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Revelli L, Gallucci P, Marchese MR, Voloudakis N, Di Lorenzo S, Montuori C, D'Alatri L, Pennestri F, De Crea C, Raffaelli M. Is There Any Reliable Predictor of Functional Recovery Following Post-thyroidectomy Vocal Fold Paralysis? World J Surg 2023; 47:429-436. [PMID: 36222871 DOI: 10.1007/s00268-022-06765-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Predicting definitive outcomes of post-thyroidectomy vocal fold paralysis (VFP) is challenging. We aimed to identify reliable predictors based on intraoperative neuromonitoring (IONM) and flexible fiberoptic laryngostroboscopy (FFL) findings. METHODS Among 1172 thyroid operations performed from April to December 2021, all patients who exhibited vocal fold paralysis (VFP) at post-operative laryngoscopy were included. IONM data, including type of loss of signal (LOS), were collected. Patients underwent FFL, with arytenoid motility assessment, at 15, 45 and 120 days post-operatively. Patients were divided into two groups: those who recovered vocal fold motility (VFM) by the 120th post-operative day (recovery group) and those who did not (non-recovery group). RESULTS Fifty-nine VFP cases (5.0% of total patients) met the inclusion criteria. Eight patients were lost at follow-up and were excluded. Overall, 9 patients were included in the non-recovery group (0.8% of total patients) and 42 in the recovery group. Among various predictive factors, only arytenoid fixation (AF) at the 15th post-operative day and Type I LOS were significant predictors for no VFM recovery (p = 0.007, RR = 9.739, CI:1.3-72.3 and p = 0.001, RR = 9.25, CI:2.2-39.3 for AF and Type I injury, respectively). The combination of type of LOS and arytenoid motility at the 15th post-op day yielded satisfactory predictive values for the progression of transient VFP to permanent. CONCLUSIONS Arytenoid motility at the 15th post-op day and type II LOS are associated with recovery of VFM. Type of LOS and FFL could be included in the follow-up protocols of patients with VFP to reliably predict clinical outcomes.
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Affiliation(s)
- Luca Revelli
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Pierpaolo Gallucci
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Maria Raffaella Marchese
- UOC Otorinolaringoiatria, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Nikolaos Voloudakis
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy.
- UOC Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Sofia Di Lorenzo
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Claudio Montuori
- UOC Otorinolaringoiatria, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Lucia D'Alatri
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Otorinolaringoiatria, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Pennestri
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Carmela De Crea
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Marco Raffaelli
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
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Senosiain IM, Urdiain AG, Egea MPS, Garayoa PA, Apiñaniz EA, Saiz IB, Montes RL. Utility of the continuous intraoperative neuromonitoring in the prevention of the recurrent laryngeal nerve paralysis during thyroid surgery. A prospective observational study. Cir Esp 2022:S2173-5077(22)00236-8. [PMID: 35792249 DOI: 10.1016/j.cireng.2022.06.050] [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: 03/09/2022] [Accepted: 06/11/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The continuous intraoperative neuromonitoring (C-IONM) of the recurrent laryngeal nerve (RLN) could help reducing the incidence of nerve paralysis after thyroid surgery, in comparison with the mere anatomical visualization of the RLN. The objective is to assess the efficacy and utility of C-IONM as a predictive test for recurrent laryngeal nerve paralysis after thyroidectomy. METHODS A prospective observational study was performed in 248 patients who underwent thyroid surgery where C-IONM was applied, between September 2018 and December 2019, in a high-volume center. A previous and later laryngoscopy was performed, which allowed to evaluate the reliability of the C-IONM as a predictive test for recurrent paralysis. Sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) were studied. RESULTS A total number of 171 thyroidectomies, 62 hemithyroidectomies, 15 totalization thyroidectomies and 27 thyroidectomy with cervical dissections were performed. Postoperative laryngoscopy was altered in 40 patients (16.12%). The SE, SP, PPV and NPV values were 65%, 94.7%, 70.2% and 93.4% respectively. CONCLUSIONS C-IONM is a safe technique that provides real-time information about anatomical and functional integrity of the RLN and can improve the results of thyroid surgery.
