Soft tissue injury events associated with neural integrity monitoring endotracheal tubes: A MAUDE database analysis.

OBJECTIVE: Neural integrity monitoring (NIM) endotracheal tubes are widely used to provide intraoperative monitoring of the recurrent laryngeal nerve during certain neck surgeries, especially thyroidectomy, in order to reduce the risk of nerve injury and subsequent vocal fold paralysis. The unique design of NIM tubes and the increased technical skill required for correct placement compared to standard endotracheal tubes may increase the risk of upper aerodigestive tract soft tissue injury. This study aims to describe adverse events related to NIM endotracheal tubes. STUDY DESIGN: Retrospective cross-sectional study. SETTING: The US Food and Drug Administration's MAUDE database (2010-2022); (Manufacturer and User Facility Device Experience). METHODS: The MAUDE database was queried for reports of adverse events that resulted in patient soft tissue injury involving the use of endotracheal tubes approved by the Food and Drug Administration. RESULTS: There were 28 reported soft tissue injuries, with all events being related to the NIM EMG family of endotracheal tubes manufactured by Medtronic Xomed, Inc. Overall, 24 were categorized as device-related adverse events, and 4 were unspecified in the event description. The most common soft tissue injuries were edema (n = 7) and perforation (n = 7), each accounting for 25 % of adverse events. The second most common injury type was laceration (n = 4), representing 14 % of all adverse events. Overall, 9 patients (32 %) in our cohort required a surgical intervention to treat their injuries, which consisted of 6 tracheotomies and 3 instances of suture repair. CONCLUSIONS: The most commonly reported types of soft tissue injury included edema and perforation, followed by laceration. Increased awareness of device-related patient injuries associated with NIM endotracheal tubes can be used to better inform surgeons and anesthesiologists during the process of intubation and surgical decision-making.

Fluorescence imaging to visualize the recurrent laryngeal nerve during thyroidectomy procedures: analysis of 65 cases and 81 nerves.

BACKGROUND: Recurrent laryngeal nerve (RLN) injury after thyroidectomy is relatively common. Locating the RLN prior to thyroid dissection is paramount to avoid injury. We developed a fluorescence imaging system that permits nerve autofluorescence. We aimed to determine the sensitivity and specificity of fluorescence imaging at detecting the RLN relative to thyroid and other background tissue and compared it to white light. METHODS: In this prospective study, 65 patients underwent thyroidectomy from January to April 2022 (16 bilateral thyroid resections) using white and fluorescent light. Fluorescence intensity [relative fluorescence units (RFU)] was recorded for RLN, thyroid, and background. RFU mean, minimum, and maximum values were calculated using Image J software. Thirty randomly selected pairs of white and fluorescent light images were independently reviewed by two examiners to compare RLN detection rate, number of branches, and length and minimum width of nerves visualized. Parametric and nonparametric statistical analysis was performed. RESULTS: All 81 RNLs observed were visualized more clearly under fluorescence (mean intensity, µ = 134.3 RFU) than either thyroid (µ = 33.7, p < 0.001) or background (µ = 14.4, p < 0.001). Forest plots revealed no overlap between RLN intensity and that of either other tissue. Sensitivity and specificity for RLN were 100%. All 30 RLNs and all 45 nerve branches were clearly visualized under fluorescence, versus 17 and 22, respectively, with white light (both p < 0.001). Visible nerve length was 2.5 × as great with fluorescence as with white light (µ = 1.90 vs. 0.76 cm, p < 0.001). CONCLUSIONS: In 65 patients and 81 nerves, RLN detection was markedly and consistently enhanced with autofluorescence neuro-imaging during thyroidectomy, with 100% sensitivity and specificity.

Clinical validation of NerveTrend versus conventional i-IONM mode of NIM Vital in prevention of recurrent laryngeal nerve events during bilateral thyroid surgery: A randomized controlled trial.

