Permanent Nerve Injury Research Articles

Laryngeal Nerve Monitoring and Minimally Invasive Thyroid Surgery

To determine the feasibility of the combined use of laryngeal nerve monitoring and minimally invasive thyroid surgery. Prospective, nonrandomized analysis of single-surgeon experience. Academic institution. Consecutive series of patients undergoing both minimally invasive thyroid surgery and laryngeal nerve monitoring. Incision length and incidence of temporary or permanent laryngeal nerve injury. Two hundred eighty-three patients underwent thyroid surgery at the Medical College of Georgia, Augusta, between January 2004 and November 2006. Some type of minimal-access approach (endoscopic or nonendoscopic) was used in 137 cases (48.4%) in which general anesthesia was administered. Laryngeal nerve monitoring was performed in 73 (53.3%) of these 137 cases, although the proportion of cases in which it was performed increased significantly from 8.7% (2 of 23 cases) in 2004 to 95.2% (58 of 61 cases) in 2006 (P < .001). There were no cases of permanent nerve injury. The incidence of temporary recurrent laryngeal nerve paresis was 4.3% (4 of 92 nerves at risk) in the cases in which laryngeal nerve monitoring was used and 6.0% (5 of 84 nerves at risk) in the cases in which the nerve was visually identified without use of a monitor. This difference failed to reach statistical significance (P = .73), which may reflect an insufficient sample size. Monitoring of the laryngeal nerves is feasible in minimal-access thyroid surgery and may serve as a meaningful adjunct to the visual identification of nerves.

Temporomandibular Joint Arthroscopic Arthroplasty with Rigid Disc Fixation— Preliminary Results in Treatment of Wilkes Internal Joint Derangement Stages II-V: A 3-Year Retrospective Study

Temporomandibular Joint Arthroscopic Arthroplasty with Rigid Disc Fixation— Preliminary Results in Treatment of Wilkes Internal Joint Derangement Stages II-V: A 3-Year Retrospective Study

Outcome of reoperation for thyroid cancer: clinical analysis of 72 cases

To analyze the indication of reoperation of thyroid cancer and to explore the timing, surgical pattern of reoperation. Protocols of 72 patients underwent reoperation of thyroid cancer from June 2003 to August 2006 were reviewed retrospectively. Causes for reoperation were as follows: residue of the tumor locally as the inappropriate initial operation; local recurrence and cervical lymph node metastasis; before (131)I ablation which differentiated thyroid cancer with distant place metastasis. The reoperation style included residual lobectomy plus isthmus with single tumor below 2 cm, total thyroidectomy in most the other conditions and selective lymph node dissection in finding or suspected cervical lymph node metastasis. The rate of residual in thyroid confirmed by postoperative pathology was 47.1% (32/68). The rate of residual in cervical lymph node was 81.4% (35/43). The rates of temporary and permanent laryngeal recurrent nerve injury were 5.6% (4/72) and 1.4% (1/72) respectively. The rates of temporary and permanent hypocalcemia were 26.4% (19/72) and 1.4% (1/72) respectively. Inadequate operation, local recurrence and cervical lymph node metastasis of thyroid cancer need revision surgery undoubtedly. The optimal treatment was total thyroidectomy and level VI, VII central compartment lymph node dissection plus intraoperative frozen-section evaluation.

Intraneural Injection of Local Anesthetics during Ultrasound-guided Peripheral Nerve Block May Lead to Nerve Injury

