Bédat B, Demarchi MS. Safety of continuous intraoperative vagus nerve neuromonitoring during thyroid surgery. BJS Open 2023; 7:zrad039. [PMID: 37289251 PMCID: PMC10249491 DOI: 10.1093/bjsopen/zrad039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 02/02/2023] [Accepted: 03/08/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Continuous intraoperative neuromonitoring has successfully demonstrated to predict impending damage to the recurrent laryngeal nerve, by detecting changes in electromyographic recordings. Despite the apparent benefits associated with continuous intraoperative neuromonitoring, its safety is still a debate. The aim of this study was to investigate the electrophysiological impact of continuous intraoperative neuromonitoring on the vagus nerve. METHODS In this prospective study, the amplitude of the electromyographic wave of the vagus nerve-recurrent laryngeal nerve axis was measured both proximally and distally to the stimulation electrode placed upon the vagus nerve. Electromyographic signal amplitudes were collected at three distinct events during the operation: during the dissection of the vagus nerve, before application of the continuous stimulation electrode onto the vagus nerve and after its removal. RESULTS In total, 169 vagus nerves were analysed, among 108 included patients undergoing continuous intraoperative neuromonitoring-enhanced endocrine neck surgeries. Electrode application resulted in a significant overall decrease in measured proximo-distal amplitudes of -10.94 µV (95 per cent c.i. -17.06 to -4.82 µV) (P < 0.005), corresponding to a mean(s.d.) decrease of -1.4(5.4) per cent. Before the removal of the electrode, the measured proximo-distal difference in amplitudes was -18.58 µV (95 per cent c.i. -28.31 to -8.86 µV) (P < 0.005), corresponding to a mean(s.d.) decrease of -2.50(9.59) per cent. Seven nerves suffered a loss of amplitude greater than 20 per cent of the baseline measurement. CONCLUSION In addition to supporting claims that continuous intraoperative neuromonitoring exposes the vagus nerve to injury, this study shows a mild electrophysiological impact of continuous intraoperative neuromonitoring electrode placement on the vagus nerve-recurrent laryngeal nerve axis. However, the small observed differences are negligible and were not associated with a clinically relevant outcome, making continuous intraoperative neuromonitoring a safe adjunct in selected thyroid surgeries.
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Affiliation(s)
- Timothy Mathieson
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Wedali Jimaja
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Marc Licker
- Department of Anaesthesiology and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Wolfram Karenovics
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Petra Makovac
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Mirza Muradbegovic
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Valentina Belfontali
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Benoît Bédat
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Marco Stefano Demarchi
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
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Recurrent Laryngeal Nerve with Loss of Signal During Monitored Thyroidectomy: Percentage Reduction in Sum of the Amplitude of Left and Right Channel. World J Surg 2022; 46:3017-3024. [PMID: 36138319 DOI: 10.1007/s00268-022-06726-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE The prognostication for the injured recurrent laryngeal nerve (RLN) with incomplete loss of signal (LOS) and its function outcome have not been well unified. A warning criterion was proposed to predict RLN injury during monitored thyroidectomy. METHODS A retrospective review of prospectively collected data from consecutive 357 patients with 560 nerves at risk was conducted. Vocal cords mobility with laryngoscope was performed preoperatively, on the second day, and once a month postoperatively until complete recovery. Different cutoff values of the percentage reduction in sum of the amplitude of left and right channel at the end of the surgery, for postoperative vocal cord paralysis (VCP) prediction were compared. RESULTS Percentage reduction in sum of the amplitude of left and right channel at the end of operation ranged from 30.2 to 63.6% in 27 nerves with incomplete LOS (absolute amplitude value of final R2 > 100 μV with reduction > 50% of R1). Seven (1.25%) nerves experienced transient postoperative VCP, in which one nerve with postoperative VCP showed no amplitude reduction. The positive predictive value of VCP for the sum amplitude reduction exceeding 30, 40, 50, and 60% was 22.2, 40, 85.7, and 100%, respectively. Accuracy was 96.1, 98.2, 99.6, 99.4%, respectively. CONCLUSION Percentage reduction in sum of the amplitude of left and right channel is a meaningful method to improve the accuracy of VCP prediction. When the sum amplitude reduction ≥ 50%, surgeons should consider the possibility of postoperative VCP and correct some surgical maneuvers.
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Lin YC, Lin MC, Lin WC, Shen CH. Optimal depth of electromyographic endotracheal tube: A novel approach using video laryngoscopy. J Chin Med Assoc 2022; 85:1000-1005. [PMID: 36000957 DOI: 10.1097/jcma.0000000000000800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Electromyographic (EMG) endotracheal tubes with surface electrodes are used during neck surgery to prevent recurrent laryngeal nerve (RLN) injury. Proper positioning of the EMG tube is of paramount importance. In this study, we aimed to compare the use of video laryngoscopy with other methods for achieving the optimal depth of the EMG tube. METHODS We retrospectively enrolled 489 adult patients (with 675 nerves at risk [NAR]) undergoing surgery using the EMG endotracheal tube. Patients were categorized into three groups with: rigid laryngoscope (n = 140, NAR = 187), conventional laryngoscope (n = 262, NAR = 370), and video laryngoscope (n = 87, NAR = 118). A formula for predicting optimal depths of the EMG tube was obtained from data of the standard group with rigid laryngoscope. Depths of the EMG endotracheal tube were measured and postoperative RLN injuries were analyzed. RESULTS Based on linear regression, the formula was derived for predicting the optimal depth of EMG endotracheal tube (cm) = 11.028 + 0.635 * gender (female = 0; male = 1) + 0.069 * height (cm). Compared to conventional laryngoscope, intubation of EMG tube with video laryngoscope resulted in less discrepancy between its actual value and optimal value, and the tube depth was more correct (OR = 2.888, 95% CI = 1.753-4.757, p < 0.001). All five postoperative permanent RLN injuries were found in the group with conventional laryngoscope. CONCLUSION EMG endotracheal tube insertion with video laryngoscopy is superior to conventional laryngoscopy, as well as an alternative to rigid laryngoscopy. The video laryngoscopy is a novel approach to get optimal depth of EMG endotracheal tube during neck surgery.
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Affiliation(s)
- Yu-Chun Lin
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Ming-Chih Lin
- Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
- Department of Food and Nutrition, Providence University, Taichung, Taiwan, ROC
| | - Wen-Chun Lin
- Department of Otolaryngology-Head and Neck Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Ching-Hui Shen
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
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Optimization of Intraoperative Neural Monitoring of the Recurrent Laryngeal Nerve in Thyroid Surgery. Medicina (B Aires) 2022; 58:medicina58040495. [PMID: 35454334 PMCID: PMC9028259 DOI: 10.3390/medicina58040495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/18/2022] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
The application of intraoperative neural monitoring (IONM) has been widely accepted to improve surgical outcomes after thyroid surgery. The malfunction of an IONM system might interfere with surgical procedures. Thus, the development of anesthesia modalities aimed at ensuring functional neuromonitoring is essential. Two key issues should be taken into consideration for anesthetic management. Firstly, most patients undergo recurrent laryngeal nerve monitoring via surface electrodes embedded in an endotracheal tube. Thus, advanced video-assisted devices might optimize surface electrode positioning for improved neuromonitoring signaling accuracy. Secondly, neuromuscular blocking agents are routinely used during thyroid surgery. The ideal neuromuscular block should be deep enough for surgical relaxation at excision and recovered enough for an adequate signal f nerve stimulation. Proper neuromuscular block management could be achieved by titration doses of muscle relaxants and reversal agents.
