Advertisement

Intraoperative Neuro-monitoring of the Laryngeal Nerves During Thyroidectomy

  • Yinin Hu
  • John B. Hanks
  • Philip W. Smith

Abstract

Intraoperative neuro-monitoring allows the evaluation of laryngeal motor integrity during and following operative dissection. Within this chapter, normal and anomalous pathways of the recurrent laryngeal nerve are described, as well as the electrophysiologic principles of intraoperative neuro-monitoring. There are a number of variants of neuro-monitoring; this chapter focuses on models that use electromyographic outputs, most commonly via electrode-laden endotracheal tubes. For this technique, principles of implementation and common pitfalls are summarized.

Although there has recently been an upsurge of literature pertaining to neuro-monitoring, convincing evidence for a clinically significant benefit in thyroid surgery is lacking. Due in part to the relatively low incidence of permanent recurrent laryngeal nerve injury among experienced providers, most prospective studies on the effect of neuro-monitoring are severely underpowered. However, the utility of neuro-monitoring is not limited to nerve preservation and may include delineation of complex anatomy, operative decision-making, and surgical instruction. This chapter reviews the literature regarding intraoperative neuro-monitoring to promote thoughtful implementation of this potentially useful tool.

Keywords

Intraoperative neurophysiological monitoring Thyroidectomy/adverse effects Recurrent laryngeal nerve injuries Intraoperative complications Treatment outcome Vocal cord paralysis/etiology Thyroid diseases/surgery 