Clinique du Parc saint Lazare, Beauvais, France. balnasser@wanadoo.frI read with interest the article by Bigeleisen.1In this article, the author presented a prospective study of ultrasound-guided axillary blocks and determined the incidence of nerve puncture, intraneural injection of local anesthetics, and transient or permanent nerve injuries. After reading this well-written article it occurred to me that there are some points that may add to discussion. Damage may be caused to peripheral nerves after regional anesthesia techniques by mechanical, chemical, or ischemic injuries, which may occur alone or in combination.2Iohom et al. 2reported that intraneural injection of ropivacaine in rat sciatic nerve, in a concentration routinely used in clinical practice, caused no deleterious effect on motor function. Hadzic et al. 3reported varying degrees of damage to the neural architecture after high-pressure injection of local anesthetic in dog sciatic nerve. This damage ranged from mechanical disruption and delamination to fragmentation of the myelin sheath and marked cellular infiltration. They also reported severe and persistent motor deficits.3Since the introduction of ultrasound-guided peripheral nerve blocks at my institution, I frequently observe nerve puncture during this procedure. In my experience, the combination of electrical stimulation does not result always in motor response even if the needle tip is positioned intraneurally. In the same condition, I also sometimes observe no pain on intraneural injection. The advantage of ultrasound-guided nerve blocks in my practice is that I can watch the needle’s advancement in real time. Accordingly, in case I suspect nerve puncture, I slightly withdraw the needle and avoid intraneural injection to increase safety. In this study, the author excluded 22 patients from the study because of preoperative abnormalities in their motor and sensory examination. In daily practice, patients may present some degree of neurologic abnormalities before surgery. They may also be at high risk of nerve damage. Furthermore, intraneural injection in these patients may lead to an aggravating condition of their preexisting neuropathy. There are multiple causes and a combination of factors that may lead nerve injury after regional anesthesia techniques.4However, peripheral nerves have a dual blood supply of intrinsic exchange vessels in the endoneurium and an extrinsic plexus of supply vessels in the epineurial space that cross the perineurium to anastomose with intrinsic circulation.2Accordingly, nerve ischemia due to intraneural compression (local anesthetic volume or edema) and/or perineural compression (local anesthetic volume) may cause permanent or transient nerve damage.4Moreover, high-pressure intrafascicular or endoneural injection may also cause neural damage.3Consequently, the combination of ischemia, high-pressure intrafascicular or endoneural injection and local anesthetic toxicity could be deleterious to peripheral nerves.3,4According to my experience, it is difficult to tell from the ultrasound image after apparent intraneural placement of the needle tip, whether the needle is positioned perineurially, epineurially, or endoneurially. The injection of the local anesthetic, even in a small quantity, in one of these positions may not lead to the same outcome. Furthermore, endoneural injection could result in nerve damage by promoting ischemic changes.2For this reason, I believe that avoidance of intraneural placement of the needle tip should be a major concern during ultrasound-guided peripheral nerve blocks. Moreover, performing a peripheral nerve block in real time and under direct vision gives us the possibility to correct the needle position, avoid intraneural injections, and avoid nerve injury.In conclusion, although this study and other reports1,2suggested that nerve puncture and intraneural injection of low to moderate volumes of local anesthetic do not inevitably lead to neurologic injury, the role of ultrasound-guided peripheral nerve blocks is to increase safety. Even if we hypothesize that intraneural injections do not lead to neurologic damage, they present no advantage over perineural injections in rapidity of installation or in success rate after ultrasound-guided techniques. Finally, practitioners who have already experienced neurologic problems after regional anesthesia techniques always remember the difficulties encountered during the long way of patient care.Clinique du Parc saint Lazare, Beauvais, France. balnasser@wanadoo.fr

Central Lymph Node Dissection in Differentiated Thyroid Cancer

There has been renewed interest in extensive lymph node dissection for papillary thyroid cancer (PTC), and a number of reports have been published concerning compartment-oriented dissection of regional lymph nodes in PTC. A comprehensive review of this body of literature using evidence-based methodology is pending. Systematic review of the literature using evidence-based criteria. Issue 1: Systematic compartment-oriented central lymph node dissection (CLND) may decrease recurrence of PTC (Levels IV and V data, no recommendation) and likely improves disease-specific survival (grade C recommendation). Limited level III data suggest survival benefit with the addition of prophylactic dissection to thyroidectomy (grade C recommendation). The addition of CLND to total thyroidectomy can significantly reduce levels of serum thyroglobulin and increase rates of athyroglobulinemia (level IV data, no recommendation). Issue 2: There may be a higher rate of permanent hypoparathyroidism and unintentional permanent nerve injury when CLND is performed with total thyroidectomy than for total thyroidectomy alone (grade C recommendation). Issue 3: Reoperation in the central neck compartment for recurrent PTC may increase the risk of hypoparathyroidism and unintentional nerve injury when compared with total thyroidectomy with or without CLND (grade C recommendation), supporting a more aggressive initial operation. Evidence-based recommendations support CLND for PTC in patients under the care of experienced endocrine surgeons.

