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Saxe A, Idris M, Gemechu J. Does the Use of Intraoperative Neuromonitoring during Thyroid and Parathyroid Surgery Reduce the Incidence of Recurrent Laryngeal Nerve Injuries? A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2024; 14:860. [PMID: 38732275 PMCID: PMC11083343 DOI: 10.3390/diagnostics14090860] [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: 03/02/2024] [Revised: 04/07/2024] [Accepted: 04/11/2024] [Indexed: 05/13/2024] Open
Abstract
Injury to the recurrent laryngeal nerve (RLN) can be a devastating complication of thyroid and parathyroid surgery. Intraoperative neuromonitoring (IONM) has been proposed as a method to reduce the number of RLN injuries but the data are inconsistent. We performed a meta-analysis to critically assess the data. After applying inclusion and exclusion criteria, 60 studies, including five randomized trials and eight non-randomized prospective trials, were included. A meta-analysis of all studies demonstrated an odds ratio (OR) of 0.66 (95% CI [0.56, 0.79], p < 0.00001) favoring IONM compared to the visual identification of the RLN in limiting permanent RLN injuries. A meta-analysis of studies employing contemporaneous controls and routine postoperative laryngoscopy to diagnose RLN injuries (considered to be the most reliable design) demonstrated an OR of 0.69 (95% CI [0.56, 0.84], p = 0.0003), favoring IONM. Strong consideration should be given to employing IONM when performing thyroid and parathyroid surgery.
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Affiliation(s)
- Andrew Saxe
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA; (M.I.); (J.G.)
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Mu Y, Bian X, Yang J, Li Y, Zhang Y, Dionigi G, Zhao Y, Sun H. Recurrent laryngeal never monitoring versus non-monitoring in parathyroid surgery. Front Endocrinol (Lausanne) 2023; 14:1299943. [PMID: 38089613 PMCID: PMC10715272 DOI: 10.3389/fendo.2023.1299943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
Background Although intraoperative neural monitoring (IONM) is well established in thyroid surgery, it is less commonly analyzed in parathyroid operations. This study presents the results of IONM for primary and secondary hyperparathyroidism surgery. Methods We retrospectively assessed 270 patients with primary hyperparathyroidism (PHPT), 53 patients with secondary hyperparathyroidism (SHPT), and 300 patients with thyroid cancer from June 2010 to June 2022 in one hospital in China. The follow-up was 12 months. Demographic, electromyography data from IONM, laboratory, and clinical information were collected. Laryngoscopy was collected from 109 patients with PHPT in whom IONM was not used. All groups were assessed by Pearson's chi-square test and Fisher's exact probability method to verify the relationship between parathyroid size and location, duration of surgery, preoperative concordant localization, laryngeal pain, IONM outcomes, cure rate, and RLN injury. Visual analog scale (VAS) assessed laryngeal pain. RLN outcomes were measured according to nerves at risk (NAR). Results The study comprehended 918 NAR, that is 272, 105, 109, and 432 NAR for PHPT, SHPT with IONM, PHPT without IONM, and thyroid surgery control group, respectively. IONM successfully prevented RLN injury (P<0.001, P=0.012): Fifteen (5.51%) RLNs experienced altered nerve EMG profiles during surgery, and five (1.84%) experienced transient RLN injury in PHPT patients. Five (4.76%) RLNs were found to have altered EMG profiles during surgery, and one (0.95%) RLN had a transient RLN injury in SHPT patients. There was no permanent nerve injury (0.00%) in this series. There was no association between location, gland size, preoperative concordant localization, cure rate, duration of surgery, and IONM (P >0.05). Duration of surgery was associated with postoperative pharyngeal discomfort (P=0.026, P=0.024). Transient RLN injury was significantly lower in patients with PHPT who underwent IONM than in those who did not. Intraoperative neuromonitoring played an effective role in protecting the recurrent laryngeal nerve (P=0.035). Compared with parathyroidectomy, thyroidectomy had a higher rate of RLN injury (5.32%, P<0.001). Conclusion IONM for SHPT and PHPT offers rapid anatomical gland identification and RLN functional results for effective RLN protection and reduced RLN damage rates.
