Permanent Recurrent Laryngeal Nerve Palsy Research Articles

The Impact of Thyroiditis on Morbidity and Safety in Patients Undergoing Total Thyroidectomy.

Background:The indications for surgery in thyroiditis vary from compressive symptoms to cosmesis. We analyzed the complications in patients who underwent total thyroidectomy (TT) in goiters associated with thyroiditis.Materials and Methods:This retrospective study was done in an endocrine surgical center over 4 years. A total of 724 patients, who underwent TT for benign thyroid disorders, were included in the study. Patients were divided into two groups based on histopathology into Group A (nonthyroiditis cases) and Group B (thyroiditis cases); Group B is subdivided into Group B1 (nodular goiter with associated thyroiditis) and Group B2 (Hashimoto's thyroiditis). The preoperative parameters analyzed were serum calcium, serum Vitamin D, serum parathyroid hormone (PTH), and vocal cord status. The intraoperative parameters observed were operating time, parathyroid preservation, and autotransplantation and course of recurrent laryngeal nerve (RLN). Postoperative parameters monitored were serum calcium, serum PTH, serum magnesium, signs and symptoms of hypocalcemia, and vocal cord status. Follow-up was done at 6 months with serum calcium, serum PTH, and video laryngoscopy.Results:Both groups were age and sex matched. All preoperative and intraoperative parameters were comparable among groups. Both transient complications (<6 months) were higher in Group B than A. Transient hypocalcemia was higher in Group B (39.70%) than Group A (24.77%) (P = 0.001). Transient hypocalcemia was higher in Group B1 (36.58%) than Group B2 (44.44%) (P = 0.014). Transient RLN palsy was higher in Group B (9.55%) than Group A (7.52%) (P = 0.040). Transient RLN palsy was higher in Group B1 (8.53%) than Group B2 (11.11%) (P = 0.039). Permanent hypoparathyroidism and permanent RLN palsy were comparable between the Groups A and B and between Groups B1 and B2.Conclusion:The incidences of transient complications are higher in patients with thyroiditis. Careful analysis of surgical indications will avoid unnecessary surgery in thyroiditis cases.

Complication Risk in Secondary Thyroid Surgery.

Objectives:Secondary thyroid surgery is rare, compared with primary thyroid surgery. However, secondary surgery has a greater risk of complications due to the formation of scar tissue as well as increased fragility of the tissues following the previous surgery. Several surgical techniques and strategies have been recommended to decrease the complication rate associated with secondary surgery. The aim of this study was to evaluate the complication rate in patients who underwent secondary thyroid surgery using a lateral approach and intraoperative nerve monitoring (IONM).Methods:The data of 44 patients who underwent secondary surgical intervention after thyroid surgery performed for benign or malignant thyroid disease (Group 1), and of 44 patients who underwent primary surgery (Group 2) were compared. Lobectomy patients with a histopathological result of malignant disease, whom were applied completion thyroidectomy were excluded from the study. Secondary surgery was performed using a lateral approach. Access was achieved between the anterior edge of the sternocleidomastoid muscle and the strap muscles. In primary surgery, the thyroid lodge was entered through the midline. Standard IONM was applied in all cases. Hypocalcemia was defined as a serum calcium level of ≤8 mg/dL within the first postoperative 48 hours, regardless of clinical symptoms. Transient and permanent recurrent laryngeal nerve paralysis was evaluated based on the number of nerves at risk. The lobectomy was considered to be high-risk with the presence of recurrence, Graves’ disease, substernal goiter, and application of central dissection.Results:The mean age of Group 1 and 2 was 49.9±14.1 years and 45±12.6 years , respectively (range: 22-90 years; p=0.69). Female patients constituted 90.9% (n=40) of the population in Group 1 and 75% (n=33) of the patient population in Group 2 (p=0.87). In Group 1, 11 (25%) patients, and 7 (15.9%) patients in Group 2 underwent surgical intervention due to the presence of a malignant disease (p=0.29). Bilateral intervention was applied in 26 (59.1%) patients in Group 1 and 28 (63.6%) patients in Group 2. The rate of transient and permanent hypocalcemia in Groups 1 and 2 was 34.1% (n=15) vs 22.5%, and 2.5% (n=1) vs 0%, respectively, without any significant intergroup difference (p=0.237, p=1). In Group 1, 71 lobes were operated on, and there were 72 in Group 2. All of the interventions in Group 1 (100%), and 31.9% (n=23) of those in Group 2 were high-risk, and there was a significant intergroup difference (p<0.0001). The rate of transient and permanent vocal cord paralysis were 4.2% (n=3) vs 2.8% (n=2) and 6.9 % (n=5) vs 0% in Groups 1 and 2, respectively (p=0.719; p=0.245).Conclusion:When performed with a meticulous and attentive technique, secondary surgical intervention can be applied without increasing the incidence of permanent complications. Though there is substantial risk associated with all of these procedures, the rate of vocal cord paralysis was similar to that seen after primary intervention, and was thought to be related to surgical experience and technique, as well as the use of IONM.

