Abstract
Simple SummaryThyroid operations in children are difficult because children have thinner nerves than adults, and there is less space for the surgeon to operate. Since it runs closely behind the thyroid capsule, the nerve innervating the vocal cords can be injured during the operation. In thyroid cancer, the thyroid gland typically needs to be removed completely, putting the nerve at greater risk of injury. This surgical risk can be reduced by monitoring the function of the nerve before it is lastingly damaged. There are two methods to achieve this: intermittent (longer intervals between pulses) and continuous (very small intervals between pulses) nerve stimulation. In this study of 258 children with suspected or confirmed thyroid cancer, nerve damage and vocal cord palsy were observed only after intermittent and not after continuous nerve stimulation. This demonstrated that continuous nerve stimulation was safer than intermittent nerve stimulation.(1) Background: Pediatric thyroidectomy is characterized by considerable space constraints, thinner nerves, a large thymus, and enlarged neck nodes, compromising surgical exposure. Given these challenges, risk-reduction surgery is of paramount importance in children, and even more so in pediatric thyroid oncology. (2) Methods: Children aged ≤18 years who underwent thyroidectomy with or without central node dissection for suspected or proven thyroid cancer were evaluated regarding suitability of intermittent vs. continuous intraoperative neuromonitoring (IONM) for prevention of postoperative vocal cord palsy. (3) Results: There were 258 children for analysis, 170 girls and 88 boys, with 486 recurrent laryngeal nerves at risk (NAR). Altogether, loss of signal occurred in 2.9% (14 NAR), resulting in six early postoperative vocal cord palsies, one of which became permanent. Loss of signal (3.5 vs. 0%), early (1.5 vs. 0%), and permanent (0.3 vs. 0%) postoperative vocal cord palsies occurred exclusively with intermittent IONM. With continuous nerve stimulation, sensitivity, specificity, positive and negative predictive values, and accuracy reached 100% for prediction of early and permanent postoperative vocal cord palsy. With intermittent nerve stimulation, sensitivity, specificity, positive and negative predictive values, and accuracy were consistently lower for prediction of early and permanent postoperative vocal cord palsy, ranging from 78.6% to 99.8%, and much lower (54.2–57.9%) for sensitivity. (4) Conclusions: Within the limitations of the study, continuous IONM, which is feasible in children ≥3 years, was superior to intermittent IONM in preventing early and permanent postoperative vocal cord palsy.
Highlights
The operative morbidity of pediatric thyroid surgery is well defined for various age groups of children who undergo thyroidectomy at a tertiary referral center for Graves’disease [1], papillary and medullary thyroid cancer [2], and neoplastic C-cell disease associated with multiple endocrine neoplasia type 2 [3]
(4) Conclusions: Within the limitations of the study, continuous intraoperative neuromonitoring (IONM), which is feasible in children ≥3 years, was superior to intermittent
Within the limitations of this observational study, continuous IONM, which is feasible in children ≥3 years of age, was superior to intermittent IONM in preventing postoperative vocal cord palsy in pediatric thyroid oncology
Summary
The operative morbidity of pediatric thyroid surgery is well defined for various age groups of children who undergo thyroidectomy at a tertiary referral center for Graves’disease [1], papillary and medullary thyroid cancer [2], and neoplastic C-cell disease associated with multiple endocrine neoplasia type 2 [3]. Pediatric thyroidectomy is characterized by considerable space constraints, thinner nerves, a large thymus, and enlarged neck nodes, compromising surgical exposure. Breathing and swallowing greatly impact on health-related quality of life, which, if impaired, become a pain point for affected children and their parents [5,6]. Given these challenges, surgical risk reduction is of paramount importance in children. Surgical risk reduction is of paramount importance in children This is even more important when surgery is the mainstay of therapy, as in thyroid cancer. The American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine
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