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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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Huang J, Hsu C, Wu S, Kuo Y, Huang T, Wu C, Lu I. Optimization of electromyographic endotracheal tube electrode position by UEScope for monitored thyroidectomy. Laryngoscope Investig Otolaryngol 2021; 6:1214-1219. [PMID: 34667867 PMCID: PMC8513421 DOI: 10.1002/lio2.635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Proper position of an electromyographic (EMG) endotracheal tube within the larynx plays a key role in functional electrophysiologic intraoperative neural monitoring (IONM) in thyroid surgery. The purpose of this study was to determine the feasibility of a portable video-assisted intubation device (UEScope) to verify the optimal placement of an EMG tube. METHODS A retrospective study enrolled 40 consecutive patients who underwent monitored thyroidectomies. After positioning the patient for surgery, an anesthesiologist performed tracheal intubation with UEScope and checked the position of the tube at the proper depth without rotation to the vocal cords. The main outcome measured was the proper EMG tube position, free from further adjustment. The secondary outcomes assessed were the percentage of available initial vagal stimulation (V1) signals. RESULTS All tracheal intubations were successful at first attempt. Proper EMG tube placement without position adjustment was found in 97.5% of the patients. Tube withdrawal was required in a male patient. All patients obtained detectable V1 signals; the lowest and median V1 amplitude was 485 and 767 μV as a reference value, respectively. CONCLUSION The UEScope is a valuable and reliable tool for placing an EMG tube and confirming its position during monitored thyroidectomy. In addition, further tube adjustment might be waived in most cases when the anesthesiologist placed the EMG tube after patient positioning for surgery. Routine use of video-assisted intubation devices is highly recommended. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Jui‐Mei Huang
- Department of AnesthesiologyKaohsiung Municipal Ta‐Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Chun‐Dan Hsu
- Department of AnesthesiologyKaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Sheng‐Hua Wu
- Department of AnesthesiologyKaohsiung Municipal Ta‐Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
- Faculty of MedicineCollege of Medicine, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Yi‐Wei Kuo
- Department of AnesthesiologyKaohsiung Medical University HospitalKaohsiungTaiwan
| | - Tzu‐Yen Huang
- Faculty of MedicineCollege of Medicine, Kaohsiung Medical UniversityKaohsiungTaiwan
- Department of Otorhinolaryngology—Head and Neck SurgeryKaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Che‐Wei Wu
- Faculty of MedicineCollege of Medicine, Kaohsiung Medical UniversityKaohsiungTaiwan
- Department of Otorhinolaryngology—Head and Neck SurgeryKaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
- Department of Otorhinolaryngology‐Head and Neck SurgeryKaohsiung Municipal Siaogang Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - I‐Cheng Lu
- Department of AnesthesiologyKaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
- Faculty of MedicineCollege of Medicine, Kaohsiung Medical UniversityKaohsiungTaiwan
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Laryngeal Neural Monitoring during Pediatric Thyroid Cancer Surgery-Is Transcartilage Recording a Preferable Method? Cancers (Basel) 2021; 13:cancers13164051. [PMID: 34439205 PMCID: PMC8392016 DOI: 10.3390/cancers13164051] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/21/2021] [Accepted: 08/08/2021] [Indexed: 12/31/2022] Open
Abstract
The use of transcartilage (TC) intraoperative neuromonitoring (IONM) in a pediatric population has not been reported. This study evaluated the feasibility and the benefit of using TC-IONM for thyroid cancer surgery in a pediatric population. This retrospective single-center study enrolled 33 pediatric patients who had received an IONM-assisted thyroidectomy. Demographic characteristics, standardized IONM laryngeal examinations and stimulation information (L1-V1-R1-R2-V2-L2) were compared between endotracheal tube (ET) and TC methods. In the 15 cancer patients (30 nerves), TC-IONM provided significant higher electromyography (EMG) amplitude (p < 0.001), signal stability (lower V1/V2 signal correlation, r = 0.955 vs. r = 0.484, p = 0.004), signal quality (higher ratio of V1 or V2 amplitude <500 µV, 0.0% vs. 43.8%, p = 0.005) and lower R1-R2p change (7.1% vs. 37.5%, p = 0.049) compared to ET-IONM. In the 18 benign patients (28 nerves), TC-IONM provided significantly higher EMG amplitude (p < 0.001), signal stability (r = 0.945 vs. r = 0.746, p = 0.0324) and non-significant higher signal quality and R1-R2p change. This report is the first to discuss the use of TC-IONM in pediatric thyroid surgery. In contrast with ET-IONM, TC-IONM had superior amplitude, stability and quality of EMG signals, which greatly facilitates the meticulous recurrent laryngeal nerve dissection in pediatric thyroidectomies. The TC-IONM method can be considered a feasible, effective and preferable method of monitored thyroidectomy in pediatric thyroid cancer.
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Zhang D, Wu CW, Wang T, Zhao Y, Kim HY, Pino A, Dionigi G, Sun H. Drawbacks of neural monitoring troubleshooting algorithms in transoral endoscopic thyroidectomy. Langenbecks Arch Surg 2021; 406:2433-2440. [PMID: 34264393 DOI: 10.1007/s00423-021-02217-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 05/24/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The application of intraoperative neural monitoring (IONM) trouble-shooting algorithms procedures in transoral endoscopic thyroidectomy vestibular approach (TOETVA) was investigated. METHODS Loss of signal (LOS) is defined as a loss of the primary electromyographic (EMG) normal biphasic waveform with reduced amplitude response to less than 100μV with a stimulation level intensity of 1-2mA. A systematic review of the IONM system at LOS was covered methodically: (i) correct endotracheal tube verification, (ii) stimulation of the recurrent laryngeal nerve (RLN) at entry point, (iii) ipsilateral or contralateral vagal nerve (VN) stimulation, and (iv) laryngeal twitch (LT). RESULTS The function of 223 nerves at risk (NAR) was recorded with IONM. Twenty-seven (12%) NAR experienced a suspected LOS. LT could not be appreciated. In 15/27 (55%) cases, the application of the IONM trouble-shooting algorithm revealed upward displacement of the EMG tube (all orotracheal intubations). In 9 (4%) NAR, VN stimulation was not accomplished. In detail, there were n.5 left and n. 4 right VNs. Two VNs were ipsilateral, and 7 VNs contralateral. For EMG tube displacement, because the oral/nasal area is included in the aseptic field, it is less possible to re-check by the laryngoscope or fiberscope. CONCLUSIONS A limit for applying the IONM trouble-shooting algorithm to TOETVA is determined by (a) inability to appreciate the LT, (b) difficulty in stimulating the ipsilateral and contralateral VN, and (c) remodeling EMG endotracheal tube position. A modified IONM trouble-shooting algorithm for TOETVA is proposed.
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Affiliation(s)
- Daqi Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, 126 Xiantai Blvd, Changchun City, Jilin Province, China
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tie Wang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, 126 Xiantai Blvd, Changchun City, Jilin Province, China
| | - Yishen Zhao
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, 126 Xiantai Blvd, Changchun City, Jilin Province, China
| | - Hoon Yub Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Antonella Pino
- Division of Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy.
| | - Gianlorenzo Dionigi
- Division of Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, 126 Xiantai Blvd, Changchun City, Jilin Province, China.
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Zhao Y, Zhang D, Zhou L, Li S, Wang T, Li F, Han Y, Dionigi G, Sun H. Proprieties of adhesive surface arrays to thyroid cartilage for recurrent laryngeal nerve monitoring. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:690. [PMID: 33987388 PMCID: PMC8106000 DOI: 10.21037/atm-21-1229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background To investigate the optimal placement and size of adhesive thyroid cartilage electrodes (ATCEs) placed on the thyroid cartilage in porcine models for evaluating recurrent laryngeal nerve function compared with the other 3 recording electrode types. Methods Four Meishan piglets were used for this study. The electromyogram (EMG) signal stability was detected by intraoperative nerve monitoring (IONM). Best location and size of ATCEs were detected, and the EMG signals from each were compared. Latency data were tested by stimulating the different nerve points, and 6 manipulations of the trachea and endotracheal tube (ET) were applied to test the stability of EMG signals. ET electrodes, needle electrodes, and transcutaneous recording electrodes were simultaneously tested with comparison to ATCEs. Results The optimal placement locations and sizes of ATCEs were determined. The amplitudes and latencies recorded from the ATCEs were consistent with those of the ET electrodes. More anti-interference was observed with the ATCEs than with the ET electrodes in surgical manipulations. ATCEs could be used during intermittent and continuous monitoring in similar fashion to ET electrodes and needle electrodes. Conclusions ATCEs had consistent monitoring function with ET electrodes and needle electrodes. Feasibility, EMG stability, and optimal location and size of ATCEs for IONM were resolved. The EMG profiles from the ATCEs were more stable during surgical manipulations.