BACKGROUND: The aim of this study was to test the hypothesis that use of NerveTrend™ mode of intermittent neuromonitoring (i-IONM) during thyroidectomy may identify and prevent impending recurrent laryngeal nerve (RLN) injury. METHODS: A randomized clinical trial. The primary outcome was prevalence of RLN injury on postoperative day 1. In NerveTrend™ group the i-IONM stimulator was used for trending of amplitude and latency changes from initial vagal electromyographic baseline to tailor surgical strategy. RESULTS: Some 264 patients were randomized into the intervention versus the control group, 132 patients each. RLN injury was found on postoperative day 1 in 5/264 (1.89%) nerves at risk (NAR) versus 12/258 (4.65%) NAR whereas staged thyroidectomy was used in 0/132 (0.00%) versus 6/132 (4.54%) patients (p = 0.067 and p = 0.029, respectively). CONCLUSION: The use of NerveTrend™ mode resulted in tendency towards reduced RLN injury on postoperative day 1 and significant decrease of need for a staged thyroidectomy.

Refining postoperative monitoring of recurrent laryngeal nerve injury in esophagectomy patients through transcutaneous laryngeal ultrasonography.

BACKGROUND: Recurrent laryngeal nerve injury (RLNI) leading to vocal cord paralysis (VCP) is a significant complication following minimally invasive esophagectomy (MIE) with upper mediastinal lymphadenectomy. Transcutaneous laryngeal ultrasonography (TLUSG) has emerged as a non-invasive alternative to endoscopic examination for evaluating vocal cord function. Our study aimed to assess the diagnostic value of TLUSG in detecting RLNI by evaluating vocal cord movement after MIE. METHODS: This retrospective study examined 96 patients with esophageal cancer who underwent MIE between January 2021 and December 2022, using both TLUSG and endoscopy. RESULTS: VCP was observed in 36 out of 96 patients (37.5%). The incidence of RLNI was significantly higher on the left side than the right (29.2% vs. 5.2%, P < 0.001). Postoperative TLUSG showed a sensitivity and specificity of 88.5% (31/35) and 86.5% (45/52), respectively, with an AUC of 0.869 (P < 0.001, 95% CI 0.787-0.952). The percentage agreement between TLUSG and endoscopy in assessing VCP was 87.4% (κ = 0.743). CONCLUSIONS: TLUSG is a highly effective screening tool for VCP, given its high sensitivity and specificity. This can potentially eliminate the need for unnecessary endoscopies in about 80% of patients who have undergone MIE.

Recurrent laryngeal never monitoring versus non-monitoring in parathyroid surgery.

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.

Prophylactic central neck dissection for cN0 papillary thyroid carcinoma: is there any difference between western countries and China? A systematic review and meta-analysis.

Background: Recommendations for the performance of prophylactic central neck dissection (pCND) in patients with clinically node-uninvolved (cN0) papillary thyroid carcinoma (PTC) are not the same. This meta-analysis set out to compare the effectiveness of pCND with total thyroidectomy (TT) in different countries and regions, mainly between western countries and China. Methods: The electronic databases PubMed, EMBASE, and Cochrane Library were searched for studies published until August 2022. The incidence rate of cervical lymph node metastases (LNMs), locoregional recurrences (LRRs), and postoperative complications were pooled by a random-effects model. Subgroup analyses based on different countries and regions were performed. Results: Eighteen studies involving 5,346 patients were analyzed. In the subgroup of western countries, patients undergoing pCND with TT had a significantly lower LRR rate [69/1,804, 3.82% vs. 139/2,541, 5.47%; odds ratio (OR) = 0.56; 95% CI 0.37-0.85] and a higher rate of temporary hypoparathyroidism (HPT) (316/1,279, 24.71% vs. 194/1,467, 13.22%; OR = 2.23; 95% CI 1.61-3.08) than that of the TT alone group, while no statistically significant difference was found in the rate of permanent HPT and temporary and permanent recurrent laryngeal nerve (RLN) injury. In the Chinese subgroup, the pCND with TT group had a significantly higher incidence rate of both temporary HPT (87/374, 23.26% vs. 36/324, 11.11%; OR = 2.24; 95% CI 1.32-3.81) and permanent HPT (21/374, 5.61% vs. 4/324, 1.23%; OR = 3.58; 95% CI = 1.24-10.37) than that of the TT alone group, while no significant difference was detected in the rate of LRR and temporary and permanent RLN injury. Conclusion: Compared with the TT alone for cN0 PTC patients, pCND with TT had a significantly lower LRR rate while having a higher temporary HPT rate in Europe, America, and Australia; however, it showed no significant difference in decreasing LRR rate while having a significantly raised rate of temporary and permanent HPT in China. More population-based results are required to advocate precision medicine in PTC. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022358546.