References

  1. 1.
    Cernea CR, Ferraz AR, Furlani J, Monteiro S, Nishio S, Hojaij FC, Dutra Jr A, Marques LA, Pontes PA, Bevilacqua RG. Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Am J Surg. 1992;164(6):634–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Cernea CR, Ferraz AR, Nishio S, Dutra Jr A, Hojaij FC, dos Santos LR. Surgical anatomy of the external branch of the superior laryngeal nerve. Head Neck. 1992;14(5):380–3.CrossRefPubMedGoogle Scholar
  3. 3.
    Jonas J, Bahr R. Neuromonitoring of the external branch of the superior laryngeal nerve during thyroid surgery. Am J Surg. 2000;179(3):234–6.CrossRefPubMedGoogle Scholar
  4. 4.
    Kierner AC, Aigner M, Burian M. The external branch of the superior laryngeal nerve: its topographical anatomy as related to surgery of the neck. Arch Otolaryngol Head Neck Surg. 1998;124(3):301–3.CrossRefPubMedGoogle Scholar
  5. 5.
    Randolph GW, editor. Surgery of the thyroid and parathyroid glands. Philadelphia, PA: Elsevier Science; 2002.Google Scholar
  6. 6.
    Serpell JW, Yeung MJ, Grodski S. The motor fibers of the recurrent laryngeal nerve are located in the anterior extralaryngeal branch. Ann Surg. 2009;249(4):648–52.CrossRefPubMedGoogle Scholar
  7. 7.
    Kandil E, Abdelghani S, Friedlander P, Alrasheedi S, Tufano RP, Bellows CF, Slakey D. Motor and sensory branching of the recurrent laryngeal nerve in thyroid surgery. Surgery. 2011;150(6):1222–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Kandil E, Abdel Khalek M, Aslam R, Friedlander P, Bellows CF, Slakey D. Recurrent laryngeal nerve: significance of the anterior extralaryngeal branch. Surgery. 2011;149(6):820–4.CrossRefPubMedGoogle Scholar
  9. 9.
    Henry JF, Audiffret J, Denizot A, Plan M. The nonrecurrent inferior laryngeal nerve: review of 33 cases, including two on the left side. Surgery. 1988;104(6):977–84.PubMedGoogle Scholar
  10. 10.
    Brauckhoff M, Thanh NP, Dralle H. Images in thyroidology. Nervus laryngeus inferior non recurrens and lusorial artery. Thyroid. 2004;14(1):79–81.CrossRefPubMedGoogle Scholar
  11. 11.
    Avisse C, Marcus C, Delattre JF, Marcus C, Cailliez-Tomasi JP, Palot JP, Ladam-Marcus V, Menanteau B, Flament JB. Right nonrecurrent inferior laryngeal nerve and arteria lusoria: the diagnostic and therapeutic implications of an anatomic anomaly. Review of 17 cases. Surg Radiol Anat. 1998;20(3):227–32.CrossRefPubMedGoogle Scholar
  12. 12.
    Steurer M, Passler C, Denk DM, Schneider B, Niederle B, Bigenzahn W. Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope. 2002;112(1):124–33.CrossRefPubMedGoogle Scholar
  13. 13.
    Sritharan N, Chase M, Kamani D, Randolph M, Randolph GW. The vagus nerve, recurrent laryngeal nerve, and external branch of the superior laryngeal nerve have unique latencies allowing for intraoperative documentation of intact neural function during thyroid surgery. Laryngoscope. 2015;125(2):E84–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Genther DJ, Kandil EH, Noureldine SI, Tufano RP. Correlation of final evoked potential amplitudes on intraoperative electromyography of the recurrent laryngeal nerve with immediate postoperative vocal fold function after thyroid and parathyroid surgery. JAMA Otolaryngol Head Neck Surg. 2014;140(2):124–8.PubMedCentralCrossRefPubMedGoogle Scholar
  15. 15.
    Chiang FY, Lu IC, Kuo WR, Lee KW, Chang NC, Wu CW. The mechanism of recurrent laryngeal nerve injury during thyroid surgery–the application of intraoperative neuromonitoring. Surgery. 2008;143(6):743–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Poveda M, Dionigi G, Sitges-Serra A, Barczynski M, Angelos P, Dralle H, Phelan E, Randolph G. Intraoperative monitoring of the recurrent laryngeal nerve during thyroidectomy: a standardized approach part 2. World J Endocr Surg. 2012;4(1):33–40.Google Scholar
  17. 17.