Safety and Outcomes of the Transoral Endoscopic Thyroidectomy Vestibular Approach

Natural orifice transluminal endoscopic surgery thyroidectomy is a novel approach to avoid surgical scars. To compare the safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) with those of open thyroidectomy (OT). This study retrospectively reviewed all TOETVA and OT operations performed from April 1, 2014, through August 31, 2016, at Police General Hospital, Bangkok, Thailand. All patients who underwent TOETVA and patients who underwent OT were included. Exclusion criteria were (1) previous neck surgery, (2) substernal goiter, (3) lymph node or distance metastasis, and (4) suspicious invasion to the adjacent organs. Propensity score matching was conducted to reduce selective bias. Operative time, blood loss, and complications related to thyroid surgery. Of the 425 patients who underwent transoral endoscopic thyroidectomy (mean age, 35.3 [12.1] years; age range, 16-81 years; 389 [92.2%] female), 422 successfully were treated with the TOETVA; 3 patients were converted to a conventional operation because of bleeding. Twenty-five patients (5.9%) had transient recurrent laryngeal nerve palsy, and 46 (10.9%) had transient hypoparathyroidism. None had permanent recurrent laryngeal nerve palsy or permanent hypoparathyroidism. Three patients (0.7%) had transient mental nerve injury; all cases resolved by 4 months. One patient developed postoperative hematoma treated by OT. Twenty patients (4.7%) had seroma treated by simple aspiration. Operative time was longer for the TOETVA compared with the OT group (100.8 [39.7] vs 79.4 [32.1] minutes, P = 1.61 × 10-10). The mean (SD) visual analog scale score for pain was lower in the TOETVA group (1.1 [1.2] vs 2.8 [1.2], P = 2.52 × 10-38). Estimated mean (SD) blood loss (36.9 [32.4] vs 37.6 [23.1] mL, P = .43) and rate of complications (45 of 216 [20.8%] vs 38 of 216 [17.6%], P = .41) were not significantly different in the TOETVA vs OT group. The TOETVA was performed as safely as OT, requires only conventional laparoscopic instruments, and avoids incisional scars; thus, the approach may be an option for select patients.

Comparison of EMG signals recorded by surface electrodes on endotracheal tube and thyroid cartilage during monitored thyroidectomy

A variety of electromyography (EMG) recording methods were reported during intraoperative neural monitoring (IONM) of recurrent laryngeal nerve (RLN) in thyroid surgery. This study compared two surface recording methods that were obtained by electrodes on endotracheal tube (ET) and thyroid cartilage (TC). This study analyzed 205 RLNs at risk in 110 patients undergoing monitored thyroidectomy. Each patient was intubated with an EMG ET during general anesthesia. A pair of single needle electrode was inserted obliquely into the TC lamina on each side. Standard IONM procedure was routinely followed, and EMG signals recorded by the ET and TC electrodes at each step were compared. In all nerves, evoked laryngeal EMG signals were reliably recorded by the ET and TC electrodes, and showed the same typical waveform and latency. The EMG signals recorded by the TC electrodes showed significantly higher amplitudes and stability compared to those by the ET electrodes. Both recording methods accurately detected 7 partial loss of signal (LOS) and 2 complete LOS events caused by traction stress, but only the ET electrodes falsely detected 3 LOS events caused by ET displacement during surgical manipulation. Two patients with true complete LOS experienced temporary RLN palsy postoperatively. Neither permanent RLN palsy, nor complications from ET or TC electrodes were encountered in this study. Both electrodes are effective and reliable for recording laryngeal EMG signals during monitored thyroidectomy. Compared to ET electrodes, TC electrodes obtain higher and more stable EMG signals as well as fewer false EMG results during IONM.

