Bilateral Recurrent Laryngeal Nerve Injury Research Articles

Factors Predisposing to Post Thyroidectomy Vocal Cord Paralysis at Ospital ng Maynila Medical Center

Objective: To determine the prevalence of vocal cord paralysis among post thyroidectomy patients based on severity and laterality, and explore possible associations with age, sex, diagnosis and type of thyroid lesion and surgical procedure.
 Methods:Design: Cross-sectional studySetting: Tertiary Government Training HospitalParticipants: Records of patients who underwent thyroidectomy under the Department of Otorhinolaryngology – Head and Neck Surgery of the Ospital ng Maynila Medical Center from January 1, 2014 to June 30, 2021.
 Results: There were strong associations between the type of lesion and the presence of recurrent laryngeal nerve injury (V=.211, p=.001) and the diagnosis and the presence of RLNI (V=.245, p=.006). There were no significant associations between patient’s sex, age, diagnosis, type of thyroid lesion, surgical procedure with laterality and severity of RLNI. It was notable that all cases of bilateral recurrent laryngeal nerve injury were due to carcinoma only. Patients with malignant tumors were 2.8x (95% CI: 1.48-5.29) as likely to develop post surgical RLNI than those with benign tumors (p=.0015).
 Conclusion: The factors that had a strong association with the presence of vocal cord paralysis among post-thyroidectomy patients were the diagnosis and type of thyroid lesion. Malignant thyroid lesions (specifically thyroid carcinoma) had a higher incidence of recurrent laryngeal nerve injury compared to benign thyroid lesions. More data from different institutions and including other predisposing factors may confirm our findings.

Impact of Lymph Node Dissection on Postoperative Complications of Total Thyroidectomy in Patients with Thyroid Carcinoma.

Lymph node dissection (LND) in primary treatment of differentiated thyroid carcinoma is controversial. The aim of our retrospective study was to analyse the risk factors of post-thyroidectomy complications and to assess the morbidity of lymph node dissection, especially in the central neck compartment, since prophylactic central lymph node dissection has not been proven to bring an overall survival benefit. We performed a retrospective analysis of postoperative complications from 1547 consecutive patients with differentiated thyroid carcinoma in an academic department of endocrine surgery over a period of 10 years. A total of 535 patients underwent lymph node dissection, whereas the other 1012 did not. The rate of postoperative hypoparathyroidism was higher in patients with LND (17.6% vs. 11.4%, p = 0.001). No significant difference in the rate of permanent hypoparathyroidism (2.4% vs. 1.3%, p = 0.096) was observed between these two groups. A multivariate analysis was performed. Female gender, ipsilateral and bilateral central LND (CLND), parathyroid autotransplantation, and the presence of the parathyroid gland on the resected thyroid were associated with transient hypoparathyroidism. Bilateral CLND and the presence of the parathyroid gland on specimen were associated with permanent hypoparathyroidism. The rate of transient recurrent laryngeal nerve (RLN) injury (15.3% vs. 5.4%, p < 0.001) and permanent RLN injury (6.5% vs. 0.9%, p < 0.001) were higher in the LND group. In multivariate analysis, ipsilateral and bilateral lateral LND (LLND) were the main predictive factors of transient and permanent RLN injury. Bilateral RLN injury (2.6% vs. 0.4%, p < 0.001), chyle leakage (2.4% vs. 0%, p < 0.001), other nerve injuries (2.2% vs. 0%, p < 0.001), and abscess (2.4% vs. 0.5%, p = 0.001) were higher in the patients with LND. The surgical technique and the extent of lymph node dissection during surgery for thyroid carcinoma increase postoperative morbidity. A wider knowledge of lymph-node-dissection-related complications associated with thyroid surgery could help surgeons to carefully evaluate the surgical and medical therapeutic options.