Preoperative Computed Tomography Imaging in the Management of Impacted Mandibular Third Molars

The purpose of this study was to examine the role of preoperative computed tomography (CT) imaging of the inferior alveolar nerve (IAN) for patients at increased risk for nerve injury during mandibular third molar (M3) extraction. To address the research purpose, the investigators enrolled a sample composed of subjects who presented for mandibular M3 extraction and had panoramic radiographic signs interpreted as being associated with an increased risk for inferior alveolar nerve injury. All subjects had preoperative CT imaging studies done to ascertain the position of the IAN with respect to M3. The predictor variable was the preoperative assessment of risk for IAN injury based on panoramic imaging. The outcome variable was the preoperative assessment of IAN injury risk after reviewing the CT studies. We documented the number of IAN injuries. Descriptive statistics were computed as indicated. The sample consisted of 23 patients who had bilaterally impacted wisdom teeth. The sample's mean age was 26 +/- 6 years (range: 18-48 years); 69.6% of the patients were female. After reviewing the panoramic radiographic, 80.4% of M3s were classified as having an increased risk for IAN injury. Upon examining the CT imaging, 32.6% were classified as high risk for IAN injury. After reviewing all imaging studies, 71.7% of the teeth in the sample were extracted. Intraoperative IAN visualization occurred in 21.2% of the cases. At 1 week postoperative, 3 patients had dysesthesia (9.1%); none had a permanent nerve injury. In this small series of patients, the additional information provided by 3-dimensional imaging changed the majority of patients from increased risk for nerve injury to low risk for nerve injury.

A Report of the Vancouver Forum on the Care of the Live Organ Donor: Lung, Liver, Pancreas, and Intestine Data and Medical Guidelines

An international conference of transplant physicians, surgeons, and allied health professionals was held in Vancouver, Canada, on September 15 and 16, 2005 to address the care of the live lung, liver, pancreas, and intestine organ donor. The Vancouver Forum was convened under the auspices of the Ethics Committee of The Transplantation Society. Forum participants included over 100 leaders in organ transplantation, representing many countries from around the world, including participants from the following continents: Africa, Asia, Australia, Europe, North and South America. The objective of the Vancouver Forum was to develop an international standard of care for the live lung, liver, pancreas and intestinal organ donor. This Vancouver Forum followed a conference convened in Amsterdam on the care of the live kidney donor (1, 2). There were four organ specific work groups at the Vancouver Forum: lung, liver, pancreas and intestine. Each organ work group addressed the following topics in concert and reported their findings in a plenary presentation to all participants:

Assessing recovery from lingual nerve injury

Objective To determine the sensitivity of conventional sensory assessment in monitoring lingual nerve recovery subsequent to third molar surgery and to evaluate if the assessment methods can be predictive of injury outcome. Method A prospective case series of 94 patients presenting with lingual nerve injuries evaluated using objective mechanosensory and subjective methods during the recovery period of up to 12 months. Results The conventional tests were often unable to diagnose the presence of injury due to variability and they were not predictive of outcome. As a result of this study, we are able to identify patients more likely to have permanent rather than temporary lingual nerve injury at four to eight weeks post injury, using patient reported subjective function. The subjective function test also minimises the requirements for specialist training or equipment providing an ideal method for general dental practice. Conclusions The development of these simple subjective tests may enable us to identify which patients are at risk of permanent lingual nerve injuries in the early post injury phase, thus allowing expeditious therapy when indicated.

Simplifying the assessment of the recovery from surgical injury to the lingual nerve

To determine the sensitivity of conventional sensory assessment in monitoring lingual nerve recovery subsequent to third molar surgery and to evaluate if the assessment methods can be predictive of injury outcome. A prospective case series of 94 patients presenting with lingual nerve injuries evaluated using objective mechanosensory and subjective methods during the recovery period of up to 12 months. The conventional tests were often unable to diagnose the presence of injury due to variability and they were not predictive of outcome. As a result of this study, we are able to identify patients more likely to have permanent rather than temporary lingual nerve injury at four to eight weeks post injury, using patient reported subjective function. The subjective function test also minimises the requirements for specialist training or equipment providing an ideal method for general dental practice. The development of these simple subjective tests may enable us to identify which patients are at risk of permanent lingual nerve injuries in the early post injury phase, thus allowing expeditious therapy when indicated.

AB5-4: How safe is cryoablation near the right phrenic nerve?

Radiofrequency catheter ablation (CA) may cause permanent phrenic nerve injury. Cryothermal (CRYO) injury is usually reversible if cooling is stopped immediately. The safety of CRYO CA near the phrenic nerve is unknown.

