Intra Operative Recurrent Laryngeal Nerve Monitering During Thyroid Surgery - Is It Worth?

The basic principle of head and neck surgery is based on the identification and preservation of important structures, rather than avoidance. Thyroid surgeries are the most frequently performed endocrine procedures worldwide. Recurrent laryngeal nerve (RLN) palsy after thyroid surgery is a serious postoperative complication that can diminish the quality of life. While it is generally accepted that direct visualisation of the nerve is the gold standard, intraoperative nerve monitoring (IONM) is being used increasingly as an adjuvant to help identify the nerve. This study was carried out in Mahatma Gandhi medical college and hospital, Jaipur, Rajasthan from June 2018 to March 2020. 100 patients were enrolled in the study. RLN is identified & visualized in Beahr's triangle or in Lore's triangle. We have randomly selected the patient and use IONM as an adjunct to standard visual identification of the recurrent laryngeal nerve (RLN) to prevent nerve lesion. 8 out of 108 nerves which were at risk during thyroid surgery were found injured. 2 of 50 (4%) nerves at risk were injured with IONM that caused temporary paresis. Without IONM, 5 of 58 (8.6%) nerves at risk suffered temporary paresis and 1of 58(1.72%) had paralysis. Visual nerve identification alone remains the gold standard of recurrent laryngeal nerve management in thyroid surgery and one can use operating microscope for magnification. Neuromonitoring helps to identify the RLN particularly in difficult cases, but it does not decrease the injury to RLN as compared to visualization alone.

Is Routine Use of High Resolution Computerized Tomography of Temporal Bone in Patients of Atticoantral Chronic Suppurative Otitis Media without Intracranial Complications Justified?

Role of high resolution computerized tomography (HRCT) of temporal bone is established in cases of atticoantral chronic suppurative otitis media (CSOM) with intracranial complications. Routine use of HRCT in management of patients of atticoantral CSOM without intracranial complications has been an issue of debate. The aim of this study was to evaluate the routine use of HRCT of temporal bone in such cases. This study was a prospective study done at LG hospital, AMC MET Medical College, Ahmedabad to evaluate and compare the temporal bone findings in HRCT and intraoperative findings in 100 patients with atticoantral CSOM. All patients underwent HRCT screening followed by surgical exploration of middle ear cleft. In extent of disease HRCT showed very high sensitivity and specificity for epitympanum (100, 94%) and mesotympanum (98, 98%) areas. It gave valuable information of disease extent in hidden areas like sinus tympani and facial recess of mesotympanum. HRCT satisfactorily delineated malleus and incus erosion but had 75% sensitivity for detecting erosion of stapes suprastructure, though specificity was of 97%. For bony anatomical landmarks HRCT showed very high sensitivity and specificity for detecting erosion of lateral semicircular canal, tegmen tympani and sinus plate. Detection of facial canal erosion on HRCT had moderate sensitivity of 75%. We concluded that routine use of HRCT is justified as a reliable preoperative tool in patients with atticoantral CSOM without intracranial complications and it helps to plan type of surgical intervention. HRCT has limited role to distinguish between granulations and cholesteatoma and also to delineate stapes supra structure and facial nerve canal.