Intra-capsular total thyroid enucleation versus total thyroidectomy in treatment of benign multinodular goiter. A prospective randomized controlled clinical trial

BackgroundDue to high recurrence rate after subtotal thyroidectomy, most of centers have shifted to total thyroidectomy as a surgical treatment for benign multinodular goiter (BMNG), but serious complications, as laryngeal nerve affection & hypocalcaemia, are still present. This study aimed to evaluate treatment of BMNG using intra-capsular total thyroid enucleation in comparison to standard total thyroidectomy. Patients &methodsThis is a prospective randomized controlled clinical trial conducted in a hospital in the period from December 2009 to December 2015. Of total 224 patients with clinically BMNG. 112 patients operated by intracapsular total thyroid enucleation (ITTE group) and the other 112 patients operated by standard total thyroidectomy (STT group). The minimal follow up period was 36 months. ResultsThe mean operative time in ITTE group was (93.7 ± 9.6 min) compared to (86.9 ± 8.3 min) in STT group. Transient recurrent laryngeal nerve (RLN) palsy was 0% in ITTE group VS 7.1% in STT group. No cases (0%) developed permanent RLN palsy in ITTE group VS 0.9% in STT group. Symptomatic transient hypocalcaemia occurred in 1.8% in ITTE group VS 11.6% in STT group. No cases (0%) developed permanent hypocalcaemia in ITTE group VS 0.9% in STT group. No recurrence (0%) in both groups after minimal 3 years of follow up. ConclusionIntracapsular Total thyroid enucleation technique is safe with the least serious complications, especially RLN injury and hypoparathyroidism, with no recurrence, but this technique still not radical so couldn't be used in suspicious cases for malignancy.

A meta-analysis of intraoperative neuromonitoring of recurrent laryngeal nerve palsy during thyroid reoperations.

The rate of recurrent laryngeal nerve (RLN) palsy, a common complication of thyroid surgery, is especially high in thyroid reoperations. The present meta-analysis assesses whether intraoperative neuromonitoring (IONM) reduces the prevalence of RLN palsy in thyroid reoperations. A systematic literature search was conducted in the PubMed, SCIE and Wan Fang databases for studies published up to 31 August 2016. All data were analysed using STATA (version 11) software. Publication bias was assessed using Begg's funnel plot and Egger's test, and sensitivity analysis was performed. Nine studies including 2436 at-risk nerves met the inclusion criteria. The results were presented as pooled relative risks (RRs) with 95% confidence intervals (CI). The overall RLN palsy rate was significantly lower in reoperations conducted with IONM than in those conducted without IONM (RR=0.434, 95% CI=0.206-0.916, P=.029). High heterogeneity was found (I2 =70.2%, P=.001). The rates of transient RLN palsy with and without IONM did not differ significantly (RR=0.607, 95% CI=0.270-1.366, P=.227). The heterogeneity was high (I2 =67.4%, P=.005). However, IONM was significantly associated with a reduction in permanent RLN palsy (RR=0.426, 95% CI=0.196-0.925, P=.031). No significant heterogeneity was found (I2 =13.7%, P=.325). Funnel plots for overall and transient RLN palsy showed a possible publication bias. Intraoperative neuromonitoring (IONM) is associated with a reduction in overall and permanent RLN palsy in thyroid reoperations. However, given the limited sample size and heterogeneity in this meta-analysis, further studies are required to confirm our preliminary findings.

Transoral endoscopic thyroidectomy: our initial experience using a new endoscopic technique.