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Affiliation(s)
| | | | | | | | - Emma Anda Apiñaniz
- Endocrine Surgery Unit, Complejo Hospitalario de Navarra, Pamplona, Spain.
| | - Isabel Blanco Saiz
- Nuclear Medicine Department. Complejo Hospitalario de Navarra, Pamplona, Spain.
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Al Naem M, Litzke LF, Mourad AAG. Thyroidectomy facilitated with Harmonic Caliper and intraoperative neural monitoring in three horses. EQUINE VET EDUC 2022. [DOI: 10.1111/eve.13635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M. Al Naem
- Equine Clinic (Surgery, Orthopaedics) Faculty of Veterinary Medicine Justus‐Liebig‐University Giessen Germany
| | - L. F. Litzke
- Equine Clinic (Surgery, Orthopaedics) Faculty of Veterinary Medicine Justus‐Liebig‐University Giessen Germany
| | - A. A. G. Mourad
- Department of Surgery, Anaesthesiology and Radiology Faculty of Veterinary Medicine University of Sadat City Sadat City Egypt
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McManus C, Kuo JH. Intraoperative Neuromonitoring: Evaluating the Role of Continuous IONM and IONM Techniques for Emerging Surgical and Percutaneous Procedures. Front Endocrinol (Lausanne) 2022; 13:808107. [PMID: 35432220 PMCID: PMC9005846 DOI: 10.3389/fendo.2022.808107] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
Intraoperative nerve monitoring (IONM) is a tool used during thyroid surgery to assist in the identification of the recurrent laryngeal nerve (RLN). Multiple IONM systems that exist for thyroidectomy require intubation with an endotracheal tube. Given that one of the advantages of thermal ablation procedures, such as radiofrequency ablation, is that they can be done safely without the use of general anesthesia, nerve monitoring systems that utilize cutaneous surface electrodes have been developed, though are not widely available in the United States. This article will review the use of IONM for RFA including the cutaneous surface electrode system.
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Bidault S, Girard E, Attard M, Garcia G, Guerlain J, Breuskin I, Baudin E, Hadoux J, Garcia C, Lamartina L, Hartl DM. Preoperative ultrasound mapping of the vagus nerve in thyroid surgery. Gland Surg 2022; 11:91-99. [PMID: 35242672 PMCID: PMC8825509 DOI: 10.21037/gs-21-580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/05/2021] [Indexed: 08/29/2023]
Abstract
BACKGROUND Intraoperative neuromonitoring (IONM) in thyroid surgery requires electric stimulation of the vagus nerve to verify correct electrode placement. Classically the nerve is found deep to or in-between the common carotid artery and internal jugular vein, but previous studies have shown that the nerve can sometimes be found superficial to the vessels. Our aim was to determine the incidence of a superficial vagus nerve using ultrasound (US) and study possible clinical factors associated with an anteriorly-located vagus nerve. METHODS Retrospective study of patients undergoing thyroid surgery (lobectomy or total thyroidectomy) with intermittent IONM. Substernal goiters, locally invasive tumors or bulky lymph nodes were excluded. The vagus nerve was identified at the level of the mid-thyroid lobe on each side on preoperative US performed by two specialized radiologists, and its location according to 6 possible positions in relationship to the common carotid artery was recorded. The anatomic variability of the vagus nerve was analyzed in relationship to patient demographics and thyroid pathology. RESULTS Five-hundred twenty-seven patients were included. The right vagus nerve (n=522) was in-between, superficial or deep to the vessels in 92.3%, 6.1% and 1.5% and of cases, respectively, and the left vagus (n=517) in 80.2%, 18.6% and 1.2% of cases, respectively, with a statistically significant difference between right and left vagus nerves (P<0.001). The type of pathology, size of the dominant nodule or the volume of the thyroid lobe were not correlated to finding a superficial vagus nerve. CONCLUSIONS The vagus nerve was identified in all cases on US and found to be anterior to common carotid artery at the level of the thyroid lobe in 18.6% of cases on the left and 6.1% of cases on the right. Identifying this anatomic variant preoperatively may facilitate IONM and avoid inadvertent trauma to the vagus nerve during thyroid surgery.