    Randolph GW, Dralle H, Abdullah H, Barczynski M, Bellantone R, Brauckhoff M, Carnaille B, Cherenko S, Chiang FY, Dionigi G, Finck C, Hartl D, Kamani D, Lorenz K, Miccolli P, Mihai R, Miyauchi A, Orloff L, Perrier N, Poveda MD, Romanchishen A, Serpell J, Sitges-Serra A, Sloan T, van Slycke S, Snyder S, Takami H, Volpi E, Woodson G. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope. 2011;121 Suppl 1:S1–16.CrossRefPubMedGoogle Scholar
  18. 18.
    Jansson S, Tisell LE, Hagne I, Sanner E, Stenborg R, Svensson P. Partial superior laryngeal nerve (SLN) lesions before and after thyroid surgery. World J Surg. 1988;12(4):522–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Barczynski M, Konturek A, Stopa M, Honowska A, Nowak W. Randomized controlled trial of visualization versus neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy. World J Surg. 2012;36(6):1340–7.PubMedCentralCrossRefPubMedGoogle Scholar
  20. 20.
    Barczynski M, Randolph GW, Cernea CR, Dralle H, Dionigi G, Alesina PF, Mihai R, Finck C, Lombardi D, Hartl DM, Miyauchi A, Serpell J, Snyder S, Volpi E, Woodson G, Kraimps JL, Hisham AN, International Neural Monitoring Study Group. External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: International Neural Monitoring Study Group standards guideline statement. Laryngoscope. 2013;123 Suppl 4:S1–14.CrossRefPubMedGoogle Scholar
  21. 21.
    Randolph GW, Kobler JB, Wilkins J. Recurrent laryngeal nerve identification and assessment during thyroid surgery: laryngeal palpation. World J Surg. 2004;28(8):755–60.CrossRefPubMedGoogle Scholar
  22. 22.
    Cernea CR, Brandao LG, Hojaij FC, DE Carlucci Jr D, Brandao J, Cavalheiro B, Sondermann A. Negative and positive predictive values of nerve monitoring in thyroidectomy. Head Neck. 2012;34(2):175–9.CrossRefPubMedGoogle Scholar
  23. 23.
    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):240–6.CrossRefPubMedGoogle Scholar
  24. 24.
    Beldi G, Kinsbergen T, Schlumpf R. Evaluation of intraoperative recurrent nerve monitoring in thyroid surgery. World J Surg. 2004;28(6):589–91.CrossRefPubMedGoogle Scholar
  25. 25.
    Dralle H, Sekulla C, Haerting J, Timmermann W, Neumann HJ, Kruse E, Grond S, Muhlig HP, Richter C, Voss J, Thomusch O, Lippert H, Gastinger I, Brauckhoff M, Gimm O. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery. 2004;136(6):1310–22.CrossRefPubMedGoogle Scholar
  26. 26.
    Snyder SK, Hendricks JC. Intraoperative neurophysiology testing of the recurrent laryngeal nerve: plaudits and pitfalls. Surgery. 2005;138(6):1183–91. Discussion 1191–2.CrossRefPubMedGoogle Scholar
  27. 27.
    Snyder SK, Sigmond BR, Lairmore TC, Govednik-Horny CM, Janicek AK, Jupiter DC. The long-term impact of routine intraoperative nerve monitoring during thyroid and parathyroid surgery. Surgery. 2013;154(4):704–11. Discussion 711–3.CrossRefPubMedGoogle Scholar
  28. 28.
    de Pedro Netto I, Vartanian JG, Ferraz PR, Salgado P, Azevedo JB, Toledo RN, Testa JR, Carrara-de-Angelis E, Kowalski LP. Vocal fold immobility after thyroidectomy with intraoperative recurrent laryngeal nerve monitoring. Sao Paulo Med J. 2007;125(3):186–90.Google Scholar
  29. 29.
    Calo PG, Pisano G, Medas F, Pittau MR, Gordini L, Demontis R, Nicolosi A. Identification alone versus intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroid surgery: experience of 2034 consecutive patients. J Otolaryngol Head Neck Surg. 2014;43(1):16.PubMedCentralCrossRefPubMedGoogle Scholar
  30. 30.
    Shindo M, Chheda NN. Incidence of vocal cord paralysis with and without recurrent laryngeal nerve monitoring during thyroidectomy. Arch Otolaryngol Head Neck Surg. 2007;133(5):481–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Chan WF, Lang BH, Lo CY. The role of intraoperative neuromonitoring of recurrent laryngeal nerve during thyroidectomy: a comparative study on 1000 nerves at risk. Surgery. 2006;140(6):866–72. Discussion 872–3.CrossRefPubMedGoogle Scholar
  32. 32.