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Affiliation(s)
- Yongliang Mu
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Translational Medicine in Surgery, Jilin Provincial Engineering, Laboratory of Thyroid Disease Prevention and Treatment Changchun, Changchun, China
| | - Xuehai Bian
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Translational Medicine in Surgery, Jilin Provincial Engineering, Laboratory of Thyroid Disease Prevention and Treatment Changchun, Changchun, China
| | - Junjie Yang
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Translational Medicine in Surgery, Jilin Provincial Engineering, Laboratory of Thyroid Disease Prevention and Treatment Changchun, Changchun, China
| | - Yang Li
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Translational Medicine in Surgery, Jilin Provincial Engineering, Laboratory of Thyroid Disease Prevention and Treatment Changchun, Changchun, China
| | - Yushuai Zhang
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Translational Medicine in Surgery, Jilin Provincial Engineering, Laboratory of Thyroid Disease Prevention and Treatment Changchun, Changchun, China
| | - Gianlorenzo Dionigi
- Division of Surgery, Istituto Auxologico Italiano IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Yishen Zhao
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Translational Medicine in Surgery, Jilin Provincial Engineering, Laboratory of Thyroid Disease Prevention and Treatment Changchun, Changchun, China
| | - Hui Sun
- Department of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Translational Medicine in Surgery, Jilin Provincial Engineering, Laboratory of Thyroid Disease Prevention and Treatment Changchun, Changchun, China
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Sanabria A, Kowalski LP, Nixon I, Angelos P, Shaha A, Owen RP, Suarez C, Rinaldo A, Ferlito A. Methodological Quality of Systematic Reviews of Intraoperative Neuromonitoring in Thyroidectomy: A Systematic Review. JAMA Otolaryngol Head Neck Surg 2019; 145:563-573. [PMID: 30973598 DOI: 10.1001/jamaoto.2019.0092] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Systematic reviews and meta-analyses are considered the best evidence for clinical decision making. Many reviews of intraoperative neuromonitoring (IONM) in thyroidectomy have conflicting results, owing in large part to methodological quality. Objective To assess the methodological quality and the causes of heterogeneous results of systematic reviews that compare routine IONM vs visual identification of the recurrent laryngeal nerve (RLN) in patients undergoing thyroidectomy. Data Sources A systematic search was performed of MEDLINE (PubMed), Embase, the Cochrane Library, LILACS (Literatura Latino Americana e do Caribe em Ciências da Saúde), Web of Science, and Google from January 1, 1968, through June 30, 2018. Data were analyzed from July 17 to November 30, 2018. Study Selection Studies that mentioned performance of a systematic review/meta-analysis during the search period. Data Extraction and Synthesis Data including study characteristics, type of patients, numbers of nerves at risk, and temporary and definitive RLN paralysis by group were extracted. Data about methodological characteristics, type of statistical analysis and summary estimator, endorsement of systematic review/meta-analysis guidelines, heterogeneity, publication bias, funding, conflict of interest, and statistical analysis were also recorded. The methodological quality was measured with the AMSTAR2 (A Measurement Tool to Assess Systematic Reviews) tool by 2 independent evaluators. Main Outcomes and Measures Methodological quality. Results The search identified 13 systematic reviews that included patients who underwent open or minimally invasive thyroidectomy, second operations, and a mixture of low- and high-risk procedures. The mean compliance with the AMSTAR2 overall criteria was 53% (range, 11%-83%); with critical criteria, 71% (range, 50%-94%). The percentage of nerves at risk from RCTs was 4.8%. The mean (SD) crude rate of definitive RLN paralysis was 0.81% (0.22%; median, 0.75% [range, 0.53%-1.30%]) in the monitoring group and 1.14% (0.56%; median, 0.96% [range, 0.57%-2.56%]) in the control group. Conclusions and Relevance A substantial number of systematic reviews of IONM in thyroidectomy have conflicting results, but their mean methodological quality is critically low. Design of a systematic review should comply with methodological standards and recommendations to offer relevant and practical information for decision making.
