Research Article
BibTex RIS Cite

Prospective Comparison of Continuous and Intermittent Intraoperative Nerve Monitoring in Thyroid Surgery

Year 2022, Volume: 3 Issue: 3, 171 - 179, 30.07.2022

Abstract

Aim: As technology progresses further in medicine, intraoperative neuro-monitorization has become a powerful safety tool especially for thyroid surgeries. The effectiveness of intermittent or continuous intraoperative nerve monitorization (IONM) on reducing recurrent laryngeal
nerve (RLN) palsy has been a highly debated issue to ensure that RLN
does not get damaged regardless of the surgeon's experience level. In this
prospective study we compared continuous intraoperative nerve monitoring (C-IONM) with intermittent intraoperative nerve monitoring
(I-IONM) for prevention of iatrogenic RLN palsy due thyroidectomy.
Material and Methods: One hundred and nine patients aged between
18 and 75 were divided into 2 groups of 64 and 45, which received either
I-IONM or C-IONM respectively. Patients were selected for minimally
invasive surgery, and those RLN cannot be totally explored or resected
on purpose due to tumor invasion are excluded.
Results: High risk intervention rate was 54% in group 2 and was significantly higher compared with group 1 (p=0.022). Temporary and permanent vocal cord paralysis in group 1 and 2 were 4,5% - 0,6% and 2,8%
- 0% respectively. There were no significant differences between groups
(p>0,05). Multi variant analysis showed that extra laryngeal branching is
an independent risk factor for vocal cord palsy (p=0.21)
Discussion and Conclusion: C-IONM is a superior technique as it enables surgeon to detect and stop preventable RLN damage beforehand.
In order to minimize the number of RLN palsy incidences and to avoid
bilateral RLN paralysis, we believe IONM should be used as a standard
approach during thyroid surgeries