Gerard W. Ostheimer “What’s New in Obstetric Anesthesia” Lecture

Gerard W. Ostheimer “What’s New in Obstetric Anesthesia” Lecture

Safely Increasing the Efficiency of Thyroidectomy Using a New Bipolar Electrosealing Device (LigaSure™) versus Conventional Clamp-and-Tie Technique

Operative time in thyroid surgery can be safely reduced through use of a new bipolar electrosealing device (LigaSure). We evaluated consecutive patients undergoing thyroid surgery from January 2003 through January 2005 (n=155). During the first half of the study, hemostasis was obtained using silk ties (conventional group, n=70). During the second half of the study period, hemostasis was obtained with a bipolar electrosealing device (LigaSure group, n=85). The mean operative time was 130 +/- 37 minutes in the conventional group and 110 +/- 33 minutes (P < 0.001) in the LigaSure group. EBL in the LigaSure group was statistically significantly less (43 +/- 53 vs 33 +/- 33 mL; P < 0.05). Postoperative calcium level was statistically significantly higher in the LigaSure group (8.2 +/- 0.5 vs 8.4 +/- 0.6 mg/dL, P < 0.05). Hospital length of stay (LOS) did not differ significantly. One patient in each group developed neck hematoma requiring reoperation. One permanent recurrent nerve injury occurred in the conventional group and one transient bilateral recurrent nerve injury occurred in the LigaSure group. The occurrence of symptomatic hypocalcemia was similar between the two groups. The training level of the surgical resident had no significant impact on the operative time, estimated blood loss (EBL), LOS, or complication rate. LigaSure bipolar electrosealer as the primary means of hemostasis during thyroidectomy significantly reduces mean operative times. Rates of operative complications were unchanged. LigaSure use in thyroid surgery can safely increase efficiency.

Exposure recurrent laryngeal nerves during the procedure of thyreoidectomy to prevent permanent nerve injuries

目的 探讨甲状腺手术中常规解剖显露喉返神经能否预防永久性神经损伤.方法对1980年1月至2004年12月手术治疗的1 523例甲状腺疾病进行回顾性分析.在1 523例中,术中未显露喉返神经1 249例,术中常规显露喉返神经274例,观察两组术后永久性喉返神经损伤发生率和暂时性喉返神经损伤发生率.结果 1 523例中共发生永久性喉返神经损伤50例,其中未显露喉返神经组发生47例(47/1 249,3.8%),显露喉返神经组发生3例(3/274,1.1%),前者永久性喉返神经损伤发生率比后者显著升高(P＜0.05).两组中暂时性喉返神经损伤发生率未见有显著差异(P＞0.05).结论术中常规显露喉返神经是甲状腺切除手术中预防喉返神经永久性损伤的有效方法。

Clinical significance of the tumour capsule in the treatment of parotid pleomorphic adenomas.

The propensity of pleomorphic adenomas to recur is generally attributed to the biological nature of the tumour, and surgery close to the capsule is perceived as undesirable. At the Christie Hospital, Manchester, between 1947 and 1992, 475 tumours arising within the superficial portion of the parotid gland were treated by two surgical techniques: extracapsular dissection (380 patients) and superficial parotidectomy (95). Recurrence rates were 2 per cent in each group (median follow-up 12.5 years). Contact of the tumour with the facial nerve was recorded in 51 per cent of patients. There was no difference between the treatment groups in the incidence of permanent facial nerve injury (2 versus 1 per cent respectively). This study demonstrates that dissection in close proximity to the tumour is possible without inducing recurrence and that in practice the microinvasion of the capsule by tumour buds has limited clinical significance.

Nerve Blocks at the Wrist for Carpal Tunnel Release Revisited: The Use of Sensory-Nerve and Motor-Nerve Stimulation Techniques