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Affiliation(s)
- Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia, Fundación Colombiana de Cancerología-Clínica Vida, Medellin, Colombia
| | - Luiz P Kowalski
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
| | - Iain Nixon
- Ear, Nose and Throat Department, NHS Lothian, Edinburgh, United Kingdom
| | - Peter Angelos
- Department of Surgery and MacLean Center for Clinical Ethics, University of Chicago Medicine, Chicago, Illinois
| | - Ashok Shaha
- Head & Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Randall P Owen
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carlos Suarez
- Instituto de Investigacion Sanitaria del Principado de Asturias, University of Oviedo, Fundación de Investigación e Innovación Biosanitaria del Principado de Asturias, Oviedo, Spain
| | - Alessandra Rinaldo
- Ear, Nose, and Throat Section, University of Udine School of Medicine, Udine, Italy
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
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Protective Effects of Intraoperative Nerve Monitoring (IONM) for Recurrent Laryngeal Nerve Injury in Thyroidectomy: Meta-analysis. Sci Rep 2018; 8:7761. [PMID: 29773852 PMCID: PMC5958090 DOI: 10.1038/s41598-018-26219-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 05/04/2018] [Indexed: 12/13/2022] Open
Abstract
Recurrent laryngeal nerve (RLN) injury is an intractable complication of thyroidectomy. Intraoperative nerve monitoring (IONM) was designed to prevent RLN injury. However, the results concerning the protective effect of IONM on RLN injury are still controversial. We searched all eligible databases from 1980 to 2017. Meta-analysis was performed to evaluate the effect of IONM on RLN injury. Sensitivity analysis was also conducted to check the stability of our results. There were 34 studies included in the analysis. Overall analysis found a significant decrease in total injury (RR = 0.68, 95%CI: 0.55 to 0.83), transient injury (RR = 0.71, 95%CI: 0.57 to 0.88), and permanent injury (RD = −0.0026, 95%CI: −0.0039 to −0.0012) with IONM. Subgroup analysis found IONM played a preventive role of total, transient and permanent injury in patients undergoing bilateral thyroidectomy. IONM also reduced the incidence of total and transient injury for malignancy cases. Operations with IONM were associated with fewer total and transient RLN injuries in operation volume < 300 NARs per year and fewer total and permanent RLN injuries in operation volume ≥ 300 NARs per year. The application of IONM could reduce the RLN injury of thyroidectomy. Particularly, we recommend routine IONM for use in bilateral operations and malignancy operations.
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Kadakia S, Mourad M, Hu S, Brown R, Lee T, Ducic Y. Utility of intraoperative nerve monitoring in thyroid surgery: 20-year experience with 1418 cases. Oral Maxillofac Surg 2017; 21:335-339. [PMID: 28577127 DOI: 10.1007/s10006-017-0637-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/29/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE The efficacy of intraoperative nerve monitoring is controversial in the literature. This study of a single surgeon's experience seeks to determine if the use of intraoperative nerve monitoring influences recurrent laryngeal nerve injury during thyroid surgery. METHODS Six hundred fifty-seven patients with normal pre-operative vocal fold function underwent thyroid surgery without the use of intraoperative nerve monitoring from September 1997 to January 2007, while 761 patients underwent thyroid surgery from February 2007 to February 2016 with routine use of nerve monitoring. Patients were followed for a minimum of 6 months after surgery, and postoperative nerve function was determined by fiberoptic laryngoscopy. A Fisher test was used to determine if nerve injury was statistically different between both groups. RESULTS In patients operated on without nerve monitoring, 21 patients were found to have postoperative vocal fold paralysis with nine regaining functioning. In patients operated on with nerve monitoring, 27 were found to have vocal fold dysfunction with 17 regaining function. Fisher test analysis, both with and without patients regaining function, showed no difference in nerve injury between groups (p > 0.05, p > 0.05). CONCLUSION Intraoperative monitoring during thyroidectomy may not prevent injury to the recurrent laryngeal nerve.
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Affiliation(s)
- Sameep Kadakia
- New York Eye and Ear Infirmary of Mount Sinai, New York, NY, USA.