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Affiliation(s)
- Sophie Bidault
- Department of Radiology, Gustave Roussy Cancer Campus and University Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Elizabeth Girard
- Department of Radiology, Gustave Roussy Cancer Campus and University Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Marie Attard
- Department of Radiology, Gustave Roussy Cancer Campus and University Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Gabriel Garcia
- Department of Radiology, Gustave Roussy Cancer Campus and University Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Joanne Guerlain
- Department of Surgery, Anesthesia and Interventional Medicine, Thyroid Surgery Unit, Gustave Roussy, Villejuif, France
| | - Ingrid Breuskin
- Department of Surgery, Anesthesia and Interventional Medicine, Thyroid Surgery Unit, Gustave Roussy, Villejuif, France
| | - Eric Baudin
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy Cancer Campus and University Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Julien Hadoux
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy Cancer Campus and University Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Camilo Garcia
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy Cancer Campus and University Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Livia Lamartina
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy Cancer Campus and University Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Dana M. Hartl
- Department of Surgery, Anesthesia and Interventional Medicine, Thyroid Surgery Unit, Gustave Roussy, Villejuif, France
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Sinclair CF, Buczek E, Cottril E, Angelos P, Barczynski M, Ho AS, Makarin V, Musholt T, Scharpf J, Schneider R, Stack BC, Tellez MJ, Tolley N, Woodson G, Wu CW, Randolph G. Clarifying optimal outcome measures in intermittent and continuous laryngeal neuromonitoring. Head Neck 2021; 44:460-471. [PMID: 34850992 DOI: 10.1002/hed.26946] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/15/2021] [Accepted: 11/18/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Intraoperative neuromonitoring (IONM) techniques have evolved over the past decade into intermittent IONM (I-IONM) and continuous IONM (C-IONM) modes of application. Despite many prior publications on both types of IONM, there remains uncertainty about what outcomes should be measured for each form of IONM. The primary objective of this paper is to define categories of benefit for I-IONM/C-IONM and to clarify and standardize their reporting outcomes. METHODS Expert review consensus statement utilizing modified Delphi methodology. RESULTS I-IONM provides diagnosis, classification, and prevention of nerve injury through accurate and early nerve identification. C-IONM provides real-time information on nerve functional integrity and thus may prevent some types of nerve injury but cannot assist in nerve localization. Sudden mechanisms of nerve injury cannot be predicted or prevented by either technique. CONCLUSIONS I-IONM and C-IONM are complementary techniques. Future studies evaluating the utility of IONM should focus on outcomes that are appropriate to the type of IONM being utilized.