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Affiliation(s)
- Yishen Zhao
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Daqi Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Le Zhou
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Shijie Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Tie Wang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Fang Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Yujia Han
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
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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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Lu CY, Wu TS, Wu KL, Wu ZF, Lai HC. A modified modality for intubation and check the position of intraoperative neuromonitoring endotracheal tube for thyroidectomy by Trachway. JOURNAL OF MEDICAL SCIENCES 2021. [DOI: 10.4103/jmedsci.jmedsci_123_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Jung SM, Tae K, Song CM, Lee SH, Jeong JH, Ji YB. Efficacy of Transcartilaginous Electrodes for Intraoperative Neural Monitoring During Thyroid Surgery. Clin Exp Otorhinolaryngol 2020; 13:422-428. [PMID: 32492990 PMCID: PMC7669316 DOI: 10.21053/ceo.2019.01529] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/07/2020] [Indexed: 12/01/2022] Open
Abstract
Objectives. This study was conducted evaluate the efficacy of electromyography (EMG) using transcartilaginous (TC) electrodes through the thyroid cartilage and perichondrium. Methods. We prospectively collected EMG data from intraoperative neuromonitoring (IONM) of 54 nerves at risk in 38 patients during thyroidectomy. We followed standardized IONM procedures in all operations. EMG signals from both endotracheal tube (ET) electrodes and TC needle electrodes were recorded simultaneously. We compared the characteristics of the EMG signals and the efficacy of both methods. Results. Significantly higher mean EMG amplitudes were recorded by TC electrodes than by ET electrodes in all four-step procedures (V1-R1-R2-V2, P<0.001). Loss of signal (LOS) occurred in five patients in ET electrodes, but in only two patients in TC electrodes. Postoperative laryngoscopy revealed recurrent laryngeal nerve palsy in the two patients who showed LOS from both the ET and TC electrodes, and vocal cord movement was intact in the other three patients. Therefore, the positive predictive values of LOS in ET and TC electrodes were 40% and 100%, respectively. Conclusion. EMG recording using TC needle electrodes is feasible and effective, making it a good alternative technique for IONM.
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Affiliation(s)
- Seon Min Jung
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Kyung Tae
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Chang Myeon Song
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Seung Hwan Lee
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Jin Hyeok Jeong
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Yong Bae Ji
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
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The transcutaneous electromyography recording method for intraoperative neuromonitoring of recurrent laryngeal nerve during minimally invasive parathyroidectomy. Sci Rep 2020; 10:7609. [PMID: 32376878 PMCID: PMC7203296 DOI: 10.1038/s41598-020-64675-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 03/12/2020] [Indexed: 11/20/2022] Open
Abstract
Intraoperative neuromonitoring (IONM) facilitates recurrent laryngeal nerve (RLN) protection in thyroid and parathyroid surgeries. This study aimed to investigate a novel transcutaneous electromyography (EMG) recording method for IONM of the RLN during minimally invasive parathyroidectomy (MIP). Twenty patients with primary hyperparathyroidism undergoing MIP were enrolled. Two paired needle electrodes were percutaneously inserted into the bilateral laminas of thyroid cartilage for monitoring the vagus nerve and RLN. A standardized IONM procedure (V1-R1-R2-V2 signals) was strictly followed, and the RLN was routinely located and mapped. Pre- and postoperative laryngofiberoscopy was performed to confirm vocal cord function. The proposed technique was successfully used in all patients, and typical EMG signals were effectively detected. No significant change in EMG signals before and after tumor resection was noted, and a normal vocal cord movement was ensured in all patients with postoperative laryngofiberoscopy. IONM helped localize the position of the RLN and facilitated the safe resection of the parathyroid tumor during MIP. The novel transcutaneous EMG recording method proposed in this study was feasible, convenient, reliable, and inexpensive.
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Ji YB, Ko SH, Song CM, Sung ES, Lee BJ, Wu CW, Chiang FY, Tae K. Feasibility and efficacy of intraoperative neural monitoring in remote access robotic and endoscopic thyroidectomy. Oral Oncol 2020; 103:104617. [DOI: 10.1016/j.oraloncology.2020.104617] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/24/2020] [Accepted: 02/22/2020] [Indexed: 10/24/2022]
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Chiang F, Wu C, Chang P, Wu S, Chen H, Lin Y, Huang T, Zesendavaa E, Lu I. Trans–thyroid cartilage recording for neural monitoring of the recurrent laryngeal nerve in thyroid surgery. Laryngoscope 2020; 130:E280-E283. [DOI: 10.1002/lary.28049] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/15/2019] [Accepted: 04/17/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Feng‐Yu Chiang
- Faculty of MedicineCollege of Medicine, Kaohsiung Medical University Kaohsiung Taiwan
- Department of Otorhinolaryngology–Head and Neck SurgeryCollege of Medicine, Kaohsiung Medical University Kaohsiung Taiwan
- and Graduate Institute of MedicineCollege of Medicine, Kaohsiung Medical University Kaohsiung Taiwan
| | - Che‐Wei Wu
- Faculty of MedicineCollege of Medicine, Kaohsiung Medical University Kaohsiung Taiwan
- Department of Otorhinolaryngology–Head and Neck SurgeryCollege of Medicine, Kaohsiung Medical University Kaohsiung Taiwan
| | - Pi‐Ying Chang
- Department of Anesthesiology Kaohsiung Municipal Ta‐Tung Hospital Kaohsiung Taiwan
| | - Sheng‐Hua Wu
- Faculty of MedicineCollege of Medicine, Kaohsiung Medical University Kaohsiung Taiwan
- Department of Anesthesiology Kaohsiung Municipal Hsiao‐Kang Hospital Kaohsiung Taiwan
| | - Hsiu‐Ya Chen
- Department of Anesthesiology Kaohsiung Medical University Hospital Kaohsiung Taiwan
| | - Yi‐Chu Lin
- Department of Otorhinolaryngology–Head and Neck SurgeryCollege of Medicine, Kaohsiung Medical University Kaohsiung Taiwan
| | - Tzu‐Yen Huang
- Department of Otorhinolaryngology–Head and Neck SurgeryCollege of Medicine, Kaohsiung Medical University Kaohsiung Taiwan
| | - Enkhtuvshin Zesendavaa
- and Graduate Institute of MedicineCollege of Medicine, Kaohsiung Medical University Kaohsiung Taiwan
| | - I‐Cheng Lu
- Faculty of MedicineCollege of Medicine, Kaohsiung Medical University Kaohsiung Taiwan
- Department of Anesthesiology Kaohsiung Municipal Hsiao‐Kang Hospital Kaohsiung Taiwan
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Kim J, Moon HJ, Chai YJ, Lee JM, Hwang KT, Wu CW, Dionigi G, Kim HY, Park KS, Kim SW, Yi KH. Feasibility of Attachable Ring Stimulator for Intraoperative Neuromonitoring during Thyroid Surgery. Int J Endocrinol 2020; 2020:5280939. [PMID: 32411225 PMCID: PMC7204267 DOI: 10.1155/2020/5280939] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/23/2019] [Accepted: 12/31/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Stimulator-attached dissecting instruments are useful for intraoperative nerve monitoring during thyroidectomy. The aim of this study was to evaluate the feasibility of an attachable ring stimulator (ARS) by comparing the electromyography (EMG) amplitudes evoked by an ARS and a conventional stimulator. METHODS Medical records of fourteen patients who underwent thyroidectomy using intraoperative neuromonitoring between June and August 2019 were retrospectively reviewed. The amplitudes of V1, R1, R2, and V2 signals were checked using both the ARS and a conventional stimulator, at the same point. RESULTS Both stimulators were tested on 20 recurrent laryngeal nerves (RLNs) and 20 vagus nerves (VNs). In all the nerves, the amplitudes of V1, R1, R2, and V2 were greater than 500 μV. The mean amplitudes of V1, R1, R2, and V2 checked with the ARS were 1175, 1432, 1598, and 1279 μV, respectively. The mean amplitudes of V1, R1, R2, and V2 checked with the conventional stimulator were 1140, 1425, 1557, and 1217 μV, respectively. Difference between amplitudes evoked by the two stimulators for V1, R1, R2, and V2 was 77, 110, 102, and 99 μV, respectively. There was no statistical difference in the amplitudes between the two groups for V1, R1, R2, and V2. CONCLUSION The ARS transferred electric stimulation as effectively as the conventional stimulator. It is an effective tool for repeated stimulation and facilitates continuous feedback regarding the functional integrity of nerves during thyroid surgery.
