Neuromonitoring of the recurrent laryngeal nerve in thyroid gland surgery – results and experiences
Authors:
Hložek J.; Rotnágl J.; Astl J.
Authors‘ workplace:
Klinika otorinolaryngologie a maxilofaciální chirurgie 3. LF UK a ÚVN Praha
Published in:
Otorinolaryngol Foniatr, 70, 2021, No. 2, pp. 89-96.
Category:
Original Article
doi:
https://doi.org/10.48095/ccorl202189
Overview
Paresis of the recurrent laryngeal nerve (RLN) is one of the serious complications of thyroid and parathyroid gland surgery. The intraoperative neural monitoring (IONM) enables to verify the functionality of RLN. The aim of this study is to compare the incidence of postoperative RLN palsy in patients who underwent surgery with and without the use of IONM RLN and to evaluate the positive and negative predictive values, sensitivity, specifi city and accuracy of the method. Methods: Retrospective analysis of thyroid gland surgeries performed within the period from 1. 7. 2016 to 1. 7. 2018. A total of 467 operations were performed (780 nerves exposed). One hundred and thirty procedures (215 nerves) were carried out without IONM (group A). In total, 337 procedures (565 nerves) were performed with IONM (group B). Results: In group A, unilateral postoperative RLN paresis occurred in 7 cases (3.26%); 6 of them were temporary (2.79%) and 1 was permanent (0.47%). In group B, unilateral postoperative RLN paresis occurred in 33 cases (5.84%); 32 of them were temporary (5.66%) and 1 was permanent (0.18%). The incidence of postoperative RLN paresis related to the use of IONM was not considered statistically signifi cant. (Chi-square test: P = 0.146; Fisher‘s exact test: P = 0.2015, P = 0.4715). The sensitivity, specifi city, positive predictive value, negative predictive value and accuracy were 78.79%, 99.25%, 86.67%, 98.69%, and 98.05%, respectively. There was no case of bilateral postoperative RLN paresis. Conclusion: There was no statistically significant diff erence in the incidence of postoperative RLN palsy in patients who underwent surgery with IONM compared to the group without IONM. The high negative predictive value, specifi city and accuracy indicate high reliability of the method. The IONM provides the surgeon with valuable information regarding the functional status of the nerve. This knowledge allows for changing the operative strategy during the procedure.
Keywords:
intraoperative neural monitoring – IONM – recurrent laryngeal nerve injury – recurrent laryngeal nerve – thyroid surgery
Sources
1. Astl J. Chirurgická léčba nemocí štítné žlázy. 2. rozšíř. vyd. Praha: Maxdorf Jessenius 2013.
2. Wojtczak B, Sutkowski K, Kaliszewski K et al. Experience with intraoperative neuromonitoring of the recurrent laryngeal nerve improves surgical skills and outcomes of non-monitored thyroidectomy. Langenbecks Arch Surg 2017; 402(4): 709–717. Doi: 10.1007/ s004 23-016-1449-5.
3. Minuto MN, Reina S, Monti E et al. Morbidity following thyroid surgery: acceptable rates and how to manage complicated patients. J Endocrinol Invest 2019; 42(11): 1291–1297. Doi: 10.1007/ s40618-019-01064-z.
4. Barczynski M, Konturek A, Cichon S. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg 2009; 96(3): 240–246. Doi: 10.1002/ bjs.6417.
5. Chiang FY, Lu IC, Kuo WR et al. The mechanism of recurrent laryngeal nerve injury during thyroid surgery--the application of intraoperative neuromonitoring. Surgery 2008; 143(6): 743–749. Doi: 10.1016/ j.surg.2008.02.006.
6. Sadowski SM, Soardo P, Leuchter I et al. Systematic use of recurrent laryngeal nerve neuromonitoring changes the operative strategy in planned bilateral thyroidectomy. Thyroid 2013; 23(3): 329–333. Doi: 10.1089/ thy.2012.0368.
7. Dralle H, Sekulla C, Haerting J et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 2004; 136(6): 1310–1322. Doi: 10.1016/ j.surg.2004.07.018.
8. Dralle H, Sekulla C, Lorenz K et al. Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg 2008; 32(7): 1358–1366. Doi: 10.1007/ s00268-008-9 483-2.
