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Incidence of Vocal Cord Paralysis with and Without Recurrent Laryngeal Nerve Monitoring During Thyroidectomy

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Incidence of Vocal Cord Paralysis with and Without Recurrent Laryngeal Nerve Monitoring During Thyroidectomy ORIGINAL ARTICLE Incidence of Vocal Cord Paralysis With and Without Recurrent Laryngeal Nerve Monitoring During Thyroidectomy Maisie Shindo, MD; Neil N. Chheda, MD Objective: To compare the incidence of postoperative Results: The incidence of unexpected unilateral vocal vocal cord paresis or paralysis in a cohort of patients who cord paresis based on RLNs at risk was 2.09% (n=14) in underwent thyroidectomy with and without continu- the monitored group and 2.96% (n=11) in the unmoni- ous recurrent laryngeal nerve (RLN) monitoring by a tored group. This difference was not statistically signifi- single senior surgeon. We hypothesize that continuous cant. The incidence of unexpected complete unilateral RLN monitoring reduces the rate of nerve injury during vocal cord paralysis was 1.6% in each group. Two of the thyroidectomy 5 paralyses in the unmonitored group and 7 of the 11 paralyses in the monitored group had complete resolu- Design: Retrospective medical chart review. tion. Setting: Academic tertiary care medical center. Conclusions: Monitoring of the RLN does not appear to reduce the incidence of postoperative temporary or per- Patients: A total of 684 patients (1043 nerves at risk) who manent complete vocal cord paralysis. There appeared underwent thyroid surgery under general anesthesia. to be a slightly lower rate of postoperative paresis with RLN monitoring, but this difference was not statisti- Main Outcome Measure: Incidence of vocal cord pa- cally significant. resis or paralysis in patients who underwent thyroid sur- gery with continuous RLN monitoring vs those under- going surgery without continuous RLN monitoring. Arch Otolaryngol Head Neck Surg. 2007;133:481-485 NJURY OF THE RECURRENT LARYN- tended stretch may be reduced by early geal nerve (RLN) is fortunately no warning signals and that the nerve posi- longer a very common compli- tion can be confirmed by direct stimula- cation of thyroid surgery. Nev- tion to differentiate it from surrounding ertheless, it can be quite trouble- vasculature or fibrous attachment.5-7 Fur- Isome for patients when it does occur. Many thermore, the presence of a positive sig- techniques have been described to re- nal with stimulation at the end of the pro- duce the risk of nerve injury. Intraopera- cedure has been shown to correlate with tive identification of the nerve has been normal postoperative mobility.3,4,8 How- shown to decrease the risk of postopera- ever, the use of RLN monitoring is also as- tive nerve dysfunction.1,2 Various meth- sociated with increased time of setup, in- ods of nerve monitoring have been de- creased cost of equipment, and the scribed, including direct visualization of the potential for false security when no warn- vocal cords during dissection; intermit- ing signals are generated owing to an im- tent monitoring techniques such as palpa- properly functioning system (eg, malpo- tion of the cricothyroid after stimulation of sitioned tube). the nerve with a disposable stimulator; and In recent years, it appears that RLN continuous monitoring methods such as (1) monitoring is probably being used with in- intramuscular electromyographic (EMG) creasing frequency in the United States electrodes placed in the thyroarytenoid during thyroidectomy, partly driven by the Author Affiliations: Division of muscle, (2) postcricoid surface elec- medicolegal system. Whether its use truly Otolaryngology–Head and Neck trodes, and (3) surface electrodes placed be- reduces the risk of RLN injury has yet to 2-6 Surgery, School of Medicine, tween the vocal cords. be proven. Prior studies have reported on State University of New York Among the advantages of RLN moni- the benefit of continuous RLN monitor- at Stony Brook. toring are that neurapraxic injury from ex- ing. However, very few studies have ac- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 133, MAY 2007 WWW.ARCHOTO.COM 481 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 true vocal folds oriented at 3 and 9-o’clock positions. The sur- Table 1. Distribution of Procedures by Monitored and geon confirmed the endotracheal tube position by verifying ap- Unmonitored Recurrent Laryngeal Nerves* propriate EMG signals and/or direct laryngoscopy. A Prass stimu- lation probe (Medtronic Xomed) was used for nerve stimulation Total No. of during the thyroidectomy procedure. No muscle relaxants were Type of Operation Procedures Monitored Unmonitored used after the skin flaps were elevated. The operative procedure Left thyroidectomy 152 89 63 was conducted in the same manner for all patients. In all of the Right thyroidectomy 173 94 79 patients, the RLN was identified and dissected prior to removal Total thyroidectomy 211 118 93 of the gland. The nerve was identified in the same manner in all Total thyroidectomy and 123 107 16 cases and was exposed from approximately 2 to 3 cm inferior to central neck dissection the lower border of the cricothyroid muscle to its laryngeal en- Total