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Affiliation(s)
- Jongjin Kim
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Hyeon Jong Moon
- Department of Thoracic and Cardiovascular Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Young Jun Chai
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Jung-Man Lee
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Ki-Tae Hwang
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Che-Wei Wu
- Department of Otorhinolaryngology–Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital “G. Martino”, University of Messina, Messina, Italy
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Kyung Sik Park
- Department of Surgery, Konkuk University School of Medicine, Seoul 05030, Republic of Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Ka Hee Yi
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
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Lu IC, Wu SH, Wu CW. Neuromuscular blockade management for intraoperative neural monitoring. Kaohsiung J Med Sci 2019; 36:230-235. [PMID: 31713975 DOI: 10.1002/kjm2.12153] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/17/2019] [Indexed: 12/17/2022] Open
Abstract
This article reviews the literature on development of neuromuscular blockade management in thyroid surgery with intraoperative neural monitoring (IONM) in the past decade. Neuromuscular blockade management includes the choice of neuromuscular blocking agents (NMBAs) and reversal of neuromuscular blockade by sugammadex. A series of animal study and clinical trials showed NMBAs effect on IONM in thyroid surgery. We summarized five NMBA regimens for IONM: (a) relaxant-free regimen, (b) depolarizing NMBA-succinylcholine, (c) titration of nondepolarizing NMBA, and (d) rocuronium combined with sugammadex. The proper management of neuromuscular blockade during IONM has greatly developed over the past decade. The misuse of NMBAs is associated with false IONM interpretations to surgeons. A detailed understanding of NMBAs and neuromuscular blockade management by sugammadex may optimize IONM quality in patients receiving monitored thyroid surgery.
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Affiliation(s)
- I-Cheng Lu
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Sheng-Hua Wu
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
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Li P, Liang QZ, Wang DL, Han B, Yi X, Wei W. Modified arytenoid muscle electrode recording method for neuromonitoring during thyroidectomy. Gland Surg 2019; 8:469-476. [PMID: 31741877 DOI: 10.21037/gs.2019.08.07] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Intraoperative neuromonitoring (IONM) is an important application for protecting recurrent laryngeal nerve (RLN) during thyroid surgery. The method for recording arytenoid muscle electromyography (EMG) signals is reported to be feasible and reliable. However, the parameters of EMG signals are not provided. This study aimed to analyze the clinical characteristics of EMG signal parameters by modifying the insertion direction of needle electrodes. Methods A total of 92 patients who were scheduled to undergo thyroidectomy were recruited. Two paired needle electrodes were inserted in bilateral angle points between rectus cricothyroid muscle and inferior margin of thyroid cartilage (TC) intraoperatively, and then the information from the EMG signals was recorded according to four-step method (V1-R1-R2-V2). Pre-and post-operative laryngo-fiberoscopy was performed to confirm the vocal cord function. Results A total of 122 RLNs were successfully recorded during thyroidectomy, with the mean EMG amplitude and latency were 1,857±1,718/2,347±2,323 µV and 3.89±1.12/2.26±0.05 ms for V1/R1 signals before resection, and 1,924±1,705/2,450±2,345 µV and 3.87±1.17/2.27±0.08 ms for R2/V2 signals after resection. There were no significant changes before and after resection, and a normal vocal cord movement was observed postoperatively. The amplitude of left nerves was higher than that of the right ones. Furthermore, the latency of the right vagus was shorter than the left ones, but there was no difference in the amplitude and latency between age, sex and pathological types. Conclusions Modified arytenoid muscle EMG recording method was considered to be safe, feasible and reliable. The latency of right vagus EMG signals were shorter than the left ones, and the amplitude of EMG signals might be related to different sides.
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Affiliation(s)
- Peng Li
- Department of Thyroid and Parathyroid Surgery, Peking University Shenzhen Hospital, Peking University Health Science Center, Shenzhen 518000, China
| | - Qing-Zhuang Liang
- Department of Thyroid and Parathyroid Surgery, Peking University Shenzhen Hospital, Peking University Health Science Center, Shenzhen 518000, China
| | - Dong-Lai Wang
- Department of Thyroid and Parathyroid Surgery, Peking University Shenzhen Hospital, Peking University Health Science Center, Shenzhen 518000, China
| | - Bin Han
- Department of Thyroid and Parathyroid Surgery, Peking University Shenzhen Hospital, Peking University Health Science Center, Shenzhen 518000, China
| | - Xin Yi
- Department of Thyroid and Parathyroid Surgery, Peking University Shenzhen Hospital, Peking University Health Science Center, Shenzhen 518000, China
| | - Wei Wei
- Department of Thyroid and Parathyroid Surgery, Peking University Shenzhen Hospital, Peking University Health Science Center, Shenzhen 518000, China
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Sung ES, Lee JC, Shin SC, Kwon HG, Kim MS, Kim DJ, Ro JH, Lee BJ. Development of a Novel Intraoperative Neuromonitoring System Using a Surface Pressure Sensor to Detect Muscle Movement: A Rabbit Model Study. Clin Exp Otorhinolaryngol 2018; 12:217-223. [PMID: 30531650 PMCID: PMC6453788 DOI: 10.21053/ceo.2018.01207] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 10/18/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES False-negative or false-positive responses in intraoperative neuromonitoring (IONM) using electromyography (EMG) in thyroid surgery pose a challenge. Therefore, we developed a novel IONM system that uses a surface pressure sensor instead of EMG to detect muscle twitching. This study aimed to investigate the feasibility and safety of a new IONM system using a piezo-electric surface pressure sensor in an experimental animal model. METHODS We developed the surface pressure sensor by modifying a commercial piezo-electric sensor. We evaluated the stimulus thresholds to detect muscle movement, as well as the amplitude and latency of the EMG and surface pressure sensor in six sciatic nerves of three rabbits, according to the stimulus intensity. RESULTS The surface pressure sensor detected the muscle movements in response to a 0.1 mA stimulation of all six sciatic nerves. There were no differences in the thresholds of stimulus intensity between the surface pressure sensor and EMG recordings to detect muscle movements. CONCLUSION It is possible to measure the change in surface pressure by using a piezo-electric surface pressure sensor instead of EMG to detect muscle movement induced by nerve stimulation. The application of IONM using a piezo-electric surface pressure sensor during surgery is noninvasive, safe, and feasible. Measuring muscle twitching to identify the state of the nerves using the novel IONM system can be an alternative to recording of EMG responses.
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Affiliation(s)
- Eui-Suk Sung
- Department of Otolaryngology, Head and Neck Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University College of Medicine, Yangsan, Korea
| | - Jin-Choon Lee
- Department of Otolaryngology, Head and Neck Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University College of Medicine, Yangsan, Korea
| | - Sung-Chan Shin
- Department of Otolaryngology, Head and Neck Surgery and Medical Research Institute, Pusan National University College of Medicine, Busan, Korea
| | - Hyun-Geun Kwon
- Department of Otolaryngology, Head and Neck Surgery and Medical Research Institute, Pusan National University College of Medicine, Busan, Korea
| | - Min-Sik Kim
- Department of Otolaryngology, Head and Neck Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University College of Medicine, Yangsan, Korea
| | - Dong-Jo Kim
- Department of Otolaryngology, Head and Neck Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University College of Medicine, Yangsan, Korea
| | - Jung-Hoon Ro
- Department of Biomedical Engineering, Pusan National University Hospital, Busan, Korea
| | - Byung-Joo Lee
- Department of Otolaryngology, Head and Neck Surgery and Medical Research Institute, Pusan National University College of Medicine, Busan, Korea
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Wu CW, Chiang FY, Randolph GW, Dionigi G, Kim HY, Lin YC, Chen HC, Chen HY, Kamani D, Tsai TY, Lu IC, Chang PY. Feasibility of Intraoperative Neuromonitoring During Thyroid Surgery Using Transcartilage Surface Recording Electrodes. Thyroid 2018; 28:1508-1516. [PMID: 30255736 DOI: 10.1089/thy.2017.0680] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Intraoperative neural monitoring (IONM) has gained widespread acceptance as an adjunct to the gold standard of visual identification of the recurrent laryngeal nerve (RLN) during thyroid surgery. Currently, laryngeal electromyography (EMG) recording during IONM is almost always performed using endotracheal tube (ETT) surface electrodes placed adjacent to vocal folds originating from the inner surface of the thyroid cartilage (TC). Therefore, it was hypothesized that surface recording electrodes placed on the outer surface of the TC should enable access to the EMG response of the vocal folds during IONM. The aim of this experimental study was to evaluate the feasibility of the transcartilage approach for laryngeal EMG recording during IONM. METHODS A porcine model (12 pigs and 24 RLN sides) with well established applicability in IONM research was used for the experiments. Both ETT electrodes adjacent to vocal folds and adhesive pre-gelled electrodes on the TC were used for EMG recording during IONM. Electrically evoked EMG signals detected by both electrode types were recorded and analyzed. EMG changes during tracheal displacement and RLN traction injury were compared. RESULTS Both the ETT and TC recording electrodes recorded typical laryngeal EMG waveforms evoked by a 1 mA stimulus current applied on both sides of the RLNs and vagus nerves (VNs). Under RLN stimulation, the mean EMG amplitudes recorded with the ETT and TC electrodes were 973 ± 79 μV and 695 ± 150 μV, respectively. Under VN stimulation, the mean amplitudes were 841 ± 163 μV and 607 ± 162 μV, respectively. When upward displacement of the trachea was experimentally induced, the TC electrodes showed less variation in recorded EMG signals compared to ETT electrodes. When RLN traction stress was experimentally induced, both the ETT and TC electrodes accurately recorded the typical EMG pattern of progressively degrading amplitude and gradual recovery after release of traction. CONCLUSIONS This study confirms the feasibility of using transcartilage surface electrodes for recording laryngeal EMG signals evoked during IONM in an animal model. However, before practical application of this approach in clinical thyroid surgery, further studies are needed to improve electrode designs by optimizing their shapes and sizes, and increasing their adhesive stability and sensitivity.