9. Scott AR, Chong PS, Hartnick CJ et al. Spontaneous and evoked laryngeal electromyography of the thyroarytenoid muscles: a canine model for intraoperative recurrent laryngeal nerve monitoring. Ann Otol Rhinol Laryngol 2010; 119(1): 54–63. Doi: 10.1177/ 000348941011900111.
10. Lorenz K, Sekulla C, Schelle J et al. What are normal quantitative parameters of intraoperative neuromonitoring (IONM) in thyroid surgery? Langenbecks Arch Surg 2010; 395(7): 901– 909. Doi: 10.1007/ s00423-010-0691-5.
11. Schneider R, Randolph GW, Dionigi G et al. International neural monitoring study group guideline 2018 part I: Staging bilateral thyroid surgery with monitoring loss of signal. Laryngoscope 2018; 128 Suppl 3: S1–S17. Doi: 10.1002/ lary.27359.
12. Phelan E, Schneider R, Lorenz K et al. Continuous vagal IONM prevents recurrent laryngeal nerve paralysis by revealing initial EMG changes of impending neuropraxic injury: a prospective, multicenter study. Laryngoscope 2014; 124(6): 1498–1505. Doi: 10.1002/ lary.24550.
13. Ulmer C, Friedrich C, Kohler A et al. Impact of continuous intraoperative neuromonitoring on autonomic nervous system during thyroid surgery. Head Neck 2011; 33(7): 976–984. Doi: 10.1002/ hed.21564.
14. Alesina PF, Rolfs T, Hommeltenberg S et al. Intraoperative neuromonitoring does not reduce the incidence of recurrent laryngeal nerve palsy in thyroid reoperations: results of a retrospective comparative analysis. World J Surg 2012; 36(6): 1348–1353. Doi: 10.1007/ s00268-012- 1548-6.
15. Mirallie E, Caillard C, Pattou F et al. Does intraoperative neuromonitoring of recurrent nerves have an impact on the postoperative palsy rate? Results of a prospective multicenter study. Surgery 2018; 163(1): 124–129. Doi: 10.1016/ j. surg.2017.03.029.
16. Dionigi G, Frattini F. Staged thyroidectomy: time to consider intraoperative neuromonitoring as standard of care. Thyroid 2013; 23(7): 906–908. Doi: 10.1089/ thy.2013.0004.
17. Randolph GW, Kamani D. Intraoperative neural monitoring in thyroid cancer surgery. Langenbecks Arch Surg 2014; 399(2): 199–207. Doi: 10.1007/ s00423-013-1141-y.
18. Calo PG, Pisano G, Medas F et al. Identifi - cation alone versus intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroid surgery: experience of 2034 consecutive patients. J Otolaryngol Head Neck Surg 2014; 43: 16. Doi: 10.1186/ 1916-0216- 43-16.
19. Wu SY, Shen HY, Duh QY et al. Routine intraoperative neuromonitoring of the recurrent laryngeal nerve to facilitate complete resection and ensure safety in thyroid cancer surgery. Am Surg 2018; 84(12): 1882–1888.
20. Melin M, Schwarz K, Lammers BJ et al. IONM- -guided goiter surgery leading to two-stage thyroidectomy indication and results. Langenbecks Arch Surg 2013; 398(3): 411–418. Doi: 10.1007/ s00423-012-1032-7.
21. Stopa M, Barczynski M. Prognostic value of intraoperative neural monitoring of the recurrent laryngeal nerve in thyroid surgery. Langenbecks Arch Surg 2017; 402(6): 957–964. Doi: 10.1007/ s00423-016-1441-0.
22. Randolph GW, Dralle H, International Intraoperative Monitoring Study G et al. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international stan- dards guideline statement. Laryngoscope 2011; 121 Suppl 1: S1–16. Doi: 10.1002/ lary.21119.
23. Potenza AS, Phelan EA, Cernea CR et al. Normative intra-operative electrophysiologic waveform analysis of superior laryngeal nerve external branch and recurrent laryngeal nerve in patients undergoing thyroid surgery. World J Surg 2013; 37(10): 2336–2342. Doi: 10.1007/ s00268-013-2148-9.
24. Uludag M, Aygun N, Kartal K et al. Contribution of intraoperative neural monitoring to preservation of the external branch of the superior laryngeal nerve: a randomized prospective clinical trial. Langenbecks Arch Surg 2017; 402(6): 965–976. Doi: 10.1007/ s00423-016-1544-7.
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Otorhinolaryngology and Phoniatrics
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