Pulmonary sarcoidosis with bilateral recurrent laryngeal nerve injury

Sarcoidosis is a multisystem granulematosis of unknown ethology which occurs predominantly in young people and affects mediastinal lymph nodes and their parenchyma. Sarcoidosis is the most common among diffuse interstitial lung diseases. The systemic character of the injury leads to involvement of a number of organs into the pathologic process and polymorphism of the clinical manifestations of the disease, which causes challenges in the diagnosis and treatment of patients. In recent years, along with increased sarcoidosis morbidity, there has been noted pathomorphisis of the disease with growing incidence of the extensive forms of sarcoidosis, damage to the central and peripheral nervous systems, internal organs. The article considers a clinical case of sarcoidosis with atypical course. The disease was manifested in damage to the peripheral nervous system. The article discusses the features of the course and difficulties in the diagnosis of sarcoidosis in the patient. It has been shown that the histological study, which is the gold standard of granulematosis verification, was not informative at the early period of the disease.

Dysphagia due to Bilateral Recurrent Laryngeal Nerve Injury after Attempted Suicide by Hanging: A Case Report

Dysphagia due to Bilateral Recurrent Laryngeal Nerve Injury after Attempted Suicide by Hanging: A Case Report

Pediatric intraoperative nerve monitoring during thyroid surgery: A review from the American Head and Neck Society Endocrine Surgery Section and the International Neural Monitoring Study Group.

Children are more likely to experience recurrent laryngeal nerve (RLN) injury during thyroid surgery. Intraoperative nerve monitoring (IONM) may assist in nerve identification and surgical decision making. A literature review of pediatric IONM was performed and used to inform a monitoring technique guide and expert opinion statements. Pediatric IONM is achieved using a variety of methods. When age-appropriate endotracheal tubes with integrated surface electrodes are not available, an alternative method should be used. Patient age and surgeon experience with laryngoscopy influence technique selection; four techniques are described in detail. Surgeons must be familiar with the nuances of monitoring technique and interpretation; opinion statements address optimizing this technology in children. Adult IONM guidelines may offer strategies for surgical decision making in children. In some cases, delay of second-sided surgery may reduce bilateral RLN injury risk.

Discussion

Discussion

Medical Malpractice Trends in Thyroidectomies among General Surgeons and Otolaryngologists.

ObjectivesThis study aims to examine litigation trends with thyroidectomies in the United States from 1984 to 2018.MethodsWe used the Westlaw legal database to collect data on the defendant, plaintiff, case demographics, alleged reasons for malpractice, additional complications, and case outcomes.ResultsThe most common reason for litigation was vocal cord paralysis (51%, n = 28), with the majority ruling in favor of the defendant (64%, P = .042). Of those, 43% of cases (n = 12) were due to unilateral recurrent laryngeal nerve (RLN) injury, and 39% (n = 11) were due to bilateral RLN injury. Of the claims due to vocal cord paralysis that resulted in indemnity payment (36%), the majority included additional damages, such as lack of informed consent (30%) or subsequent damages from permanent tracheostomy (40%), which is usually a result of bilateral nerve paralysis.ConclusionRLN injury was the most common complication leading to trial, with most cases ruling in favor of the defense. However, most verdicts that favored the plaintiff or those that settled were due to subsequent damages from bilateral nerve paralysis, such as permanent tracheostomy. We encourage surgeons to consider a staged procedure in high-risk cases or cases with signal loss. There needs to be a bigger emphasis on informed consent in the training of surgeons. Surgeons should educate patients at high risk on potential surgical complications that may drastically affect their quality of life.

A Surgical Mouse Model for Advancing Laryngeal Nerve Regeneration Strategies.