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Affiliation(s)
- Che-Wei Wu
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Gregory W Randolph
- 2 Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School , Boston, Massachusetts
- 3 Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital , Harvard Medical School, Boston, Massachusetts
| | - Gianlorenzo Dionigi
- 4 Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi," University Hospital G. Martino, University of Messina , Sicily, Italy
| | - Hoon Yub Kim
- 5 Department of Surgery, Korea University College of Medicine , Seoul, Korea
| | - Yi-Chu Lin
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Hui-Chun Chen
- 6 Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Hsiu-Ya Chen
- 7 Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Dipti Kamani
- 2 Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School , Boston, Massachusetts
| | - Tsung-Yi Tsai
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - I-Cheng Lu
- 7 Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Pi-Ying Chang
- 7 Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
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25
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Wu CW, Chiang FY, Randolph GW, Dionigi G, Kim HY, Lin YC, Huang TY, Lin CI, Hun PC, Kamani D, Chang PY, Lu IC. Transcutaneous Recording During Intraoperative Neuromonitoring in Thyroid Surgery. Thyroid 2018; 28:1500-1507. [PMID: 30027832 DOI: 10.1089/thy.2017.0679] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) palsy remains a major source of morbidity after thyroid surgeries. Intraoperative neural monitoring (IONM) has gained increasing acceptance as an adjunct to standard practice of visual RLN identification. Endotracheal tube (ETT) surface recording electrodes systems are now widely used for IONM; however, a malpositioned ETT can cause false IONM results and requires time-consuming intraoperative verification of the ETT position and readjustment by the anesthesiologist. The aim of this experimental study was to evaluate the feasibility of the transcutaneous approach for recording evoked laryngeal electromyography (EMG) signals during IONM. METHODS A porcine model with well-established applicability in IONM research was used. Twelve piglets (24 nerve sides) were enrolled. Electrically evoked EMGs were recorded from surface electrodes on the ETT and from the adhesive pre-gelled surface electrodes on the anterior neck skin. The evoked EMG waveforms were measured and analyzed. The real-time signal stability of the electrodes during tracheal displacement and their accuracy in reflecting adverse EMG changes during RLN stress were evaluated during continuous IONM performed with automatic periodic vagus nerve (VN) stimulation. RESULTS In all nerves, both the ETT and neck adhesive skin electrodes successfully recorded typical evoked laryngeal EMG waveforms from the RLNs and VNs under stimulation with 1 mA. The transcutaneous electrodes recorded mean EMG amplitudes of 264 μV (±79) under RLN stimulation and 202 μV (±55) under VN stimulation. The electrodes recorded mean EMG latencies of 2.98 ms (±0.20) under RLN stimulation, 4.51 ms (±0.50) under right VN stimulation, and 8.13 ms (±0.94) under left VN stimulation, respectively. When tracheal displacement was experimentally induced, the EMG signals obtained by ETT electrodes varied significantly, but those obtained by transcutaneous electrodes did not. When RLN traction stress was experimentally induced, both ETT and transcutaneous electrodes recorded the same pattern of progressively degrading EMG amplitude with gradual recovery after release of traction. CONCLUSIONS This study confirms the feasibility of transcutaneous recording of evoked laryngeal EMG during IONM. Although this study confirms the stability and accuracy of the transcutaneous approach, it also revealed the need for new electrode designs to improve EMG amplitudes before practical clinical application of this approach.
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Affiliation(s)
- Che-Wei Wu
- 1 Department of Otolaryngology-Head and Neck Surgery and Kaohsiung Medical University , Kaohsiung, Taiwan
- 2 Department of Faculty of Medicine, College of Medicine, and Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- 1 Department of Otolaryngology-Head and Neck Surgery and Kaohsiung Medical University , Kaohsiung, Taiwan
- 2 Department of Faculty of Medicine, College of Medicine, and Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Gregory W Randolph
- 3 Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital , Harvard Medical School, Boston, Massachusetts
- 4 Department of Otology and Laryngology, Massachusetts General Hospital , Harvard Medical School, Boston, Massachusetts
- 5 Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital , Harvard Medical School, Boston, Massachusetts
| | - Gianlorenzo Dionigi
- 6 Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi," University Hospital G. Martino, University of Messina , Sicily, Italy
| | - Hoon Yub Kim
- 7 Department of Surgery, Korea University College of Medicine , Seoul, Korea
| | - Yi-Chu Lin
- 1 Department of Otolaryngology-Head and Neck Surgery and Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- 1 Department of Otolaryngology-Head and Neck Surgery and Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Chiao-I Lin
- 1 Department of Otolaryngology-Head and Neck Surgery and Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Pao-Chu Hun
- 8 Department of Laboratory Animal Center, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - Dipti Kamani
- 3 Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital , Harvard Medical School, Boston, Massachusetts
| | - Pi-Ying Chang
- 9 Department of Anesthesiology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University , Kaohsiung, Taiwan
| | - I-Cheng Lu
- 2 Department of Faculty of Medicine, College of Medicine, and Kaohsiung Medical University , Kaohsiung, Taiwan
- 9 Department of Anesthesiology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University , Kaohsiung, Taiwan
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26
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Zhao Y, Li C, Zhang D, Zhou L, Liu X, Li S, Wang T, Dionigi G, Sun H. Experimental study of needle recording electrodes placed on the thyroid cartilage for neuromonitoring during thyroid surgery. Br J Surg 2018; 106:245-254. [PMID: 30273975 DOI: 10.1002/bjs.10994] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/11/2018] [Accepted: 08/02/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Needle electrodes placed on the thyroid cartilage (TC) are an alternative to endotracheal tube (ET) electrodes for assessing recurrent laryngeal nerve (RLN) function during thyroid surgery. Needle electrodes placed on the TC were evaluated in an experimental porcine model. METHODS Continuous intraoperative neuromonitoring was used to record the electromyogram. Each TC side was delineated into nine areas to determine the optimal placement of the electrode, and needle electrode area, depth and orientation for optimal electromyographic (EMG) amplitudes were evaluated. RLN root locations were stimulated at four locations: vagus nerve distal to the neuromonitoring electrode, and most proximal, middle and laryngeal entry points of the nerve. A nerve retraction injury model was adapted to compare RLN monitoring by TC versus ET electrodes. RESULTS An optimal site for placement of needle electrodes was identified, and electromyograms obtained from the various needle insertion depths and orientations were similar. Latencies recorded from the TC and ET electrodes were similar. The amplitude profile of TC electrodes responded earlier to RLN injury than that of ET electrodes. Amplitude and drop to loss of signal were also registered earlier. CONCLUSION EMG amplitudes obtained using TC electrodes were higher, and identified RLN injury earlier than ET electrodes. Surgical relevance Needle electrodes placed on the thyroid cartilage (TC) are an alternative to endotracheal tube (ET) electrodes for assessing the function of the recurrent laryngeal nerve (RLN) in thyroid surgery. This study used an experimental porcine model to evaluate the use of needle electrodes inserted in the TC, compared with ET electrodes, for producing an electromyographic (EMG) profile of the RLN. Nine areas of the TC, with various needle insertion depths and orientations, were compared. Perichondral insertion into the avascular area of the TC was found to be safe. The EMG amplitude and latency features recorded via the TC and ET electrodes were compared, using both intermittent and continuous monitoring. Changes in EMG amplitudes in response to nerve traction injury were registered earlier with TC electrodes than with ET electrodes, and the amplitudes were higher and more stable. Latencies obtained via the TC and ET electrodes were similar. These results indicate that the development of a non-invasive monitoring electrode with improved function, easy placement and low cost is possible.