The TOFr of 0.75 to 0.85 is the optimal timing for IONM during thyroid surgery: a prospective observational cohort study.

BACKGROUD: Recurrent laryngeal nerve (RLN) injury is one of the serious complications of thyroid tumour surgery, surgical treatment of thyroid cancer requires careful consideration of the RLN and its impact on glottis function. There has been no unified standard for precise neuromuscular block monitoring to guide the monitoring of RLN in thyroid surgery. This study aimed to investigate the correlation between Train-of-four stabilization ratio (TOFr) and neural signal values of intraoperative neurophysiological monitoring (INOM) during thyroid operation, and further to determine the optimal timing for INOM during thyroid operation. METHODS: Patients scheduled for thyroid tumour resection with INOM and RLN monitoring from April 2018 to July 2018 in our center were recruited. Electromyography (EMG) signals and corresponding TOFr were collected. All nerve stimulation data were included in group VR. Vagus nerve stimulation data were included in Subgroup V. RLN stimulation data were included in Subgroup R. The timing of recording was as follows: Vagus nerve EMG amplitude after opening the lateral space between the thyroid and carotid sheath and before the initiation of thyroid dissection, RLN EMG amplitude at first recognition, RLN EMG amplitude after complete thyroid dissection (Repeat three times), and Vagus nerve EMG amplitude after resection of the thyroid (Repeat three times). Correlation analysis of continuous variables was described by a scatter diagram. Pearson correlation analysis or Spearman correlation analysis was used for the two groups of variables. RESULTS: Finally, 134 vagus nerve signals and 143 RLN signals were analysed after matching with TOFr. The EMG amplitude in the VR group and subgroups after nerve stimulation was positively correlated with TOFr (p < 0.05). In the VR, V and R group, the incidence of EMG ≥ 500 µV in the 0.75 < TOFr ≤ 0.85 interval was significantly higher than the 0 < TOFr ≤ 0.75 interval (P = 0.002, P = 0.013 and P = 0.029), and has no statistical difference compared to 0.85 < TOFr ≤ 0.95 interval (P > 0.05). CONCLUSIONS: The EMG signals of the RLN and vagus nerve stimulation during thyroid surgery were positively correlated with TOFr. TOFr > 0.75 could reflect more than 50% of the effective nerve electrophysiological signals, 0.75 < TOFr ≤ 0.85 interval was the optimal timing for IONM during thyroid surgery. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR1800015797) Registered on 20/04/2018. https://www.chictr.org.cn .

Comparison of Recurrent Laryngeal Nerve Injury during Thyroidectomy with and Without Routine Identification of the Nerve Peroperatively.

Thyroidectomy is one of the commonest operative procedures performed in the neck and injury to recurrent laryngeal nerve (RLN) is not uncommon. It results in hoarseness to serious respiratory distress depending on the extent of the injury. The incidence of RLN injury varies widely and is multifactorial depending on the extent of surgical procedures, experience and expertise of the surgeons, nature of the thyroid diseases and a wide range of anatomical variations. Peroperative routine identification of the nerve during thyroidectomy can be a way to prevent injury. Despite recommendation for identification of the RLN peroperatively in thyroid surgery, a debate still exists whether the nerve to be identified peroperatively or not, to avoid its inadvertent injury. The aim of this study was to compare the incidence of RLN injury between two groups where RLN was identified peroperatively in one group and the nerve was not attempted for identification in the other group in thyroid surgery. A comparative cross-sectional study was carried out in the department of surgery and otolaryngology at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from June 2018 to November 2019, on patients who underwent elective thyroid surgery. Patients were included in RLN identified group and in RLN not identified group, by individual surgeons' preference to identify or not to identify the RLN peroperatively. Peroperative identification of the nerve was done by direct visualization. All cases were evaluated for vocal cord palsy preoperatively, during extubation and postoperatively. Patient's particulars, other parameters and perioperative data were recorded. A total of 80 cases were included in this study, 40 cases (50.0%) in the peroperative RLN identified group and 40 cases (50.0%) in the RLN not identified group. Unilateral RLN palsy was encountered in 2.5% (2 cases) in the RLN identified group and 6.3% (5 cases) in the nerve not identified group (p value 0.192). Transient unilateral RLN palsy was seen in 7.5% (6 cases) of patients; 2.5% (2 cases) in the RLN identified group and 5.0% (4 cases) in the RLN not identified group. And 1.3% (1 case) of permanent unilateral RLN palsy was encountered in this study, which was in the RLN not identified group; there was no permanent palsy in the RLN identified group. We did not encounter any bilateral RLN palsy. There was no statistically significant difference in the incidence of RLN injury between the peroperatively RLN identified group and no attempt to identify the nerve group despite recommendation for peroperative RLN identification in thyroid surgery to avoid its inadvertent injury. However, from this study, we recommend peroperative RLN identification in thyroid surgery to enhance surgical skill.