Because the median nerve at the wrist has mainly sensory endings, the aim of this study was to assess the response of the median nerve to nerve stimulation at the wrist and to evaluate the quality of median nerve block. A control group of patients who received blinded injections was analyzed and compared post hoc. One hundred and eleven patients scheduled for ambulatory endoscopic carpal-tunnel release performed under median and ulnar nerve blocks at the wrist were prospectively studied. The blocks were performed with a nerve stimulator. Nerve-stimulation techniques were explained to the patient before the block was performed. The patient was trained to inform the anesthetist of their perception of an electrical paresthesia that was synchronized to the nerve stimulator. The anesthetist recorded the first response of the patient to nerve stimulation: sensory (S), sensory-motor (SM), or motor response (M). When the minimal stimulating current was obtained, an equal volume of 4 mL of 1.5% mepivacaine was injected on median and ulnar nerves. If necessary, a lateral subcutaneous injection of 2 mL of 1.5% mepivacaine was administered at the wrist crease in the musculocutaneous nerve area. Thirty-five patients who received blinded local anesthetics injections were included post hoc. Quality of anesthesia was compared between groups. Responses included 89 S (80.2%), 18 SM (16.2%), and 4 M (3.71%). No differences occurred in time to perform the block, minimal current intensity, and efficacy. More punctures were necessary in the M group compared with the S group and the control group (P < .05). The onset time of sensory blocks increased significantly in control-group patients (P < .05), but the duration of the nerve-block procedure decreased in comparison with the M group. Respectively, 10% and 20% of patients experienced mild or severe pain in the nerve-stimulation group and control group. At 20 minutes, the block was complete for the median and ulnar nerves in 96.4% and 85% of the nerve-stimulation patients and control patients (P < .05). Two patients in the control group experienced painful mechanical paresthesia. Neither permanent nor transient nerve injuries were observed during or after the nerve block or surgery. This study describes how infrequently an initial motor response is identified when a nerve stimulator is used on the median nerve at the wrist. A very high success rate of median and ulnar nerve block at the wrist is obtained by use of sensory or sensory-motor-nerve stimulation and less than 10 mL of anesthetic solution.

Patterns of Use of Facial Nerve Monitoring During Parotid Gland Surgery

To determine current patterns of use of facial nerve monitoring during parotid gland surgery by otolaryngologists in the United States. A questionnaire encompassing surgeon training background, practice setting, patterns of facial nerve monitor usage during parotid gland surgery, and history of permanent facial nerve injury or legal action resulting from parotid surgery was mailed to 3139 otolaryngologists in the United States. Associations between facial nerve monitor usage and dependent variables were examined by using the chi(2) test. Magnitudes of the associations were determined from odds ratios calculated using logistic regression. A 49.3% questionnaire response rate was achieved. Sixty percent of respondents who perform parotidectomy employed facial nerve monitoring some or all of the time. Respondents were 5.6 times more likely to use the monitor in practice if they used it in training and 79% more likely to use it if they performed more than 10 parotidectomies per year. Respondents were 35% less likely to have a history of inadvertent nerve injury if they performed more than 10 parotidectomies per year. Surgeons who employed monitoring in their practice were 20.8% less likely to have a history of a parotid surgery-associated lawsuit. Additional information regarding surgeon demographics, types of nerve monitors used, and reasons for and against monitor usage are discussed. Permanent facial nerve paralysis after parotidectomy occurs in 0-7% of cases. Currently, a majority of otolaryngologists in the United States are employing facial nerve monitoring during parotid surgery some or all of the time, even though no studies to date have demonstrated improved outcomes with its use. Physician training background and surgery caseload were significant factors influencing usage of facial nerve monitoring in this study.

Safety and Efficacy of Eversion Carotid Endarterectomy for the Treatment of Recurrent Stenosis: 20-Year Experience