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Affiliation(s)
- Y Zhao
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - C Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - D Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - L Zhou
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - X Liu
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - S Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - T Wang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - G Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood 'Gaetano Barresi', University Hospital G. Martino, University of Messina, Messina, Italy
| | - H Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
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27
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Lu IC, Lin IH, Wu CW, Chen HY, Lin YC, Chiang FY, Chang PY. Preoperative, intraoperative and postoperative anesthetic prospective for thyroid surgery: what's new. Gland Surg 2017; 6:469-475. [PMID: 29142836 DOI: 10.21037/gs.2017.05.02] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The aim of this review is to analyze what's new on anesthetic prospective to perioperative management for thyroid surgery. For recent decades intraoperative neuromonitoring (IONM) during thyroid and parathyroid surgery has obtained more and more popularity. New modality of anesthetic technique was also developed to incorporate into surgical teamwork. For example, the precise position of EMG tube and optimal use of neuromuscular blocking agents (NMBAs) play key roles in successful IONM system. Special focus is paid to following issues: (I) preoperative airway evaluation and pre-op preparation; (II) anesthetic managements including advanced intubation tools, NMBAs and sugammadex; and (III) post-op adverse events such as pain and postoperative nausea vomiting.
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Affiliation(s)
- I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Municipal Hsiao-Kang Hospital, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - I-Hua Lin
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Hsiu-Ya Chen
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yi-Chu Lin
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
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28
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Chang PY, Hu PY, Lin YC, Chen HY, Chiang FY, Wu CW, Dionigi G, Lu IC. Trachway video intubating stylet allows for optimization of electromyographic endotracheal tube placement for monitored thyroidectomy. Gland Surg 2017; 6:464-468. [PMID: 29142835 DOI: 10.21037/gs.2017.08.08] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Endotracheal tube-based surface electrodes are now commonly applied to measure evoked electromyographic (EMG) response of the vocal cord during monitored thyroidectomy. The aim of the study was to determine the incidence of difficult intubation and to assess the effectiveness of using video-assisted intubating stylet (Trachway) for EMG tube placement in patients undergoing monitored thyroidectomy. Methods Medical records were collected from consecutive patients undergoing thyroid surgery before and after implementation of the protocol. A total of 748 patients intubated with EMG tube for monitored thyroidectomy by the same team were enrolled in this study. Patient allocation was based on intubation technique either conventional direct laryngoscopy (n=336) or Trachway (n=412). The intubation difficulty was assessed and analyzed. Results The overall incidence of difficult intubation was 4.4%. Incidence of difficult intubation was significantly lower in patients with the Trachway procedure (2.7%) than direct laryngoscopy (6.5%, P=0.01). The incidence of "unable to intubate" (>3 attempts, or change airway device or anesthesiologist) also significantly reduced from 2.3% to 0.5% after introduction of the Trachway intubating stylet (P=0.02). Conclusions We conclude that the incidence of difficult intubation was significantly lower with Trachway than direct laryngoscopy. The Trachway video-intubating stylet is useful and helpful to reduce EMG tube intubation difficulty for monitored thyroidectomy.
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Affiliation(s)
- Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Pin-Yang Hu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yi-Chu Lin
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiu-Ya Chen
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital-Policlinico "G. Martino", University of Messina, Messina, Italy
| | - I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Anesthesiology, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Chiang FY, Lu IC, Chang PY, Dionigi G, Randolph GW, Sun H, Lee KD, Tae K, Ji YB, Kim SW, Lee HS, Wu CW. Comparison of EMG signals recorded by surface electrodes on endotracheal tube and thyroid cartilage during monitored thyroidectomy. Kaohsiung J Med Sci 2017; 33:503-509. [DOI: 10.1016/j.kjms.2017.06.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/06/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022] Open
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30
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Liang F, Liu G, Li H, Li Y, Li X. Experience of monitoring the recurrent laryngeal nerve in thyroid surgery with endotracheal intubation. BIO WEB OF CONFERENCES 2017. [DOI: 10.1051/bioconf/20170801045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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31
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Barber SR, Liddy W, Kyriazidis N, Cinquepalmi M, Lin BM, Modi R, Patricio S, Kamani D, Belotti C, Mahamad S, Lawson B, Randolph GW. Changes in electromyographic amplitudes but not latencies occur with endotracheal tube malpositioning during intraoperative monitoring for thyroid surgery: Implications for guidelines. Laryngoscope 2016; 127:2182-2188. [DOI: 10.1002/lary.26392] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 08/26/2016] [Accepted: 09/22/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Samuel R. Barber
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Whitney Liddy
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Natalia Kyriazidis
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Matteo Cinquepalmi
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Operative Unit Surgery of Thyroid and Parathyroid; Sapienza University of Rome, Sant'Andrea Hospital; Rome Italy
| | - Brian M. Lin
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Rahul Modi
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Stephanie Patricio
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Carlo Belotti
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Operative Unit Surgery of Thyroid and Parathyroid; Sapienza University of Rome, Sant'Andrea Hospital; Rome Italy
| | - Sadhana Mahamad
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Bradley Lawson
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
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Wu CW, Randolph GW, Lu IC, Chang PY, Chen YT, Hun PC, Lin YC, Dionigi G, Chiang FY. Intraoperative neural monitoring in thyroid surgery: lessons learned from animal studies. Gland Surg 2016; 5:473-480. [PMID: 27867861 PMCID: PMC5106378 DOI: 10.21037/gs.2016.09.06] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 09/09/2016] [Indexed: 12/31/2022]
Abstract
Recurrent laryngeal nerve (RLN) injury remains a significant morbidity associated with thyroid and parathyroid surgery. In the past decade, surgeons have increasingly used intraoperative neural monitoring (IONM) as an adjunct technique for localizing and identifying the RLN, detecting RLN injury, and predicting the outcome of vocal cord function. In recent years, many animal studies have investigated common pitfalls and new applications of IONM. For example, the use of IONM technology in animal models has proven valuable in studies of the electrophysiology of RLN injury. The advent of animal studies has substantially improved understanding of IONM technology. Lessons learned from animal studies have immediate clinical applications in establishing reliable strategies for preventing intraoperative RLN injury. This article gives an overview of the research progress on IONM-relevant animal models.