Transoral endoscopic thyroidectomy vestibular approach as a novel technique for pediatric populations: Results from a single surgeon.

Background: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is increasingly being adopted worldwide because of its many advantages. However, there are few reports on the effectiveness and safety of TOETVA in children. In this study, we report the results of the application of TOETVA on 27 pediatric patients in Vietnam. To the best of our knowledge, this is also the largest sample size of the TOETVA technique performed by a single surgeon on pediatric patients worldwide. Patients and methods: From June 2020 to February 2022, we performed TOETVA on 27 pediatric patients (≤ 18 years old). The outcomes of the procedure were retrospectively reviewed. Results: Our study was conducted on 27 pediatric patients, of whom 24 were female (88.9%). The mean age was 16.3 ± 2 (range 10-18). Fifteen patients had benign thyroid nodules with a mean nodule size of 31.6 ± 7.1 (range 20-50mm), and 12 patients had papillary thyroid carcinoma with a mean nodule size of 10.2 ± 5.6 (range 4-19mm). All 27 patients underwent successful TOETVA without any conversion to open surgery. The 15 patients with benign thyroid nodules had lobectomies with a mean operative time of 83.3 ± 10.5 (range 60-105 minutes). Among the 12 patients diagnosed with thyroid cancer, ten had a lobectomy, isthmusectomy, and central neck dissection, with a mean operative time of 89.8 ± 5.7 (range 80-100 minutes). The other two underwent total thyroidectomy with central lymph node dissection with a mean operative time of 132.5 minutes. The mean hospital stay was 4.7 ± 0.9 (range 3-7 days). No patient had permanent complications, such as hypocalcemia, recurrent laryngeal nerve injury, or mental nerve injury. The rates of temporary recurrent laryngeal nerve injury and mental nerve injury were 3.7% and 11.1% respectively. Conclusions: TOETVA may be a feasible and safe surgical method for children with thyroid disease. However, we recommend that only high-volume thyroid surgeons with experience in TOETVA should perform TOETVA on the pediatric population.

Effectiveness of the recurrent laryngeal nerve monitoring during endoscopic thyroid surgery: systematic review and meta-analysis.

BACKGROUND: Thyroid disease is a common endocrine disorder, and thyroid surgeries and postoperative complications have increased recently. This study aimed to explore the effectiveness of intraoperative nerve monitoring (IONM) in endoscopic thyroid surgery using subgroup analysis and determine confounding factors. MATERIALS AND METHODS: Two researchers individually searched for relevant studies published till November 2022 in the PubMed, Embase, Web of Science and Cochrane Library databases. Eventually, eight studies met the inclusion criteria. Heterogeneity was assessed using the Cochran's Q test, and a funnel plot was implemented to evaluate publication bias. The odds ratio or risk difference were calculated using fixed-effects models. The weighted mean difference of continuous variables was calculated. Subgroup analysis was performed according to the disease type. RESULTS: Eight eligible papers included 915 patients and 1242 exposed nerves. The frequencies of transient, permanent and total recurrent laryngeal nerve (RLN) palsy were 2.64, 0.19 and 2.83%, respectively, in the IONM group and 6.15, 0.75 and 6.90%, respectively, in the conventional exposure group. In addition, analysis of the secondary outcome indicators for the average total length of surgery, localisation time of the RLN, recognition rate of the superior laryngeal nerve and length of incision revealed that IONM reduced the localisation time of the RLN and increased the identification rate of the superior laryngeal nerve. Subgroup analysis showed that IONM significantly reduced the incidence of RLN palsy in patients with malignancies. CONCLUSIONS: The use of IONM significantly reduced the incidence of transient RLN palsy during endoscopic thyroid surgery, but it did not significantly reduce the incidence of permanent RLN palsy. However, the reduction in the total RLN palsy was statistically significant. In addition, IONM can effectively reduce the location time of the RLN and increase the recognition rate of the superior laryngeal nerve. Therefore, the application of IONM for malignant tumours is recommended.