Iatrogenic recurrent laryngeal nerve (RLN) injury is a morbid complication of anterior neck surgical procedures. Existing treatments are predominantly symptomatic, ranging from behavioral therapy to a variety of surgical approaches. Though laryngeal reinnervation strategies often provide muscle tone to the paralyzed vocal fold (VF), which may improve outcomes, there is no clinical intervention that reliably restores true physiologic VF movement. Moreover, existing interventions neglect the full cascade of molecular events that affect the entire neuromuscular pathway after RLN injury, including the intrinsic laryngeal muscles, synaptic connections within the central nervous system, and laryngeal nerve anastomoses. Systematic investigations of this pathway are essential to develop better RLN regenerative strategies. Our aim was to develop a translational mouse model for this purpose, which will permit longitudinal investigations of the pathophysiology of iatrogenic RLN injury and potential therapeutic interventions. C57BL/6J mice were divided into four surgical transection groups (unilateral RLN, n = 10; bilateral RLN, n = 2; unilateral SLN, n = 10; bilateral SLN, n = 10) and a sham surgical group (n = 10). Miniaturized transoral laryngoscopy was used to assess VF mobility over time, and swallowing was assessed using serial videofluoroscopy. Histological assays were conducted 3months post-surgery for anatomical investigation of the larynx and laryngeal nerves. Eight additional mice underwent unilateral RLN crush injury, half of which received intraoperative vagal nerve stimulation (iVNS). These 8 mice underwent weekly transoral laryngoscopy to investigate VF recovery patterns. Unilateral RLN injury resulted in chronic VF immobility but only acute dysphagia. Bilateral RLN injury caused intraoperative asphyxiation and death. VF mobility was unaffected by SLN transection (unilateral or bilateral), and dysphagia (transient) was evident only after bilateral SLN transection. The sham surgery group retained normal VF mobility and swallow function. Mice that underwent RLN crush injury and iVNS treatment demonstrated accelerated and improved VF recovery. We successfully developed a mouse model of iatrogenic RLN injury with impaired VF mobility and swallowing function that can serve as a clinically relevant platform to develop translational neuroregenerative strategies for RLN injury.

A Long, Unnerving Road: Malpractice Claims Involving the Surgical Management of Thyroid and Parathyroid Disease.

Given their profound emotional, physical, and financial toll on patients and surgeons, we studied the characteristics, costs, and contributing factors of thyroid and parathyroid surgical malpractice claims. Using the Controlled Risk Insurance Company Strategies' Comparative Benchmarking System database, representing ~30% of all US paid and unpaid malpractice claims, 5384 claims filed against general surgeons and otolaryngologists from 1995-2015 were reviewed to isolate claims involving the surgical management of thyroid and parathyroid disease. These claims were studied, and multivariable regression analysis was performed to identify factors associated with plaintiff payout. One hundred twenty-eight thyroid and parathyroid surgical malpractice claims were isolated. The median time from alleged harm event to closure of a malpractice case was 39months. The most common associated complications were bilateral recurrent laryngeal nerve (RLN) injury (n = 23) and hematoma (n = 18). Complications led to death in 18 cases. Patient payout occurred in 33% of claims (n = 42), and the median cost per claim was $277,913 (IQR $87,343-$783,663). On multivariable analysis, bilateral RLN injury was predictive of patient payout (OR 3.58, p = 0.03), while procedure, death, and surgeon specialty were not. Though rare, malpractice claims related to thyroid and parathyroid surgery are costly, time-consuming, and reveal opportunities for early surgeon-patient resolution after poor outcomes.

Iatrogenic bilateral recurrent laryngeal nerve injury: a retrospective study

<p class="abstract"><strong>Background:</strong> Bilateral recurrent laryngeal nerve injury is mostly iatrogenic following thyroidectomy. Our study aims at defining need for tracheostomy, timing of intervention and best method to achieve permanent treatment in cases of iatrogenic bilateral recurrent laryngeal nerve.</p><p class="abstract"><strong>Methods:</strong> In past four years we did 34 total thyroidectomy surgeries, all patients were female between 21-65 years of age. Common indications were multi nodular goiter 25 cases, papillary carcinoma thyroid 7 cases and follicular neoplasm 2 cases. 5 patients developed bilateral recurrent laryngeal nerve injury, of which 3 were multi nodular goiter cases and papillary carcinoma thyroid 2 cases. </p><p class="abstract"><strong>Results:</strong> 5 out of 34 (14.7%) patients developed bilateral recurrent laryngeal nerve injury. 3 patients had complete bilateral abductor paralysis. 1 patient had bilateral abductor paresis and 1 patient had all bilateral recurrent laryngeal nerve and superior laryngeal nerve injury causing combined paralysis of vocal cord. Other 3 patients with bilateral abductor paralysis, 1 patient was not willing for tracheostomy and 2 patients underwent tracheostomy. Of those with tracheostomy, one had partial recovery after one year and tracheostomy was removed. The other patient had coblation arytenoidectomy.</p><p class="abstract"><strong>Conclusions:</strong> In bilateral recurrent laryngeal nerve injury, Tracheostomy to be done if airway is compromised. Patients with pathological laryngeal electromyographic findings at least two months after the paresis need laryngeal framework surgery. Endoscopic cordotomy is the preferred intervention for long-term management.</p>

Experience of thyroid surgery at tertiary referral centers in Jazan Hospitals, Saudi Arabia.