Current options for treating recurrent carotid stenosis (RCS) include standard longitudinal arteriotomy and patch angioplasty with or without carotid endarterectomy (s-PCEA), carotid-carotid bypass, or carotid angioplasty and stent (CAS). Eversion carotid endarterectomy (e-CEA) is an effective procedure for treating primary carotid stenosis, yet it has not been reported for treating RCS. We evaluated the feasibility and outcome of e-CEA for treating of RCS in comparison to s-PCEA. The records of all patients undergoing elective CEA for symptomatic and asymptomatic high-grade RCS from January 1981 to July 2002 were reviewed. Although during the earlier period s-PCEA was performed preferentially, this paradigm changed to e-CEA being the preferred technique for treatment of RCS. During the course of postoperative follow-up when duplex sonography suggested high-grade RCS, the diagnosis was confirmed via arteriography. Data on cranial nerve injury, recurrent stenosis, stroke, and death were prospectively collected into a vascular registry database and analyzed retrospectively, Students' t-test and chi-square analysis were used to compare the group's baseline characteristics and outcomes. Over a 21-year period, 7001 patients underwent primary CEA for symptomatic (n = 2405, 34%) or asymptomatic (n = 4596, 66%) high-grade stenosis via standard (n = 1501, 21%) or eversion (n = 5500, 79%) techniques. Fifteen (25%) patients had 70 to 80% stenosis, 30 (51%) had 81 to 90% stenosis, and 14 (24%) had 91 to 99% stenosis. During this time period, 59 patients presented with symptomatic (n = 18, 31%) or asymptomatic (n = 41, 69%) high-grade RCS and underwent operative repair via s-PCEA (n = 22, 37%) or eversion (n = 37, 63%) techniques. The mean time interval for repeat carotid surgery for RCS was 49 months in the s-PCEA group and 48 months in the e-CEA group. Permanent cranial nerve injuries, stroke, and recurrent restenosis occurred in one (4.5%), one (4.5%), and one (4.5%) of the patients undergoing s-PCEA, respectively. In the e-CEA group, these events occurred in one (27%), none (0%), and one (2.7%) patients, respectively, There were no deaths during the 30-day postoperative period. Eversion CEA is a feasible option for the treatment of many RCSs and can be performed safely with a low rate of cranial nerve injury, recurrent stenosis, stroke, and death.

A study of routine exposure of recurrent laryngeal nerve during thyroid surgery

One of the main complications of thyroid surgery is injury to recurrent laryngeal nerve (RLN), which causes severe morbidity to the patient in postoperative period. To find out the incidence of RLN injury and its consequences, a prospective study was done in a group of 142 cases during the years 1999-2000. Different types of thyroidectomies for various diseases lbw of the thyroid gland, wherein a routine identification and exposure of the P-R was done through out its full course till its entry into the larynx at cricothyroid membrane. Three cases of temporary RLN injury were found and not a single case of permanent nerve injury was seen during our study. Three cases of nonre current LN were found on the right side of the gland. The temporary injury of the nerve completely recovered during 2-5 months of follow-up. We present some reviews of the literature to provide various authors, views and experiences regarding injury of RLN associated with thyroid urgery.

Frequency of Trigeminal Nerve Injuries Following Third Molar Removal

To estimate oral and maxillofacial surgery reporting of the frequency of temporary and permanent inferior alveolar and lingual nerve damage from lower third molar extraction and injury etiology, and to identify factors associated with injury rates. A postal survey was sent to all members of the California Association of Oral and Maxillofacial Surgeons requesting information on known instances of inferior alveolar and lingual nerve damage that had occurred in their practices over a 12-month period and known instances of permanent damage over their entire careers. Replies were obtained from 535 California Oral and Maxillofacial Surgeons (OMFS) representing 86% of all OMFS in California. Instances of injury to the inferior alveolar nerve in a 12-month period were reported by 94.5% of OMFS; 53% reported instances of lingual nerve injury in a 12-month period. Instances of permanent nerve injury of the inferior alveolar nerve were reported by 78% of OMFS; 46% reported permanent lingual nerve injury occurring during their professional lifetime. The overall estimated self-reported rate of injury was 4 per 1,000 lower third molar extractions for the inferior alveolar nerve and 1 per 1,000 extractions for the lingual nerve for all cases (temporary and permanent). In most cases (80%) of inferior alveolar nerve injury the cause was known, but in a majority of cases of lingual nerve injury (57%) the injury etiology was unknown. Self-reported rates of permanent injury were 1 per 2,500 lower third molar extractions for the inferior alveolar nerve and 1 per 10,000 lower third molar extractions for the lingual nerve. Injury rates were associated with provider experience (ie, extractions per year) and years in practice. This survey included a high percentage of California OMFS. Injury to the inferior alveolar and lingual nerve was reported by most OMFS in California following lower third molar removal, and many reported cases of permanent nerve injury, frequently with unknown cause.

Acute Airway Obstruction Complicating Unilateral Carotid Endarterectomy

Injury to the vagus nerve or any of its branches is a recognised complication of carotid endarterectomy (CEA) under both local and general anaesthesia. Although in most cases this type of injury is transient, cases of permanent nerve injury have been reported. Despite this, the pre-operative assessment of vocal cord (VC) function in patients undergoing CEA is not undertaken routinely in clinical practice. We report a case, which we believe is of value in identifying patients undergoing CEA, where preoperative assessment of VC function is important, and provides an additional useful tool for risk benefit analysis.