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Affiliation(s)
- Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Laryngology and Otology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, USA
| | - I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Ting Chen
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pao-Chu Hun
- Laboratory Animal Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chu Lin
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- 1 Division of Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria (Como-Varese), Varese, Italy
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Liu XL, Wu CW, Zhao YS, Wang T, Chen P, Xin JW, Li SJ, Zhang DQ, Zhang G, Fu YT, Zhao LN, Zhou L, Dionigi G, Chiang FY, Sun H. Exclusive real-time monitoring during recurrent laryngeal nerve dissection in conventional monitored thyroidectomy. Kaohsiung J Med Sci 2016; 32:135-41. [DOI: 10.1016/j.kjms.2016.02.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 02/06/2016] [Accepted: 02/16/2016] [Indexed: 10/22/2022] Open
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Recurrent laryngeal nerve injury with incomplete loss of electromyography signal during monitored thyroidectomy—evaluation and outcome. Langenbecks Arch Surg 2016; 402:691-699. [DOI: 10.1007/s00423-016-1381-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 02/08/2016] [Indexed: 11/27/2022]
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Lu IC, Wu CW, Chang PY, Chen HY, Tseng KY, Randolph GW, Cheng KI, Chiang FY. Reversal of rocuronium-induced neuromuscular blockade by sugammadex allows for optimization of neural monitoring of the recurrent laryngeal nerve. Laryngoscope 2016; 126:1014-9. [PMID: 26748952 DOI: 10.1002/lary.25577] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVES/HYPOTHESIS The use of neuromuscular blocking agent may effect intraoperative neuromonitoring (IONM) during thyroid surgery. An enhanced neuromuscular-blockade (NMB) recovery protocol was investigated in a porcine model and subsequently clinically applied during human thyroid neural monitoring surgery. STUDY DESIGN Prospective animal and retrospective clinical study. METHODS In the animal experiment, 12 piglets were injected with rocuronium 0.6 mg/kg and randomly allocated to receive normal saline, sugammadex 2 mg/kg, or sugammadex 4 mg/kg to compare the recovery of laryngeal electromyography (EMG). In a subsequent clinical application study, 50 patients who underwent thyroidectomy with IONM followed an enhanced NMB recovery protocol-rocuronium 0.6 mg/kg at anesthesia induction and sugammadex 2 mg/kg at the operation start. The train-of-four (TOF) ratio was used for continuous quantitative monitoring of neuromuscular transmission. RESULTS In our porcine model, it took 49 ± 15, 13.2 ± 5.6, and 4.2 ± 1.5 minutes for the 80% recovery of laryngeal EMG after injection of saline, sugammadex 2 mg/kg, and sugammadex 4 mg/kg, respectively. In subsequent clinical human application, the TOF ratio recovered from 0 to >0.9 within 5 minutes after administration of sugammadex 2 mg/kg at the operation start. All patients had positive and high EMG amplitude at the early stage of the operation, and intubation was without difficulty in 96% of patients. CONCLUSIONS Both porcine modeling and clinical human application demonstrated that sugammadex 2 mg/kg allows effective and rapid restoration of neuromuscular function suppressed by rocuronium. Implementation of this enhanced NMB recovery protocol assures optimal conditions for tracheal intubation as well as IONM in thyroid surgery. LEVEL OF EVIDENCE NA.
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Affiliation(s)
- I-Cheng Lu
- Graduate Institute of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Anesthesiology , Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Faculty of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otolaryngology-Head and Neck Surgery , Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology , Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiu-Ya Chen
- Department of Anesthesiology , Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuang-Yi Tseng
- Department of Anesthesiology , Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Surgery, Department of Laryngology and Otology , Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.,Massachusetts Eye and Ear Infirmary, and the Division of Surgical Oncology, Department of Surgery , Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Kuang-I Cheng
- Graduate Institute of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Anesthesiology , Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- Graduate Institute of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otolaryngology-Head and Neck Surgery , Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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36
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Kim HY, Tufano RP, Randolph G, Barczyński M, Wu CW, Chiang FY, Liu X, Masuoka H, Miyauchi A, Park SY, Kwak HY, Lee HY, Dionigi G. Impact of positional changes in neural monitoring endotracheal tube on amplitude and latency of electromyographic response in monitored thyroid surgery: Results from the Porcine Experiment. Head Neck 2015; 38 Suppl 1:E1004-8. [PMID: 26040955 DOI: 10.1002/hed.24145] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 04/14/2015] [Accepted: 05/31/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate electromyography (EMG) amplitude and latency changes during tube dislocation in monitored thyroid surgery, which may be observed without recurrent laryngeal nerve injury. METHODS Duroc-Landrace piglets were intubated with the TriVantage EMG tube. We measured EMG changes during both upward and downward tube dislocation (10-20 mm) and rotation (45-90°) with continuous neuromonitoring. RESULTS The EMG amplitude varied significantly with induced endotracheal tube rotation and depth changes. However, the EMG latency was relatively unaffected by such tube dislocation, just a transient artifactual latency change was observed in the situation of extreme amplitude variation. CONCLUSION Amplitude changes without latency changes may be due to changes in tube position alone during surgery, but could still reflect a neurophysiologic event; amplitude changes during neuropraxic injury merit additional investigation. Thus, the combined event (concordant amplitude decrease and latency increase) serves as an appropriate adverse EMG event correlating with impending neural injury. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1004-E1008, 2016.
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Affiliation(s)
- Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gregory Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Laryngology and Otology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Marcin Barczyński
- Department of General Surgery, Jagiellonian University, Medical College, Krakow, Poland
| | - Che-Wei Wu
- Institute of Clinical Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- Institute of Clinical Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Xiaoli Liu
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Hiroo Masuoka
- Department of Surgery, Kuma Hospital, Center for Excellence in Thyroid Care, Kobe, Japan
| | - Akira Miyauchi
- Department of Anesthesiology, Korea University College of Medicine, Seoul, Korea
| | - Soo Young Park
- Department of Anesthesiology, Korea University College of Medicine, Seoul, Korea
| | - Hee Yong Kwak
- Department of Surgery, KUMC Thyroid Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hye Yoon Lee
- Department of Surgery, KUMC Thyroid Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Gianlorenzo Dionigi
- First Division of Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria (Como-Varese), Varese, Italy
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Chiang FY, Lu IC, Chang PY, Sun H, Wang P, Lu XB, Chen HC, Chen HY, Kim HY, Dionigi G, Wu CW. Stimulating dissecting instruments during neuromonitoring of RLN in thyroid surgery. Laryngoscope 2015; 125:2832-7. [DOI: 10.1002/lary.25251] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 01/30/2015] [Accepted: 02/11/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Feng-Yu Chiang
- Department of Otorhinolaryngology-Head and Neck Surgery; Kaohsiung Medical University (KMU); Kaohsiung Taiwan
- Faculty of Medicine; Graduate Institute of Clinical Medicine, and Department of Respiratory Therapy, College of Medicine, KMU; Kaohsiung Taiwan
| | - I-Cheng Lu
- Department of Anesthesiology; Kaohsiung Medical University (KMU)
- Faculty of Medicine; Graduate Institute of Clinical Medicine, and Department of Respiratory Therapy, College of Medicine, KMU; Kaohsiung Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology; Kaohsiung Medical University (KMU)
| | - Hui Sun
- Department of Thyroid and Parathyroid Surgery; China-Japan Union Hospital, Jilin University & Jilin Provincial Key Laboratory of Surgical Translational Medicine; Changchun Jilin
| | - Ping Wang
- Department of Surgery; the 2nd Affiliated Hospital, Zhejiang University School of Medicine; Zhejiang
| | - Xiu-Bo Lu
- Department of Thyroid Surgery; the first Affiliated Hospital of Zhengzhou University; Henan China
| | - Hui-Chun Chen
- Department of Nursing; Kaohsiung Medical University Hospital, Kaohsiung Medical University (KMU); Kaohsiung Taiwan
| | - Hsiu-Ya Chen
- Department of Anesthesiology; Kaohsiung Medical University (KMU)
| | - Hoon Yub Kim
- Department of Surgery; Korea University College of Medicine (h.y.k.); Seoul Korea
| | - Gianlorenzo Dionigi
- Endocrine Surgery Research Center; Department of Surgical Sciences and Human Morphology; University of Insubria; Varese-Como Varese Italy
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery; Kaohsiung Medical University (KMU); Kaohsiung Taiwan
- Faculty of Medicine; Graduate Institute of Clinical Medicine, and Department of Respiratory Therapy, College of Medicine, KMU; Kaohsiung Taiwan
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Wu CW, Wang MH, Chen CC, Chen HC, Chen HY, Yu JY, Chang PY, Lu IC, Lin YC, Chiang FY. Loss of signal in recurrent nerve neuromonitoring: causes and management. Gland Surg 2015; 4:19-26. [PMID: 25713776 DOI: 10.3978/j.issn.2227-684x.2014.12.03] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 12/15/2014] [Indexed: 11/14/2022]
Abstract
During recurrent laryngeal nerve (RLN) neuromonitoring in thyroid surgery, laryngeal electromyography (EMG) amplitude may be correlated with the number of muscle fibers participating in the polarization and these might be correlated with the function of RLN. If RLN is severely injured during the operation, most nerve fibers do not transmit nerve impulse and substantial decrease of EMG amplitude or loss of signal (LOS) will occur. True LOS at the end of an operation often indicates a postoperative fixed vocal cord, and the surgeon should consider the optimal contralateral surgery timing in patients with planned bilateral thyroid operation to avoid the disaster of bilateral vocal cord palsy. However, LOS recovery and false LOS may occur and may lead to an unnecessary 2(nd) operation. Therefore, a reliable modality for intraoperative LOS evaluation and management would afford the surgeon real-time information that could help guide surgical procedure and planning. The updated causes, algorithm, and management of LOS during RLN neuromonitoring are reviewed and summarized.