Increased Risk of Complications Associated With Concurrent Parathyroidectomy in Patients Undergoing Total Thyroidectomy.

INTRODUCTION: We sought to investigate the association of concurrent parathyroidectomy (PTX) with risks of total thyroidectomy (TTX) through analysis of Collaborative Endocrine Surgery Quality Improvement Program data. TTXis a common operation with complications including recurrent laryngeal nerve injury, neck hematoma, and hypoparathyroidism. A subset of patients undergoing thyroidectomy undergoes planned concurrent PTX for treatment of primary hyperparathyroidism. There are limited data on the risk profile of TTX with concurrent PTX (TTX + PTX). METHODS: We queried the Collaborative Endocrine Surgery Quality Improvement Program database for patients who underwent TTX or TTX + PTX from January 2014 through April 2020. Multivariable logistic regression was performed to predict hypoparathyroidism, vocal cord dysfunction, neck hematoma, and postoperative emergency department visit. Covariates included patient demographics, patient body mass index, indication for surgery, central neck dissection, anticoagulation use, and surgeon volume. RESULTS: Thirteen thousand six hundred forty seven patients underwent TTX and 654 patients underwent TTX + PTX. Unadjusted rates of hypoparathyroidism were higher in TTX + PTX patients at 30 d (9.6% versus 7.4%, P = 0.04) and 6 mo (7.9% versus 3.1%, P < 0.001). On multivariable regression, TTX + PTX was associated with an increased risk of hypoparathyroidism at 30 d (odds ratio [OR] 2.09, 95% confidence interval [CI] 1.57-2.79) and 6 mo (OR 4.63, 95% CI 3.06-7.00) and an increased risk of postoperative emergency department visit (OR 1.66, 95% CI 1.20-2.31). TTX + PTX was not associated with recurrent laryngeal nerve injury or neck hematoma. CONCLUSIONS: Concurrent PTX in patients undergoing TTX is associated with increased risk of immediate and long-term hypoparathyroidism, which should be considered in informed consent discussions and operative decision-making.

The role of intraoperative neuromonitoring in preventing lesions of the spinal accessory nerve during functional neck dissection.

Intraoperative neuromonitoring (IONM) in thyroid surgery offers a valid aid to the operator in identifying the recurrent laryngeal nerve and preserving its function. Recently, IONM has also been used in other surgeries, such as spinal accessory nerve dissection, during lymphectomy of the II, III, IV, and V laterocervical lymph nodes. The goal is the preservation of the spinal accessory nerve, whose macroscopic integrity does not always indicate its functionality. A further difficulty is the anatomical variability of its course at the cervical level. The aim of our study is to assess whether the use of the IONM helps to reduce the incidence of transient and permanent paralysis of the spinal accessory nerve, compared to "de visu" identification by the surgeon alone. In our case series, the use of the IONM reduced the incidence of transient paralysis, and no permanent paralysis was recorded. In addition, if the IONM registers a reduction in nerve potential, compared to the baseline value during surgery, it could indicate the need for early rehabilitation treatment, increasing the patients' chances of regaining function and reducing the costs of prolonged physiotherapy treatment.

Recurrent laryngeal nerve injury after thyroidectomy: A national study from Saudi Arabia.