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Affiliation(s)
- Catherine F Sinclair
- Department of Otolaryngology Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erin Buczek
- Department of Otolaryngology Head and Neck Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth Cottril
- Department of Otolaryngology Head and Neck Surgery, Jefferson University, Philadelphia, Pennsylvania, USA
| | - Peter Angelos
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Marcin Barczynski
- Department of Endocrine Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Allen S Ho
- Department of Otolaryngology Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Viktor Makarin
- Saint Petersburg State University Hospital, Saint Petersburg, Russian Federation
| | - Thomas Musholt
- Department of Endocrine Surgery, Gutenberg University Mainz, Mainz, Germany
| | - Joseph Scharpf
- Department of Otolaryngology Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rick Schneider
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Brendan C Stack
- Department of Otolaryngology Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Maria J Tellez
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Neil Tolley
- Department of Otolaryngology Head and Neck Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Gayle Woodson
- Department of Otolaryngology Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Che Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Greg Randolph
- Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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Sinclair CF, Randolph GW. A Thoughtful Approach to IONM Outcomes Reporting. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00364-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Kim DH, Kim SW, Hwang SH. Intraoperative Neural Monitoring for Early Vocal Cord Function Assessment After Thyroid Surgery: A Systematic Review and Meta-Analysis. World J Surg 2021; 45:3320-3327. [PMID: 34191086 DOI: 10.1007/s00268-021-06225-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 11/30/2022]
Abstract
Objective This study evaluated the diagnostic accuracies of various forms of intraoperative neural monitoring (IONM) in terms of predicting vocal cord palsy after thyroidectomy. Methods Two authors independently reviewed the six databases (PubMed, the Cochrane database, Embase, the Web of Science, SCOPUS, and Google Scholar) from their dates of inception to March 2021. Intraoperative electromyographic neuromonitoring (IONM) was compared with laryngoscopic detection (the reference method). True-positive, true-negative, false-positive, and false-negative data were extracted from each study. Methodological quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies ver. 2 tool. Results Twenty-seven prospective or retrospective studies were included. The diagnostic odds ratio for IONM was 152.9623 ([95% confidence interval [75.4249; 310.2085]. The area under the summary receiver operating characteristic curve was 0.966. The sensitivity, specificity, negative predictive value, and positive predictive value were 0.8219 ([0.6862; 0.9069]), 0.9783 ([0.9659; 0.9863]), 0.9943 ([0.9880; 0.9973]), and 0.5523 ([0.4458; 0.6542]), respectively. The correlation between sensitivity and false-positive rate was 0.200, indicating the absence of heterogeneity. Subgroup analysis showed that the diagnostic accuracies of the continuous IONM was higher than those of intermittent IONM, and recent publications (> 2011) was higher than early publication (< 2010). Conclusions As the technology and knowledge of IONM have been accumulated and progressed over the past decades, the predictive value of IONM in postoperative vocal cord palsy has also improved. Moreover, the advances of continuous IONM technology could make a breakthrough in vocal cord evaluation after thyroid surgery.
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Affiliation(s)
- Do Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Won Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 327 Sosa-ro, Bucheon-si, Gyeonggi-do, 14647, Korea.
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de Vendin OE, Fuchs-Buder T, Schmartz D, Nguyen DT, Gallet P, Bihain F, Nomine-Criqui C, Brunaud L. Impact of rocuronium on intraoperative neuromonitoring vagal amplitudes during thyroidectomy. Langenbecks Arch Surg 2021; 406:2019-2025. [PMID: 34120194 DOI: 10.1007/s00423-021-02234-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Neuromuscular blocking agents (NMBA) facilitate endotracheal intubation and reduce related laryngeal morbidity. However, NMBA interfere with intraoperative neuromonitoring amplitudes during thyroidectomy. The goal of this study was to evaluate the impact of rocuronium used for tracheal intubation on early intraoperative neuromonitoring vagal amplitudes observed during first thyroid lobe dissection. METHODS This is an observational pharmacoepidemiological study with prospective data collection and retrospective analysis. During the study period, all consecutive patients who underwent thyroid surgery with neuromonitoring were included. Patients underwent endotracheal intubation either using a single dose of rocuronium (NMBA group) or without NMBA (NMBA-free group) according to the anesthesiologist's preference. RESULTS Six hundred six patients were included (213 NMBA and 393 NMBA-free group patients). At V1, 39 patients (18%) in the NMBA group had an amplitude < 100 µV (need for curarization reversal in 30 patients) and 13 patients (3.3%) in the NMBA-free group (p < 0.001). In the remaining 554 patients, the mean V1 amplitude was significantly decreased in the NMBA group (544 versus 685 µV; p < 0.001). After exclusion of 25 patients with loss of signal types 1 and 2 during dissection, the difference between mean V1 and mean V2 was significantly lower in NMBA group patients (- 22 versus - 86 µV; p = 0.016). CONCLUSION This study provides new data showing how NMBA used for tracheal intubation significantly decrease V1 amplitude baseline and modify amplitude variations from V1 to V2 values during the first thyroid lobe dissection. LEVEL OF EVIDENCE Pharmacoepidemiological study.