References

  • 1. Rosato L, Avenia N, Bernante P, De Palma M, Gulino G, Nasi PG, et al. Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years. World journal of surgery. 2004;28(3):271-6.
  • 2. Rahim AAA, Ahmed ME, Hassan MA. Respiratory complications after thyroidectomy and the need for tracheostomy in patients with a large goitre. Journal of British Surgery. 1999;86(1):88-90.
  • 3. Lahey RF. Routine dissection and demonstration of the recurrent laryngeal nerve in subtotal thyroidectomy. Surg Gynecol Obstet. 1938;66:775-7.
  • 4. Dralle H, Sekulla C, Haerting J, Timmermann W, Neumann HJ, Kruse E, et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery. 2004;136(6):1310-22.
  • 5. Hermann M, Alk G, Roka R, Glaser K, Freissmuth M. Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon in more than 27,000 nerves at risk. Annals of surgery. 2002;235(2):261.
  • 6. Chiang F-Y, Lu IC, Kuo W-R, Lee K-W, Chang N-C, Wu C-W. The mechanism of recurrent laryngeal nerve injury during thyroid surgery—the application of intraoperative neuromonitoring. Surgery. 2008;143(6):743-9.
  • 7. Snyder SK, Lairmore TC, Hendricks JC, Roberts JW. Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy. Journal of the American College of Surgeons. 2008;206(1):123-30.
  • 8. Randolph GW, Dralle H, with the International Intraoperative Monitoring Study G, Abdullah H, Barczynski M, Bellantone R, et al. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. The Laryngoscope. 2011;121(S1):S1-S16.
  • 9. Calo PG, Medas F, Erdas E, Pittau MR, Demontis R, Pisano G, et al. Role of intraoperative neuromonitoring of recurrent laryngeal nerves in the outcomes of surgery for thyroid cancer. International Journal of Surgery. 2014;12:S213-S7.
  • 10. Calò PG, Medas F, Gordini L, Podda F, Erdas E, Pisano G, et al. Interpretation of intraoperative recurrent laryngeal nerve monitoring signals: the importance of a correct standardization. International Journal of Surgery. 2016;28:S54-S8.
  • 11. Barczyński M, Konturek A, Cichoń S. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Journal of British Surgery. 2009;96(3):240-6.
  • 12. 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 journal of surgery. 2010;34(6):1274-84.
  • 13. Chiang F-Y, Lee K-W, Chen H-C, Chen H-Y, Lu IC, Kuo W-R, et al. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation. World journal of surgery. 2010;34(2):223-9.
  • 14. Dionigi G, Donatini G, Boni L, Rausei S, Rovera F, Tanda ML, et al. Continuous monitoring of the recurrent laryngeal nerve in thyroid surgery: a critical appraisal. International Journal of Surgery. 2013;11:S44-S6.
  • 15. Schneider R, Przybyl J, Pliquett U, Hermann M, Wehner M, Pietsch U-C, et al. A new vagal anchor electrode for real-time monitoring of the recurrent laryngeal nerve. The American Journal of Surgery. 2010;199(4):507-14.
  • 16. Ulmer C, Koch KP, Seimer A, Molnar V, Meyding-Lamadé U, Thon K-P, et al. Real-time monitoring of the recurrent laryngeal nerve: an observational clinical trial. Surgery. 2008;143(3):359-65.
  • 17. Bartsch DK, Dotzenrath C, Vorländer C, Zielke A, Weber T, Buhr HJ, et al. Current practice of surgery for benign goitre—an analysis of the prospective DGAV StuDoQ| Thyroid Registry. Journal of clinical medicine. 2019;8(4):477.
  • 18. Jonas J, Boskovic A. Intraoperative neuromonitoring (IONM) for recurrent laryngeal nerve protection: comparison of intermittent and continuous nerve stimulation. Surgical Technology International. 2014;24:133-8.
  • 19. Schneider R, Machens A, Sekulla C, Lorenz K, Elwerr M, Dralle H. Superiority of continuous over intermittent intraoperative nerve monitoring in preventing vocal cord palsy. British Journal of Surgery. 2021;108(5):566-73.
  • 20. Schneider R, Sekulla C, Machens A, Lorenz K, Nguyen Thanh P, Dralle H. Postoperative vocal fold palsy in patients undergoing thyroid surgery with continuous or intermittent nerve monitoring. Journal of British Surgery. 2015;102(11):1380-7.
  • 21. Schneider R, Randolph GW, Sekulla C, Phelan E, Thanh PN, Bucher M, et al. Continuous intraoperative vagus nerve stimulation for identification of imminent recurrent laryngeal nerve injury. Head & neck. 2013;35(11):1591-8.
  • 22. Papavramidis TS, Sapalidis K, Michalopoulos N, Triantafillopoulou K, Gkoutzamanis G, Kesisoglou I, et al. UltraCision harmonic scalpel versus clamp‐and‐tie total thyroidectomy: A clinical trial. Head & Neck: Journal for the Sciences and Specialties of the Head and Neck. 2010;32(6):723-7.