OBJECTIVES: To determine the incidence and possible risk factors of recurrent laryngeal nerve injury, to provide a relevant literature review of studies from other centers in Saudi Arabia, and to present basic statistical data for future studies in our local community. METHODS: A retrospective study enrolled patients who were surgically treated for thyroid disease between January 2015 and December 2021. For concerns during the procedure, direct laryngoscopy was carried out before extubation to assess the vocal cords. Similarly, indirect laryngoscopy was carried out for patients who developed postoperative voice changes. All patients were evaluated clinically 2-3 weeks after surgery. Nerve monitors were not used in either case. RESULTS: The study examined 437 participants: 361 (82.6%) female and 76 (17.4%) male individuals. The incidence of recurrent laryngeal nerve injury was 1.1%. The demographic characteristics, pathology (benign vs. malignant), and extent of thyroidectomy were not significantly associated with the risk of recurrent laryngeal nerve injury. CONCLUSION: A recurrent laryngeal nerve injury is a serious complication, and further studies are required to determine the safest techniques for thyroidectomy. However, centralization of thyroid surgery in high-volume centers might reduce this risk.

Outcomes in pediatric total thyroidectomy following implementation of a two-surgeon operative approach.

PURPOSE: Pediatric total thyroidectomy is an uncommon procedure. Higher rates of complication are reported for pediatric patients compared to adults which may be secondary to lower case volume. In this study, we examine the effect of a two-surgeon operative approach on outcomes in pediatric total thyroidectomy. METHODS: A retrospective review of 152 pediatric patients undergoing total thyroidectomy at a single institution was performed. A control group of 89 patients, with one attending surgeon present, was compared to a cohort of 63 pediatric patients who underwent total thyroidectomy with two attendings present. Primary outcomes included rates of permanent hypoparathyroidism and recurrent laryngeal nerve (RLN) injury. The secondary outcomes included postoperative hematoma, length of stay (LOS), LOS greater than 1 day (>1d) secondary to hypocalcemia, and readmissions secondary to hypocalcemia. RESULTS: One RLN injury was documented in each cohort and no postoperative hematomas were documented. Rates of permanent hypoparathyroidism decreased in the two-surgeon cohort (11.48%) when compared to the control group (15.73%) but was not significant. There was a statistically significant decrease in LOS >1d secondary to hypocalcemia in the two-surgeon cohort. LOS >1d attributable to hypocalcemia was seen in 38.2% in the control group versus 15.87% in the 2-surgeon cohort (p = 0.003). CONCLUSIONS: Implementation of a two-surgeon operative approach was shown to lead to a significant decrease in length of stay >1d attributable to hypocalcemia. However, this change was in the setting of multidisciplinary thyroid team and postoperative protocol implementation, and concentration of surgeons performing the operation. Further studies are needed to investigate the effects of the two-surgeon operative approach further.

Recurrent Nerve Injury After Total Thyroidectomy: Risk Factor Analysis of a Targeted NSQIP Data Set.

BACKGROUND: Recurrent laryngeal nerve (RLN) injury is a significant complication after thyroidectomy. Understanding risk factors for RLN injury and the associated postoperative complications may help inform quality improvement initiatives. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) thyroidectomy-targeted database was utilized for patients undergoing total thyroidectomy between 2016 and 2017. Univariable and multivariable regression were used to identify factors associated with RLN injury. RESULTS: A total of 6538 patients were identified. The overall rate of RLN injury was 7.1% (467/6538). Of these, 4129 (63.1%) patients had intraoperative neuromonitoring (IONM), with an associated RLN injury rate of 6.5% (versus 8.2% without). African American and Asian race, non-elective surgery, parathyroid auto-transplantation, and lack of RLN monitoring were all significantly associated with nerve injury on multivariable analysis (P<.05). Patients with RLN injury were more likely to experience cardiopulmonary complications, re-intubation, longer length of stay, readmission, and reoperation. Patients who had IONM and sustained RLN injury remained at risk for developing significant postoperative complications, although the extent of cardiopulmonary complications was less severe in this cohort. DISCUSSION: Recurrent laryngeal nerve injury is common after thyroidectomy and is associated with significant morbidity, despite best practices. Attention to preoperative characteristics may help clinicians to further risk stratify patients prior to thyroidectomy. While IONM does not mitigate all complications, use of this technology may decrease severity of postoperative complications.