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Affiliation(s)
- Ombeline Empis de Vendin
- Department, of Anesthesiology, Université de Lorraine, CHRU Nancy-Brabois, Vandœuvre-lès-Nancy, France
| | - Thomas Fuchs-Buder
- Department, of Anesthesiology, Université de Lorraine, CHRU Nancy-Brabois, Vandœuvre-lès-Nancy, France
| | - Denis Schmartz
- Department, of Anesthesiology, Université de Lorraine, CHRU Nancy-Brabois, Vandœuvre-lès-Nancy, France.,Department of Anesthesiology, Université Libre de Bruxelles, Brussels, Belgium
| | - Duc-Trung Nguyen
- Department of Oto-Rhino-Laryngology, Université de Lorraine, CHRU Nancy-Brabois, Vandœuvre-lès-Nancy, France
| | - Patrice Gallet
- Department of Oto-Rhino-Laryngology, Université de Lorraine, CHRU Nancy-Brabois, Vandœuvre-lès-Nancy, France
| | - Florence Bihain
- Department of Surgery (CVMC), Unit of Metabolic, Endocrine, and Thyroid Surgery, Université de Lorraine, CHRU Nancy-Brabois (7Eme Étage), Vandœuvre-lès-Nancy, France
| | - Claire Nomine-Criqui
- Department of Surgery (CVMC), Unit of Metabolic, Endocrine, and Thyroid Surgery, Université de Lorraine, CHRU Nancy-Brabois (7Eme Étage), Vandœuvre-lès-Nancy, France
| | - Laurent Brunaud
- Department of Surgery (CVMC), Unit of Metabolic, Endocrine, and Thyroid Surgery, Université de Lorraine, CHRU Nancy-Brabois (7Eme Étage), Vandœuvre-lès-Nancy, France. .,INSERM U1256, Faculty of Medicine, Université de Lorraine, CHRU Nancy-Brabois, Vandœuvre-lès-Nancy, France.
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Schneider R, Machens A, Sekulla C, Lorenz K, Elwerr M, Dralle H. Superiority of continuous over intermittent intraoperative nerve monitoring in preventing vocal cord palsy. Br J Surg 2021; 108:566-573. [PMID: 34043775 DOI: 10.1002/bjs.11901] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/20/2020] [Accepted: 06/14/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Continuous intraoperative nerve stimulation (IONM) with uninterrupted monitoring is likely better than intermittent IONM in preventing vocal cord palsy after thyroid surgery. METHODS This was a comparative study of intermittent versus continuous IONM in patients with benign and malignant thyroid disease treated at a tertiary centre over 10 years. Early postoperative and permanent vocal cord palsy rates were estimated. Multivariable logistic regression analysis was used to quantify the contributions of clinical and histopathological variables to early postoperative and permanent vocal cord palsy. RESULTS A total of 6029 patients were included, of whom 3139 underwent continuous and 2890 intermittent IONM. Based on nerves at risk (5208 versus 5024 nerves), continuous IONM had a 1·7-fold lower early postoperative vocal cord palsy rate than intermittent monitoring (1·5 versus 2·5 per cent). This translated into a 30-fold lower permanent vocal cord palsy rate (0·02 versus 0·6 per cent). In multivariable logistic regression analysis, continuous IONM independently reduced early postoperative vocal cord palsy 1·8-fold (odds ratio (OR) 0·56) and permanent vocal cord palsy 29·4-fold (OR 0·034) compared with intermittent IONM. One permanent vocal cord palsy per 75·0 early vocal cord palsies was observed with continuous IONM, compared with one per 4·2 after intermittent IONM. Early postoperative vocal cord palsies were 17·9-fold less likely to become permanent with continuous than intermittent IONM. CONCLUSION Continuous IONM is superior to intermittent IONM in preventing vocal cord palsy.