BackgroundBenign multinodular goiter (BMNG) is a common disease of the thyroid gland with palpable thyroid nodules that may be detected in 0.8%–1.5% of men and 5.3%–6.4% of women. Three major complications could be detected after total thyroidectomy: hemorrhage, recurrent laryngeal paralysis, and hypoparathyroidism.AimsThe aim of this study was to review and assess the experience of total thyroidectomy in patients with BMNG at tertiary referral centers in Jazan Hospitals, Saudi Arabia.MethodsA retrospective study was conducted on 320 patients diagnosed with BMNG and subjected to primary total thyroidectomy. Operative mortality and major complications [bleeding, recurrent laryngeal nerve (RLN) injury, and hypoparathyroidism] were recorded.ResultsPostoperative hemorrhage was reported in four patients (1.25%). Bilateral RLN injuries occurred in two patients (0.6%), whereas unilateral RLN injuries occurred in nine patients (2.8%). Permanent hypoparathyroidism was diagnosed in three patients (0.9%), while transient hypoparathyroidism occurred in eight patients (2.5%) and improved after 4 months.ConclusionsTotal thyroidectomy represents today the treatment of choice for BMNG. Proper preoperative preparations, meticulous surgical dissection with careful follow-up of patients will improve the surgical results and reduce postoperative complications.

Effect of cricothyroid and thyroarytenoid muscle botulinum toxin injection on patients with dyspnea caused by bilateral recurrent laryngeal nerve paresis

Objective: To discuss the clinical effect of small dose of botulinum toxin injection in cricothyroid muscle and thyroarytenoid muscle on patients with incomplete bilateral recurrent laryngeal nerve paresis. Methods: Six patients were selected with Ⅰor Ⅱ or Ⅲ degree of dyspnea diagnosed as bilateral recurrent laryngeal nerve injury by laryngeal electromyography, and small dose of botulinum toxin injection was performed in cricothyroid muscle and thyroarytenoid muscle as a treatment. Degree of dyspnea was assessed one month before and after the treatment, and the stroboscopic laryngoscope results, acoustic parameters and CT image of the patients were collected in the 6 patients. The relevant parameters were also collected one month before and after treatment, including the degree of dyspnea, stroboscopic laryngoscope results, acoustic parameters and CT image of the patients. The angle between bilateral vocal cords in stroboscopy at full inspiratory was calculated, acoustic parameters (F0, jitter, shimmer) were analysed, and vocal length, width and the vocal region were measured. Then, the paired t test was performed for statistical analysis between before and after one month injection, the one way analysis of variance was performed among vocal parameters in CT image. Result: Botulinum toxin injection was successfully completed in the 6 patients, followed without any serious complications. The degree of dyspnea was alleviated to some extent after treatment in all 6 patients; the angle between bilateral vocal cords at the end of a deep inspiration was significantly increased (t=2.44, P<0.05) after the treatment. The changes of F0 and jitter between before and after treatment were not statistically significant (t=0.72, t=1.42, P>0.05). Shimmer was significantly decreased after treatment (t=2.61, P<0.05). Vocal fold length, width and vocal region increased with F0, there was a statistically significant difference between different F0 before injection, and there was no statistically significant difference between different F0 after injection. The follow-up time was respectively seven months, 1 year, 1 year, 18 months, 22 months and 2 years respectively. Conclusion: Small dose of botulinum toxin injection in bilateral cricothyroid muscles and thyroarytenoid muscles can relieve the dyspnea caused by bilateral vocal cords paresis to some extent, accompanied without serious complications, despite the sound quality was slightly worse.