The Effect of Patient Positioning on Intraoperative Neuromonitoring During Thyroid and Parathyroid Surgery.

BACKGROUND: Intraoperative neuromonitoring (IONM) has been accepted as a routine adjunct among surgeons who perform thyroid and parathyroid surgeries. Thyroid and parathyroid surgeries use various patient positioning strategies that have poorly understood effects on IONM. The aim of this study was to compare IONM signals between the transaxillary and transcervical approaches. METHODS: In this retrospective cohort study, we evaluated 463 adult patients who underwent a total of 502 procedures. The procedures performed included total thyroidectomy, right or left hemithyroidectomy, and parathyroidectomy. Vagus nerve and recurrent laryngeal nerve (RLN) latency and amplitude measurements were analyzed intra-operatively. The distances between the vagus nerve and the trachea were measured via ultrasound during transaxillary procedures. RESULTS: Compared to the transcervical approach, the right vagus nerve latency was significantly decreased in the transaxillary approach. Transaxillary surgery was not associated with increased latency or decreased amplitude on IONM. The distance between the vagus nerve and trachea was significantly decreased post-positioning during transaxillary approaches. DISCUSSION: Despite differences in patient positioning, a transaxillary approach was not associated with increased stress on the vagus nerve or RLN, according to IONM data. The decreased right vagus nerve latency associated with a transaxillary approach highlights the importance of considering patient positioning and laterality while interpreting IONM data.

Incidence of Dysphonia and Dysphagia Exceeds Recurrent Laryngeal Nerve Injury During Thyroid Surgery.

OBJECTIVES: To determine the prevalence of separate and combined voice and swallowing impairments before and after total thyroidectomy and to delineate risk factors for these symptoms. METHODS: Retrospective review of 592 consecutive patients who underwent total thyroidectomy from July 2003 to August 2015. RESULTS: Combined voice and swallowing problems occurred preoperatively in 4.7% (11/234), 3.3% (3/92), and 6.0% (16/266) of patients with malignancy, hyperthyroidism, and benign euthyroid disease, respectively. Postoperatively, prevalence was 5.1%, 2.2%, and 1.9%, respectively. Benign euthyroid disease (20.7%) had the greatest risk of preoperative dysphagia (P = 0.003) and the largest glands (P < 0.001). Comparing before and after surgery, the cancer and benign euthyroid groups had decreased dysphagia (cancer: 11.5% vs. 6.0%, P = 0.034; benign: 20.7% vs. 3.8%, P < 0.001) but increased dysphonia (cancer: 19.2% vs. 28.6%, P = 0.017; benign: 15.8% vs. 27.1%, P = 0.002). Overall, 23/592 (3.9%) developed new dysphagia and 122/592 (20.6%) developed new dysphonia after surgery. Intraoperative recurrent laryngeal nerve transection occurred in 12 cases (2.0%). CONCLUSIONS: Total thyroidectomy resolved dysphagia but increased dysphonia in benign and malignant euthyroid patients. Voice and swallowing problems following thyroidectomy occurred more frequently than intraoperative recurrent laryngeal nerve transection, confirming symptoms often occur in the absence of suspected nerve injury.

Anatomy and motor function of extra-laryngeal branching patterns of the recurrent laryngeal nerve; an electrophysiological study of 1001 nerves at risk.

INTRODUCTION: Safe thyroid surgery depends on a deep knowledge of human neck anatomy, including the recurrent laryngeal nerve (RLN). Anatomic variations such as extra-laryngeal terminal branching (ETB) are common. PATIENTS AND METHODS: We studied the ETB pattern of 1001 RLNs at risk in 596 patients. We identified and exposed the location of division points on the cervical part of bifid RLN. The function of nerve branches was assessed through intraoperative nerve monitoring (IONM). RESULTS: Bifid RLNs was identified in 39.6% of patients. The nerve-based prevalence of ETB was 28.5%. The prevalence of ETB for the right and left RLN was 21.8% and 35.5%, respectively (p < 0.001). The location of the division point was found in the middle, distal, and proximal segments in 48.8%, 33.3%, and 18% of bifid RLNs, respectively. Electrophysiological monitoring revealed motor functions in all anterior and in 7% of posterior branches. The rate of injury was 0.4%, and 1.1% in single trunk and bifid nerves, respectively (p = 0.360), and 3.9% in nerves with proximal branching (p = 0.084). CONCLUSIONS: The ETB prevalence is high and showing division points in different cervical segments of the RLN. All anterior branches and some posterior branches contain motor fibers. Knowledge and awareness of these anatomic and functional variations are mandatory for every thyroid surgeon to avoid misidentification and misinterpretation of human RLN anatomy.