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Affiliation(s)
- R Schneider
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - A Machens
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - C Sekulla
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - K Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - M Elwerr
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - H Dralle
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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What is the impact of continuous neuromonitoring on the incidence of injury to the recurrent laryngeal nerve during total thyroidectomy? Surgery 2020; 169:63-69. [PMID: 32409167 DOI: 10.1016/j.surg.2020.03.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/17/2020] [Accepted: 03/24/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Continuous intraoperative neuromonitoring may facilitate reversal of intraoperative injurious operative maneuvers in comparison with intermittent intraoperative neuromonitoring. The aim of this study was to evaluate the impact of the routine use of continuous intraoperative neuromonitoring on intraoperative injuries to the recurrent laryngeal nerve. METHOD This study was a prospective case series with retrospective analysis of consecutive patients undergoing total thyroidectomy from August 2013 to August 2019. During this period, intermittent intraoperative neuromonitoring (before Mar 2016) and continuous intraoperative neuromonitoring (after Mar 2016) were used in all patients. RESULTS We reviewed the outcomes of 603 patients (466 female patients) comprising 236 who underwent intermittent intraoperative neuromonitoring and 367 who underwent continuous intraoperative neuromonitoring. Intraoperative adverse electromyography events (>50% decrease in amplitude between VN1 and VN2) were observed in 87 patients (14.5%) and were less frequent in the continuous intraoperative neuromonitoring group (10.6 vs 20.3%, P = .001). Intraoperative loss of signal (electromyography events with VN2 ≤100μV) were observed in 35 patients (5.8%) without any difference between the 2 groups of patients (5.2 vs 6.8%, P = .415). Postoperative recurrent laryngeal nerve palsies were observed in 36 patients (5.9%) without any difference between the 2 groups of patients (4.9 vs 7.6%, P = .168). CONCLUSION The routine use of continuous intraoperative neuromonitoring improves the rate of intraoperative adverse electromyography events but does not impact significantly the rates of loss of signal and recurrent laryngeal nerve palsy.
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Schneider R, Machens A, Lorenz K, Dralle H. Intraoperative nerve monitoring in thyroid surgery-shifting current paradigms. Gland Surg 2020; 9:S120-S128. [PMID: 32175252 DOI: 10.21037/gs.2019.11.04] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Over the past two decades, intraoperative neural monitoring (IONM) has matured into a powerful risk minimization tool. Meta-analyses of studies, most of which were limited by poor study designs and the sole use of intermittent nerve stimulation, failed to demonstrate superiority of IONM over anatomic recurrent laryngeal nerve (RLN) dissection in the absence of IONM. With the advent of continuous IONM (CIONM), intraoperative nerve electromyographic tracings, registered almost in real time during the operation, accurately predict postoperative vocal fold function when International Neural Monitoring Study Group quality standards are adhered to. CIONM aids in avoiding permanent traction-related nerve injury by urging surgeons to reverse harmful surgical maneuvers. CIONM also forms an integral part in the surgical concept of staged thyroidectomy. Delaying completion surgery on the other side until nerve function has recovered mitigates the risk of bilateral vocal fold palsy. CIONM has greatly furthered our understanding of functional RLN injury, enabling conception of effective risk minimization strategies tailored to the individual patient. The review summarizes the advances of continuous IONM technology that caused a quantum leap in risk minimization for thyroid surgery, shifting current paradigms.
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Affiliation(s)
- Rick Schneider
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Andreas Machens
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kerstin Lorenz
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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