| | - Moustafa Mourad
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, TX, USA
| | - Shirley Hu
- New York Eye and Ear Infirmary of Mount Sinai, New York, NY, USA
| | | | - Thomas Lee
- Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, TX, USA
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Wong KP, Mak KL, Wong CKH, Lang BHH. Systematic review and meta-analysis on intra-operative neuro-monitoring in high-risk thyroidectomy. Int J Surg 2017; 38:21-30. [DOI: 10.1016/j.ijsu.2016.12.039] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 12/19/2016] [Indexed: 11/16/2022]
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Morphology and Functional Anatomy of the Recurrent Laryngeal Nerve with Extralaryngeal Terminal Bifurcation. ANATOMY RESEARCH INTERNATIONAL 2016; 2016:9503170. [PMID: 27493803 PMCID: PMC4963538 DOI: 10.1155/2016/9503170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/20/2016] [Indexed: 11/20/2022]
Abstract
Anatomical variations of the recurrent laryngeal nerve (RLN), such as an extralaryngeal terminal bifurcation (ETB), threaten the safety of thyroid surgery. Besides the morphology of the nerve branches, intraoperative evaluation of their functional anatomy may be useful to preserve motor activity. We exposed 67 RLNs in 36 patients. The main trunk, bifurcation point, and terminal branches of bifid nerves were macroscopically determined and exposed during thyroid surgery. The functional anatomy of the nerve branches was evaluated by intraoperative nerve monitoring (IONM). Forty-six RLNs with an ETB were intraoperatively exposed. The bifurcation point was located along the prearterial, arterial, and postarterial segments in 11%, 39%, and 50% of bifid RLNs, respectively. Motor activity was determined in all anterior branches. The functional anatomy of terminal branches detected motor activity in 4 (8.7%) posterior branches of 46 bifid RLNs. The motor activity in posterior branches created a wave amplitude at 25–69% of that in the corresponding anterior branches. The functional anatomy of bifid RLNs demonstrated that anterior branches always contained motor fibres while posterior branches seldom contained motor fibres. The motor activity of the posterior branch was weaker than that of the anterior branch. IONM may help to differentiate between motor and sensory functions of nerve branches. The morphology and functional anatomy of all nerve branches must be preserved to ensure a safer surgery.
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Uludag M, Yazici P, Aygun N, Citgez B, Yetkin G, Mihmanli M, Isgor A. A Closer Look at the Recurrent Laryngeal Nerve Focusing on Branches & Diameters: A Prospective Cohort Study. J INVEST SURG 2016; 29:383-388. [PMID: 27159534 DOI: 10.1080/08941939.2016.1176279] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM We aimed to investigate the anatomical characteristics of the recurrent laryngeal nerve (RLN) highlighting on its diameter and branching pattern. MATERIALS AND METHODS We prospectively collected 215 patients (178 female, 37 male) who underwent thyroid/parathyroid surgery during over a 2-year period. Apart from demographic features and surgical data, diameter of RLNs, and their branches and as well as branching distance (distance between the point of bifurcation and the laryngeal entry of RLN) were recorded. RESULTS In 215 patients, 378 RLNs were assessed and 42% (n = 159) bifurcated RLNs were observed. The bifurcation rate was similar on the right and left side(s) of the neck (40% and 44%, respectively; p = 0.47). In those, who underwent bilateral exploration, in the case of bifurcation on the first side of the neck, the possibility of contralateral bifurcation was approximately 50%, whereas this rate was found to be only 30% in those with nonbranching RLNs. Mean branching distance was 18 ± 9 mm, and it was similar on the right and left sides (17 and 19 mm, respectively). Approximately 80% of bifurcations were observed within 5-24 mm of the RLN. Mean diameter of the anterior branches was found to be significantly larger compared to posterior branches (1.09 ± 0.35 and 0.82 ± 0.36 mm, respectively; p < 0.01). CONCLUSIONS There is great variability in RLN branching. We observed that approximately two out of three bifurcations were unilateral and anterior branches were thicker compared to posterior branches. These findings should be taken into consideration to avoid any damage to the RLN during thyroid and parathyroid surgery.
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Affiliation(s)
- Mehmet Uludag
- a Sisli Hamidiye Etfal Training and Research Hospital , Sisli , Istanbul , Turkey
| | - Pinar Yazici
- a Sisli Hamidiye Etfal Training and Research Hospital , Sisli , Istanbul , Turkey
| | - Nurcihan Aygun
- a Sisli Hamidiye Etfal Training and Research Hospital , Sisli , Istanbul , Turkey
| | - Bulent Citgez
- a Sisli Hamidiye Etfal Training and Research Hospital , Sisli , Istanbul , Turkey
| | - Gurkan Yetkin
- a Sisli Hamidiye Etfal Training and Research Hospital , Sisli , Istanbul , Turkey
| | - Mehmet Mihmanli
- a Sisli Hamidiye Etfal Training and Research Hospital , Sisli , Istanbul , Turkey
| | - Adnan Isgor
- b School of Medicine , Department of General Surgery , Bahcesehir Universitesi , Istanbul , Turkey
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Hei H, Zhai Y, Qin J, Song Y. Intermittent Intraoperative Neural Monitoring Technology in Minimally Invasive Video-Assisted Thyroidectomy: A Preliminary Study. J INVEST SURG 2016; 29:93-7. [DOI: 10.3109/08941939.2015.1073411] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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