Primary Nonselective Laryngeal Reinnervation in Iatrogenic Acute Recurrent Laryngeal Nerve Injury: Case Series and Literature Review.

Treating an acutely injured recurrent laryngeal nerve by primary nonselective laryngeal reinnervation (LR) during thyroidectomy is encouraged to minimize postoperative morbidity. Performing a concurrent transoral temporary injection laryngoplasty (IL) may improve the patient's voice while waiting for the effect of successful reinnervation. Chronological multidimensional voice outcomes (qualitative and quantitative) and combination of the primary nonselective LR with concurrent transoral IL were not explicitly demonstrated in previous cases that published the literature. In this study, the authors presented the multidimensional voice parameters of 3 patients undergoing primary nonselective LR with concurrent IL during thyroidectomy. The parameters were measured at different time points (2 weeks and 1, 3, 6, and 12 months) following the surgery. Laryngeal electromyography was done at 1 to 2 months and 12 months postsurgery. The results showed that the voices, qualitatively and quantitatively, were within normal range at within 3 months postintervention. The parameters were slightly beyond the normal limit at 3 months and returned to normal at 6 months postintervention and beyond. The LEMG depicted evidence of successful reinnervation in which the motor unit was normal comparable to the opposite normal vocal fold.

Standardized Intraoperative Neuromonitoring Procedure is Feasible in Transoral Endoscopic Thyroidectomy.

BACKGROUND: Intraoperative neuromonitoring in thyroid surgeries has become popular, but the standardized manner of intraoperative neuromonitoring during transoral endoscopic thyroidectomy vestibular approach (TOETVA) is not well established. This study evaluated the feasibility of using a standardized intraoperative neuromonitoring method for TOETVA. METHODS: Medical records of consecutive patients who underwent TOETVA with intraoperative neuromonitoring were retrospectively reviewed. Patients were positioned before intubation to prevent tube migration, then intubated using video laryngoscopy. The electromyography amplitudes of the vagal nerves and the recurrent laryngeal nerves were checked before (V1, R1) and after (V2, R2) thyroid resection. V1 and V2 signals were evaluated using a long ball tip stimulator with a stimulus current of 3 mA. R1 and R2 signals were obtained using the stimulus current of 1 to 3 mA. RESULTS: Forty-two patients (3 males and 39 females) were included. Lobectomy was performed in 40 patients (95.2%) and total thyroidectomy in 2 (4.8%). Pathologic diagnoses were 30 papillary thyroid carcinomas, 2 follicular thyroid carcinomas, and 9 benign diseases. Conversion to open surgery occurred in 1 patient due to bleeding. Thus, 43 nerves at risk in 41 patients were analyzed. V1 and R1 signals were detected from all nerves. The mean V1 and R1 amplitudes were 738.7±391.4 µV and 804.4±347.5 µV, respectively, and 38 (88.3%) and 39 (90.7%) nerves had R1 and V1 amplitudes of more than 500 µV. There were 2 cases (4.6%) of transient recurrent laryngeal nerve injury. R2 and V2 signals were detected in the 41 remaining nerves. The mean R2 and V2 amplitudes were 917.2±505.2 µV and 715.7±356.2 µV, respectively, and 36 (87.8%) and 32 (78.0%) nerves had respective R2 and V2 amplitudes of more than 500 µV. CONCLUSIONS: Intraoperative neuromonitoring could be performed in a standardized manner in TOETVA, and the quality of intraoperative neuromonitoring was excellent. Further studies are needed to verify the feasibility of the current approach.