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Affiliation(s)
- Che-Wei Wu
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, 2 Faculty of Medicine, College of Medicine, 3 Department of Nursing, 4 Department of Anesthesiology, Kaohsiung Medical University Hospital, 5 Graduate Institute of Clinical Medicine, Graduate Institute of Medicine, 6 Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University (KMU), Kaohsiung, Taiwan
| | - Mei-Hui Wang
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, 2 Faculty of Medicine, College of Medicine, 3 Department of Nursing, 4 Department of Anesthesiology, Kaohsiung Medical University Hospital, 5 Graduate Institute of Clinical Medicine, Graduate Institute of Medicine, 6 Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University (KMU), Kaohsiung, Taiwan
| | - Cheng-Chien Chen
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, 2 Faculty of Medicine, College of Medicine, 3 Department of Nursing, 4 Department of Anesthesiology, Kaohsiung Medical University Hospital, 5 Graduate Institute of Clinical Medicine, Graduate Institute of Medicine, 6 Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University (KMU), Kaohsiung, Taiwan
| | - Hui-Chun Chen
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, 2 Faculty of Medicine, College of Medicine, 3 Department of Nursing, 4 Department of Anesthesiology, Kaohsiung Medical University Hospital, 5 Graduate Institute of Clinical Medicine, Graduate Institute of Medicine, 6 Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University (KMU), Kaohsiung, Taiwan
| | - Hsiu-Ya Chen
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, 2 Faculty of Medicine, College of Medicine, 3 Department of Nursing, 4 Department of Anesthesiology, Kaohsiung Medical University Hospital, 5 Graduate Institute of Clinical Medicine, Graduate Institute of Medicine, 6 Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University (KMU), Kaohsiung, Taiwan
| | - Jing-Yi Yu
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, 2 Faculty of Medicine, College of Medicine, 3 Department of Nursing, 4 Department of Anesthesiology, Kaohsiung Medical University Hospital, 5 Graduate Institute of Clinical Medicine, Graduate Institute of Medicine, 6 Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University (KMU), Kaohsiung, Taiwan
| | - Pi-Ying Chang
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, 2 Faculty of Medicine, College of Medicine, 3 Department of Nursing, 4 Department of Anesthesiology, Kaohsiung Medical University Hospital, 5 Graduate Institute of Clinical Medicine, Graduate Institute of Medicine, 6 Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University (KMU), Kaohsiung, Taiwan
| | - I-Cheng Lu
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, 2 Faculty of Medicine, College of Medicine, 3 Department of Nursing, 4 Department of Anesthesiology, Kaohsiung Medical University Hospital, 5 Graduate Institute of Clinical Medicine, Graduate Institute of Medicine, 6 Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University (KMU), Kaohsiung, Taiwan
| | - Yi-Chu Lin
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, 2 Faculty of Medicine, College of Medicine, 3 Department of Nursing, 4 Department of Anesthesiology, Kaohsiung Medical University Hospital, 5 Graduate Institute of Clinical Medicine, Graduate Institute of Medicine, 6 Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University (KMU), Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, 2 Faculty of Medicine, College of Medicine, 3 Department of Nursing, 4 Department of Anesthesiology, Kaohsiung Medical University Hospital, 5 Graduate Institute of Clinical Medicine, Graduate Institute of Medicine, 6 Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University (KMU), Kaohsiung, Taiwan
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Chang PY, Wu CW, Chen HY, Chen HC, Cheng KI, Lu IC, Chiang FY. Influence of intravenous anesthetics on neuromonitoring of the recurrent laryngeal nerve during thyroid surgery. Kaohsiung J Med Sci 2014; 30:499-503. [PMID: 25438680 DOI: 10.1016/j.kjms.2014.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 05/22/2014] [Accepted: 01/17/2014] [Indexed: 11/30/2022] Open
Abstract
Limited reports are available in the literature on the impact of intravenous administration of anesthetics on laryngeal electromyographic (EMG) activity. The purpose of this study was to determine the influence of the two commonly used intravenous anesthetics (propofol and thiamylal) on EMG amplitude evoked from the recurrent laryngeal nerve (RLN) during thyroid surgery. A total of 40 patients were randomized to receive a bolus of propofol (0.5 mg/kg; n = 20) or thiamylal (1.5 mg/kg; n = 20) to increase anesthetic depth when the surgeon found patient movement intraoperatively. Evoked potentials were obtained before and every 1 minute after the administration of each agent for up to 5 minutes by stimulating the RLN. The magnitude of evoked potentials at each time point and hemodynamic response were compared within groups. The mean amplitude of evoked potentials did not change significantly after administration of either propofol or thiamylal (p > 0.05 within groups). Mean arterial pressure measured from 1 minute to 5 minutes was significantly lower in the propofol group than in the thiamylal group (p < 0.05). Heart rate measured within 5 minutes did not differ significantly within groups. Low dose of propofol (0.5 mg/kg) or thiamylal (1.5 mg/kg) did not affect EMG readings during neuromonitoring of the RLN in thyroid surgery. Our results show that thiamylal provides better hemodynamic stability than propofol, and is therefore a preferable agent to increase anesthesia depth and prevent further patient movement during intraoperative neuromonitoring.
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Affiliation(s)
- Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Hsiu-Ya Chen
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Hui-Chun Chen
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Kuang-I Cheng
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Feng-Yu Chiang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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40
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Cherng CH, Huang YH, Shih ML. Middle fixation of electromyographic endotracheal tube for intraoperative recurrent laryngeal nerve monitoring. J Clin Anesth 2014; 26:252-3. [PMID: 24793705 DOI: 10.1016/j.jclinane.2014.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 01/02/2014] [Accepted: 01/29/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Chen-Hwan Cherng
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Neihu 114, Taipei, Taiwan
| | - Yi-Hsuan Huang
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Neihu 114, Taipei, Taiwan
| | - Ming-Lang Shih
- Department of Surgery, Tri-Service General Hospital and National Defense Medical Center, Neihu 114, Taipei, Taiwan.
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41
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The Current State of Recurrent Laryngeal Nerve Monitoring for Thyroid Surgery. CURRENT OTORHINOLARYNGOLOGY REPORTS 2013. [DOI: 10.1007/s40136-013-0033-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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42
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Dionigi G, Chiang FY, Dralle H, Boni L, Rausei S, Rovera F, Piantanida E, Mangano A, Barczyński M, Randolph GW, Dionigi R, Ulmer C. Safety of neural monitoring in thyroid surgery. Int J Surg 2013; 11 Suppl 1:S120-6. [DOI: 10.1016/s1743-9191(13)60031-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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43
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Lu IC, Chang PY, Hsu HT, Tseng KY, Wu CW, Lee KW, Ho KY, Chiang FY. A comparison between succinylcholine and rocuronium on the recovery profile of the laryngeal muscles during intraoperative neuromonitoring of the recurrent laryngeal nerve: A prospective porcine model. Kaohsiung J Med Sci 2013; 29:484-7. [DOI: 10.1016/j.kjms.2013.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 09/06/2012] [Indexed: 11/17/2022] Open
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44
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Wu CW, Dionigi G, Chen HC, Chen HY, Lee KW, Lu IC, Chang PY, Hsiao PJ, Ho KY, Chiang FY. Vagal nerve stimulation without dissecting the carotid sheath during intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid surgery. Head Neck 2012; 35:1443-7. [PMID: 22987562 DOI: 10.1002/hed.23154] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2012] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Vagal nerve stimulation (VNS) has been recommended as a routine procedure during intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN). However, many surgeons have been discouraged from performing VNS because of the need for opening the carotid sheath. The purpose of this study was to investigate the feasibility and reliability of VNS without carotid sheath dissection. METHODS Two hundred twenty patients with 376 nerves at risk were enrolled in this study. VNS without nerve exposure during IONM was applied by simply pressing a ball-tip stimulator on the space between the carotid artery and jugular vein. RESULTS VNS without nerve exposure was feasible in all cases and did not result in any morbidity. All VNS signals were successfully obtained within 30 minutes of the start of the operation and all showed a clear and reliable laryngeal electromyography (EMG) response that was similar to that from the conventional method in which nerve exposure for VNS is applied. CONCLUSIONS VNS without dissecting the carotid sheath is feasible and reliable, rendering it a simple, safe, and surgeon-friendly procedure during IONM.
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Affiliation(s)
- Che-Wei Wu
- Faculty of Medicine and Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital and Kaohsiung Municipal Hsiao-Kang Hospital, Taiwan
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