  • 23. Jeannon JP, Orabi AA, Bruch GA, Abdalsalam HA, Simo R. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. International journal of clinical practice. 2009;63(4):624-9.
  • 24. Kandil E, Noureldine SI, Abbas A, Tufano RP. The impact of surgical volume on patient outcomes following thyroid surgery. Surgery. 2013;154(6):1346-53.
  • 25. Dralle H, Sekulla C, Lorenz K, Thanh PN, Schneider R, Machens A. Loss of the nerve monitoring signal during bilateral thyroid surgery. Journal of British Surgery. 2012;99(8):1089-95.
  • 26. Ho Y, Carr MM, Goldenberg D. Trends in intraoperative neural monitoring for thyroid and parathyroid surgery amongst otolaryngologists and general surgeons. European Archives of Oto-Rhino-Laryngology. 2013;270(9):2525-30.
  • 27. Bergenfelz A, Jansson S, Kristoffersson A, Mårtensson H, Reihnér E, Wallin G, et al. Complications to thyroid surgery: results as reported in a database from a multicenter audit comprising 3,660 patients. Langenbeck’s Archives of Surgery. 2008;393(5):667-73.
  • 28. Wu C-W, Dionigi G, Sun H, Liu X, Kim HY, Hsiao P-J, et al. Intraoperative neuromonitoring for the early detection and prevention of RLN traction injury in thyroid surgery: a porcine model. Surgery. 2014;155(2):329-39.
  • 29. Barczyński M, Stopa M, Konturek A, Nowak W. The overwhelming majority but not all motor fibers of the bifid recurrent laryngeal nerve are located in the anterior extralaryngeal branch. World journal of surgery. 2016;40(3):629-35.
  • 30. Casella C, Pata G, Nascimbeni R, Mittempergher F, Salerni B. Does extralaryngeal branching have an impact on the rate of postoperative transient or permanent recurrent laryngeal nerve palsy? World journal of surgery 2009;33(2):261-5. 31. Sancho JJ, Pascual-Damieta M, Pereira JA, Carrera MJ, Fontané J, Sitges-Serra A. Risk factors for transient vocal cord palsy after thyroidectomy. Journal of British Surgery. 2008;95(8):961-7.
  • 32. Fontenot TE, Randolph GW, Friedlander PL, Masoodi H, Yola IM, Kandil E. Gender, race, and electrophysiologic characteristics of the branched recurrent laryngeal nerve. The Laryngoscope. 2014;124(10):2433-7.
  • 33. Lee HY, Cho YG, You JY, Choi BH, Kim JY, Wu CW, et al. Traction injury of the recurrent laryngeal nerve: Results of continuous intraoperative neuromonitoring in a swine model. Head & Neck. 2016;38(4):582-8.
  • 34. Bai B, Chen W. Protective effects of intraoperative nerve monitoring (IONM) for recurrent laryngeal nerve injury in thyroidectomy: meta-analysis. Scientific reports. 2018;8(1):1-11.
  • 35. Deniwar A, Kandil E, Randolph G. Electrophysiological neural monitoring of the laryngeal nerves in thyroid surgery: review of the current literature. Gland surgery. 2015;4(5):368.
  • 36. Jonas J. Continuous vagal nerve stimulation for recurrent laryngeal nerve protection in thyroid surgery. European Surgical Research. 2010;44(3-4):185-91.
  • 37. Van Slycke S, Gillardin J-P, Brusselaers N, Vermeersch H. Initial experience with S-shaped electrode for continuous vagal nerve stimulation in thyroid surgery. Langenbeck’s archives of surgery. 2013;398(5):717-22.
  • 38. Yu Q, Liu K, Zhang S, Li H, Xie C, Wu Y, et al. Application of continuous and intermittent intraoperative nerve monitoring in thyroid surgery. Journal of Surgical Research. 2019;243:325-31.
  • 39. Sedlmaier A, Steinmüller T, Hermanns M, Nawka T, Weikert S, Sedlmaier B, et al. Continuous versus intermittent intraoperative neuromonitoring in complex benign thyroid surgery: a retrospective analysis and prospective follow‐up. Clinical Otolaryngology. 2019;44(6):1071-9.
  • 40. Kim SW, Hwang SH. Intraoperative neural monitoring for early vocal cord function assessment after thyroid surgery: a systematic review and meta-analysis. World journal of surgery. 2021:1-8. 41. Phelan E, Schneider R, Lorenz K, Dralle H, Kamani D, Potenza A, et al. Continuous vagal IONM prevents recurrent laryngeal nerve paralysis by revealing initial EMG changes of impending neuropraxic injury: a prospective, multicenter study. The Laryngoscope. 2014;124(6):1498-505.
There are 39 citations in total.

Details

Primary Language English
Subjects Health Services and Systems (Other)
Journal Section Research Articles
Authors

Emre Bozdağ 0000-0002-2729-1667

Publication Date July 30, 2022
Submission Date April 26, 2022
Published in Issue Year 2022 Volume: 3 Issue: 3

Cite

AMA Bozdağ E. Prospective Comparison of Continuous and Intermittent Intraoperative Nerve Monitoring in Thyroid Surgery. JMS. July 2022;3(3):171-179.