Experience of thyroid surgery at tertiary referral centers in Jazan Hospitals, Saudi Arabia

BackgroundBenign multinodular goiter (BMNG) is a common disease of the thyroid gland with palpable thyroid nodules that may be detected in 0.8%–1.5% of men and 5.3%–6.4% of women. Three major complications could be detected after total thyroidectomy: hemorrhage, recurrent laryngeal paralysis, and hypoparathyroidism.AimsThe aim of this study was to review and assess the experience of total thyroidectomy in patients with BMNG at tertiary referral centers in Jazan Hospitals, Saudi Arabia.MethodsA retrospective study was conducted on 320 patients diagnosed with BMNG and subjected to primary total thyroidectomy. Operative mortality and major complications [bleeding, recurrent laryngeal nerve (RLN) injury, and hypoparathyroidism] were recorded.ResultsPostoperative hemorrhage was reported in four patients (1.25%). Bilateral RLN injuries occurred in two patients (0.6%), whereas unilateral RLN injuries occurred in nine patients (2.8%). Permanent hypoparathyroidism was diagnosed in three patients (0.9%), while tran...

Difficult Decision on Tyroid Surgery of Expert Witness: Complication or Malpractice

Objective: Recurrent laryngeal nerve (RLN) paralysis and hypocalcemia following thyroid surgery have been designated as complication or malpractice. In this study, it was aimed to evaluate surgeons’ opinions towards RLN injury and hypocalcemia after bilateral subtotal thyroidectomy (BST) and total thyroidectomy (TT) in nodular goiter and thyroid carcinoma.&#x0D; Materials and Methods: We prepared a questionnaire to determine approaches of surgeons in such cases. We grouped the respondents according their thyroid surgery experiments and asked them to determine whether it is malpractice or complication in cases with unilateral or bilateral RLN paralysis and hypocalcemia after “bilateral subtotal thyroidectomy” and in cases with unilateral or bilateral RLN paralysis after “total thyroidectomy”.&#x0D; Results: In all groups describing bilateral RLN injury was more common. Problems which are defined as “complication” in cancer patients, were more likely defined as “malpractice” in benign cases. However, these differences were generally not statistically significant.&#x0D; Conclusion: There is no consensus about malpractice and complication discrimination among physicians. Every physician should evaluate every specific case in its own nature and conditions when asked to determine whether the case should be determined as complication or malpractice.

Postoperative Complications of Thyroid and Parathyroid Disease

Although thyroid and parathyroid surgery is considered very safe, with rare morbidity and mortality, serious complications can occur. These include bilateral recurrent laryngeal nerve injury, life-threatening hematoma, and severe hypoparathyroidism. Although infrequent, these complications require timely identification and intensive care. Critical care physicians should understand the clinical presentations and management of affected patients. This review provides a critical care–focused review of endocrine surgery complications, including relevant background information, definitions, risk factors, identification, and management. Special clinical situations and treatment considerations are included. Figures show the vocal fold anatomy in recurrent laryngeal nerve paralysis, the regulation of calcium homeostasis, and electrocardiogram changes seen in the setting of severe hypocalcemia. This review contains 3 figures, and 58 references. Key words: hypocalcemia, hypoparathyroidism, neck hematoma, parathyroid, recurrent laryngeal nerve injury, thyroid

Cost-effectiveness of intraoperative nerve monitoring in avoidance of bilateral recurrent laryngeal nerve injury in patients undergoing total thyroidectomy.