    Robertson ML, Steward DL, Gluckman JL, Welge J. Continuous laryngeal nerve integrity monitoring during thyroidectomy: does it reduce risk of injury? Otolaryngol Head Neck Surg. 2004;131(5):596–600.CrossRefPubMedGoogle Scholar
  33. 33.
    Witt RL. Electrophysiologic monitoring of the recurrent laryngeal nerves may not predict bilateral vocal fold immobility after thyroid surgery. J Voice. 2004;18(2):256–60.CrossRefPubMedGoogle Scholar
  34. 34.
    Pisanu A, Porceddu G, Podda M, Cois A, Uccheddu A. Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy. J Surg Res. 2014;188(1):152–61.CrossRefPubMedGoogle Scholar
  35. 35.
    Phelan E, Schneider R, Lorenz K, Dralle H, Kamani D, Potenza A, Sritharan N, Shin J, Randolph GW. 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):1498–505.CrossRefPubMedGoogle Scholar
  36. 36.
    Ulmer C, Friedrich C, Kohler A, Rieber F, Basar T, Deuschle M, Thon KP, Lamade W. Impact of continuous intraoperative neuromonitoring on autonomic nervous system during thyroid surgery. Head Neck. 2011;33(7):976–84.CrossRefPubMedGoogle Scholar
  37. 37.
    Aina EN, Hisham AN. External laryngeal nerve in thyroid surgery: recognition and surgical implications. ANZ J Surg. 2001;71(4):212–4.CrossRefPubMedGoogle Scholar
  38. 38.
    Lifante JC, Mcgill J, Murry T, Aviv JE, Inabnet 3rd WB. A prospective, randomized trial of nerve monitoring of the external branch of the superior laryngeal nerve during thyroidectomy under local/regional anesthesia and IV sedation. Surgery. 2009;146(6):1167–73.CrossRefPubMedGoogle Scholar
  39. 39.
    Sanabria A, Silver CE, Suarez C, Shaha A, Khafif A, Owen RP, Rinaldo A, Ferlito A. Neuromonitoring of the laryngeal nerves in thyroid surgery: a critical appraisal of the literature. Eur Arch Otorhinolaryngol. 2013;270(9):2383–95.CrossRefPubMedGoogle Scholar
  40. 40.
    Hermann M, Hellebart C, Freissmuth M. Neuromonitoring in thyroid surgery: prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury. Ann Surg. 2004;240(1):9–17.PubMedCentralCrossRefPubMedGoogle Scholar
  41. 41.
    Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg. 1998;228(3):320–30.PubMedCentralCrossRefPubMedGoogle Scholar
  42. 42.
    Sturgeon C, Sturgeon T, Angelos P. Neuromonitoring in thyroid surgery: attitudes, usage patterns, and predictors of use among endocrine surgeons. World J Surg. 2009;33(3):417–25.CrossRefPubMedGoogle Scholar
  43. 43.
    Goretzki PE, Schwarz K, Brinkmann J, Wirowski D, Lammers BJ. The impact of intraoperative neuromonitoring (IONM) on surgical strategy in bilateral thyroid diseases: is it worth the effort? World J Surg. 2010;34(6):1274–84.CrossRefPubMedGoogle Scholar
  44. 44.
    Sadowski SM, Soardo P, Leuchter I, Robert JH, Triponez F. Systematic use of recurrent laryngeal nerve neuromonitoring changes the operative strategy in planned bilateral thyroidectomy. Thyroid. 2013;23(3):329–33.CrossRefPubMedGoogle Scholar
  45. 45.
    Lorenz K, Abuazab M, Sekulla C, Schneider R, Nguyen Thanh P, Dralle H. Results of intraoperative neuromonitoring in thyroid surgery and preoperative vocal cord paralysis. World J Surg. 2014;38(3):582–91.CrossRefPubMedGoogle Scholar
  46. 46.
    de Pedro NI, Fae A, Vartanian JG, Barros AP, Correia LM, Toledo RN, Testa JR, Nishimoto IN, Kowalski LP, Carrara-de Angelis E. Voice and vocal self-assessment after thyroidectomy. Head Neck. 2006;28(12):1106–14.CrossRefGoogle Scholar
  47. 47.
    Hemmerling TM, Schmidt J, Bosert C, Jacobi KE, Klein P. Intraoperative monitoring of the recurrent laryngeal nerve in 151 consecutive patients undergoing thyroid surgery. Anesth Analg. 2001;93(2):396–9. 3rd contents page.PubMedGoogle Scholar
  48. 48.
    Dionigi G, Bacuzzi A, Boni L, Rausei S, Rovera F, Dionigi R. Visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy: what about the costs? World J Surg. 2012;36(4):748–54.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Division of General Surgery, Department of SurgeryUniversity of Virginia Health SystemCharlottesvilleUSA

Personalised recommendations