thyroidectomy and 25 19 6 trance.11 For those undergoing continuous nerve monitoring, the lateral neck dissection nerve was stimulated both at the time of its identification and af- ter removal of the gland. In the unmonitored group, a standard *All data are reported as number of procedures. endotracheal tube without EMG electrodes was used. All patients underwent preoperative and postoperative la- ryngoscopy. The postoperative examination was performed on tually compared the outcome of RLN monitoring with postoperative day 0 or 1. The incidence of “unexpected” vocal cord paresis and complete paralysis was then calculated based no RLN monitoring. These studies primarily consisted on the total number of nerves at risk (NAR). The data were fur- of either relatively small sample sizes or multiple- ther analyzed for differences in benign and malignant disease 2,9 surgeon compilations. There have only been a few stud- by calculating the overall incidence of vocal cord dysfunction ies in the literature with very large sample sizes that com- (paresis or paralysis) based on the number of patients in each pared the rate of postoperative RLN paralysis with and group. without RLN monitoring. Furthermore, variations in sur- gical technique of different surgeons could result in varia- tions in rates of RLN paralysis, as shown by Hermann RESULTS and colleagues,10 who analyzed 27 000 nerve dissec- tions by more than 11 surgeons. Of the 1059 charts reviewed, complete data were found Herein, we report the findings of a retrospective re- on 684 patients, which served as the basis for this re- view of a large series of thyroidectomies performed by a view. The monitored group consisted of 427 patients in single senior surgeon (M.S.) to analyze the rate of RLN whom the thyroidectomy was performed with continu- paresis and paralysis with and without continuous RLN ous nerve monitoring, and the unmonitored group con- monitoring. The aim of the study was to compare the rates sisted of 257 patients for whom nerve monitoring was of impaired vocal cord mobility without variability in sur- not used. Total thyroidectomy with or without paratra- gical technique. The hypothesis of the study was that con- cheal node dissection or modified neck dissection was tinuous RLN monitoring reduces the rate of nerve in- performed in 359 patients, and 325 underwent hemithy- jury during thyroidectomy. roidectomy. This resulted in 1043 NAR, 671 monitored and 372 unmonitored. Surgical procedures performed in- METHODS cluded thyroid lobectomy (including completion lobec- tomy), total thyroidectomy, total thyroidectomy with para- A retrospective review of all 1059 patients undergoing thyroid tracheal lymph node dissection, and total thyroidectomy surgery from 1998 through 2005 was conducted. This retro- with lateral neck dissection (Table 1). No patients ex- spective cohort study was approved by the institutional re- perienced a complication from the intubation of either view board. The list of all patients who underwent thyroidec- type of tube. tomy by the senior author (M.S.) was obtained from the database Pathologic results showed both benign and malig- of the clinical practice. Patients with preoperative impaired vo- nant disease, including benign nodule, benign cyst, Hashi- cal cord function, those having surgery performed under local moto thyroiditis, Grave disease, papillary carcinoma, fol- and intravenous sedation, and those undergoing surgery in con- licular carcinoma, H¨urtle cell carcinoma, medullary cell junction with laryngectomy were excluded from the study. Pa- tients with postoperative vocal cord paresis or paralysis result- carcinoma, anaplastic cell carcinoma, lymphoma, sar- ing from intentional nerve sacrifice or dissection of a tumor that coma, and metastatic squamous cell carcinoma. The dis- was encasing or severely adherent to the RLN were also ex- tribution of benign vs malignant disease was relatively cluded because the postoperative paralysis or paresis was ex- equal in both groups (Figure). pected in these types of cases. There was no intentional allo- Impairment of postoperative vocal fold mobility (pa- cation of the patients to monitoring vs no monitoring The resis or paralysis) was found in 25 patients from the moni- unmonitored cases were those performed when the nerve moni- tored group (5.8% of patients, 3.7% of NAR) and 17 pa- toring system was not available for use, primarily in the earlier tients from the unmonitored group (6.6% of patients and years of the study. These included cases from 1998 to 2002 and 4.6% of NAR). None of the patients experienced bilat- those performed after 2002 where the appropriate nerve integ- eral vocal cord paralysis. One patient in the monitored rity monitoring system was not available for use. A nerve integrity monitoring EMG endotracheal tube group was found to have bilateral abductor paresis post- (Medtronic Xomed, Jacksonville, Fla) was used for patients un- operatively, but the patient did not experience any dergoing continuous RLN monitoring. A member of the Depart- dyspnea. The fiberoptic examination on this patient re- ment of Anesthesia intubated all patients, and the tube was po- vealed bilateral arytenoid edema and erythema.
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