Intraoperative nerve monitoring (IONM) provides dynamic neural information and is recommended for high-risk thyroid surgery. In this analysis, the cost-effectiveness of IONM in preventing bilateral recurrent laryngeal nerve (RLN) injury was investigated. A Markov chain model was constructed based on IONM use. The base-case patient was defined as a 40-year-old woman presenting with a 4·1-cm left-sided papillary thyroid cancer who developed RLN injury with loss of monitoring signal during planned bilateral thyroidectomy. It was hypothesized that, if the surgeon had used IONM, the RLN injury would have been detected and the operation would have been concluded as a thyroid lobectomy to avoid the risk of contralateral RLN injury. Cost in US dollars was converted to euros; probabilities and utility scores were identified from the literature and government resources. Length of follow-up was set as 20 years, and willingness-to-pay (WTP) as €38 000 (US $50 000) per quality-adjusted life-year (QALY). At the end of year 20, the not using IONM strategy accrued €163 995·40 (US $215 783·43) and an effectiveness of 14·15 QALYs, whereas use of the IONM strategy accrued €170 283·68 (US $224 057·48) and an effectiveness of 14·33 QALYs. The incremental cost-effectiveness ratio, comparing use versus no use of IONM, was €35 285·26 (US $46 427·97) per QALY, which is below the proposed WTP, indicating that IONM is the preferred and cost-effective management plan. A Monte Carlo simulation test that considered variability of the main study factors in a hypothetical sample of 10 000 patients showed IONM to be the preferred strategy in 85·8 per cent of the population. Use of IONM is cost-effective in patients undergoing bilateral thyroid surgery.

Morbid mortality associated with total thyroidectomy for differentiated carcinoma in a training institute.

e17586 Background: Total thyroidectomy is now a common and relatively safe procedure. In the context of malignant pathology: It optimizes local control, facilitates adjuvant therapy with iodine 131, increases thyroglobulin sensitivity in patient surveillance and improves survival in patients at high risk. The reported morbimortality is related to Transient or definitive hypocalcemia, unilateral or bilateral recurrent laryngeal nerve injury (RLN), postoperative hemorrhage, wound infection, chylous fistula, tracheal injuries or esophageal perforations, cervical sympathetic chain lesions, among others Although death is rare as a result of the procedure and its complications. Methods: The present retrospective, descriptive, observational, cross-sectional, analytical study was performed based on an analysis of the records opened to patients at the National Cancer Institute between November 23, 2012, and January 5, 2015 corresponding to 100 consecutive cases with diagnosis of differentiated thyroid cancer, submitted to at least total thyroidectomy. Results: According with the AJCC 7th edition TNM distribution was: pT1 n = 13, pT2 n = 14, pT3 n = 63, pT4a n = 10, pN1a n = 12, pN1b n = 51, M1 n = 12. In 73 patients, no complications developed, and of the complications presented, 8 patients developed transient hypocalcemia, 19 permanent hypocalcemia, 3 resections of the RLN in a planned manner, 1 accidentally identified intraoperative lesion, 7 unconscious lesions of the RLN, 11 developed dysphonia, 1 Horner's syndrome, 2 Vagus lesions, 2 patients with tracheal or pharyngeal fistula, 1 chylous fistula, 1 transoperative hemorrhage and 1 hematoma. Mortality in one of the patients. Conclusions: Our results translate morbidity and mortality associated with locally advanced tumors, where the only correlation identified were the relationships with the presence of parathyroid glands in the pathology report and the development of hypocalcemia. With the above, we can assure that the best ally of the surgeon is the careful dissection based on a deep knowledge of anatomy, which could reduce the morbidity due to the surgery.

Ambulatory thyroidectomy: an anesthesiologist's perspective.

Thyroidectomy has been performed on an inpatient basis because of concerns regarding postoperative complications. These include cervical hematoma, bilateral recurrent laryngeal nerve injury and symptomatic hypocalcemia. We have reviewed the current available evidence and aimed to collate published data to generate incidence of the important complications. We performed a literature search of Medline, EMBASE and the Cochrane database of randomized trials. One hundred sixty papers were included. Twenty-one papers fulfilled inclusion criteria. Thirty thousand four hundred fifty-three day-case thyroid procedures were included. Ten papers were prospective and 11 retrospective. The incidences of complications were permanent vocal cord paralysis 7/30259 (0.02%), temporary hypocalcemia 129/4444 (2.9%), permanent hypocalcemia 405/29203 (1.39%), cervical hematoma 145/30288 (0.48%) and readmission rate 105/29609 (0.35%). Analysis of cervical hematoma data demonstrated that in only 3/14 cases the hematoma presented as an inpatient, and in the remaining 11/14, it occurred late, with a range of 2–9 days. There is a paucity of data relating to anesthetic techniques associated with ambulatory thyroidectomy. Cost comparison between outpatient and inpatient thyroidectomy was reported in three papers. Cost difference ranged from $676 to $2474 with a mean saving of $1301 with ambulatory thyroidectomy. There is a body of evidence that suggests that ambulatory thyroidectomy in the hands of experienced operating teams within an appropriate setting can be performed with acceptable risk profile. In most circumstances, this will be limited to hemithyroidectomies to reduce or avoid the potential for additional morbidity. We have found little evidence to support the use of one anesthetic technique over another. The rates of hospital admission and readmission related to anesthetic factors appear to be low and predominantly related to pain and postoperative nausea and vomiting. A balanced anesthetic technique incorporating appropriate analgesic and antiemetic regimens is essential to avoid unnecessary hospital admission/readmission.

Risk of recurrent laryngeal nerve palsy in patients undergoing thyroidectomy with and without intraoperative nerve monitoring.

Vocal cord palsy occurs in 3-5 per cent of patients after thyroidectomy. To reduce this complication, intraoperative nerve monitoring (IONM) has been introduced, although its use remains controversial. This study investigated the risk of postoperative vocal cord palsy with and without the use of intermittent IONM. Patients registered in the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery, 2009-2013, were included. Early palsy of the recurrent laryngeal nerve was diagnosed within 6 weeks after surgery. Permanent palsy was defined as that persisting after 6 months. Univariable and multivariable logistic regression analyses were used to examine risk factors for vocal cord palsy. The cohort consisted of 5252 patients undergoing thyroidectomy. IONM was used in 3277 operations (62·4 per cent); postoperative laryngoscopy was performed in 1757 patients (33·5 per cent). Early vocal cord palsy occurred in 217 patients (4·1 per cent), of which three were bilateral, all in the group without IONM. Permanent vocal cord palsy occurred in 62 patients (1·2 per cent). In the multivariable analysis of 1757 patients who had postoperative laryngoscopy, the use of IONM was not associated with a decreased risk of early vocal cord palsy (odds ratio (OR) 0·67, 95 per cent c.i. 0·44 to 1·01), but decreased the risk of permanent vocal cord palsy (OR 0·43, 0·19 to 0·93). [Correction added on 11 November 2016 after first publication: the word 'routine' has been removed from this section.] CONCLUSION: IONM reduced the risk of permanent vocal cord palsy. No bilateral recurrent laryngeal nerve injury occurred following IONM.

Bilateral Recurrent Laryngeal Nerve Injury in Total Thyroidectomy With or Without Intraoperative Neuromonitoring. Systematic Review and Meta-analysis

Introduction and objectiveThe risk of producing bilateral laryngeal paralysis (BLP) in total thyroidectomy (TT) is low, but it is a concern for the surgeon and a serious safety incident that may compromise the airway, require reintubation or tracheostomy and cause serious sequelae or death. Neuromonitoring (NM), as an early diagnostic tool for the existence of injury to the recurrent laryngeal nerve (RLN), has not been shown to have reduced the risk, even though published series show lower incidences. Our objective was to estimate the risk of bilateral RLN paralysis with and without NM TT by systematic review and meta-analysis. MethodWe performed a systematic review of clinical trials, cohort studies and case series with total thyroidectomy without NM published in the period 2000–2014. A database search was performed using PubMed, Scopus (EMBASE) and the Cochrane Library. Heterogeneity between studies was explored and weighted risks grouped according to random effects models were estimated. ResultsWe selected 40 articles and estimates of risk were identified in 54 case series (without NM, 25; with NM, 29) with 30922 patients.The prevalence of BLP in the series with NM was lower compared to that without NM (2.43‰ [1.55–3.5‰] versus 5.18‰ [2.53–8.7‰]). This difference is equivalent to an absolute risk reduction of 2.75‰ with a number needed to treat of 364.13. The NM group was more homogeneous (I2=7.52%) than those without NM (I2=79.32%). The observed differences in the subgroup analysis were very imprecise because the number of observed paralysis was very low. ConclusionsThe risk of bilateral paralysis is lower in studies with neuromonitoring.