A transoral approach has been experimentally introduced to the field of thyroid surgery and several groups in Asia have recently used the technique to treat patients. We performed transoral endoscopic thyroidectomies on patients with thyroid cancer or a benign tumor. We reviewed the medical records of patients who underwent transoral endoscopic thyroid surgery between July 2016 and January 2017. A midline incision was made in the vestibule, and a 10 mm cannula was placed; then, the working space was widened by insufflating CO2 at a pressure of 5-6mmHg. Two lateral incisions were made in the vestibule near the first molars, and 5-mm-diameter cannulas were inserted. A 10-mm 30° telescope was inserted through the midline cannula and instruments were positioned through the lateral cannulas. Thyroid surgery was endoscopically performed using conventional endoscopic instruments. We performed 18 thyroid surgeries (15 thyroid lobectomies, one completion thyroidectomy, and two total thyroidectomies) in 17 patients. The postoperative pathology was papillary thyroid cancer in 11 cases (61.1%), a follicular carcinoma in two cases (one patient) (11.1%) and benign in five cases (27.8%). The average tumor diameter was 1.75cm (range 0.5-7.5cm). No patient reported sensory changes around the lower lip. No patient developed permanent recurrent laryngeal nerve palsy or hypocalcemia. No patient developed a wound infection or a fistula between the oral incision and anterior neck. The transoral endoscopic approach provides a short, direct route to the thyroid gland and seems to be safe and feasible. It is important to further develop and refine the surgical techniques. The approach is optimal, and will become widely used for thyroid surgery in the near future.

Single-Incision, Gasless, Endoscopic Trans-Axillary Total Thyroidectomy: A Feasible and Oncologic Safe Surgery in Patients with Papillary Thyroid Carcinoma

The aim of this study is to compare the feasibility and oncologic safety of Single-incision, gasless, Endoscopic trans-axillary bilateral Total thyroidectomy (SET) with open cervical total thyroidectomy in patients with papillary thyroid carcinoma (PTC). From March 2008 to December 2012, PTC patients underwent bilateral total thyroidectomy. Conventional, open surgery was performed on 538 patients (Group O) and endoscopic surgery was performed on 200 patients (Group E). We analyzed the patient's clinicopathologic, postoperative complications, and surgical completeness. The mean ages of the patients were 48.9 ± 0.5 (range = 24-77) in Group O and 39.5 ± 0.8 (range = 17-73) in Group E with statistical significance (P < .001). Percentage of female patients were 74.3% in Group O and 96.0% in Group E with statistical significance (P < .001). The postoperative hospital stay in Group O was significantly longer than Group E (4.60 ± 0.05 versus 3.30 ± 0.05; P < .001). The operation time in Group E was significantly longer than Group O (93.9 ± 1.3 versus 142.6 ± 3.3; P < .001). More transient hypocalcemia was found in Group O compared to Group E with statistical significance (28.1% versus 22.4%; P < .001). There were no significant differences with respect to permanent hypocalcemia, permanent recurrent laryngeal nerve palsy, seroma, and hematoma. The mean 1 year-stimulated sTg was 0.23 ± 0.03 and 0.18 ± 0.02 in Group O and E, respectively. Tumor recurrence during short-term follow-up at neck ultrasonography (1 year) was detected in 4 patients in Group O. SET is safe and effective, not only for low-risk patients with early-detected cancer, but also for selected cases of advanced cancer.

Multinadular Goitre Whether to do subtotal or Total Thyroidectomy

Abstract: Multinodular goitre may be treated by subtotal thyroidectomy or total thyroidectomy depending on the factors like symptomology.Objectives: To compare the efficacy and morbidity of total thyroidectomy and subtotal thyroidectomy. Methods: Prospective study done in GMKMCH from June 2012 to June 2014.Results: Based on symptomology decision to do either a subtotal or total thyroidectomy were performed, in compressive symptoms in MNG involving both lobes total thyroidectomy was preferred especially in endemic goitre, subtotal done in MNG without compressive symptoms. No permanent recurrent laryngeal nerve palsy noted in both groups. But transient hypoparathyroidism occur in both groupsConclusion: Total thyroidectomy is a safe choice for the benign MNG disease with euthyroid state and it provide a radical but definitive control of disease without risk of recurrence. In experienced hand total thyroidectomy assures total relief of compressive symptom and comparable low incidence of major complications.

Assessment of morbidity and mortality of thyroid surgery

Background: To find out the incidence and types of complications after thyroidectomy.To analyze the factors related to the complications of thyroid surgery.Material and method: The study was carried out at Shahid Suhrawardy medical college and Hospital, Dhaka from July 2007 to June 2008. Fifty patients were selected for the study who were treated by thyroidectomy. The mean patient's age at the time of surgery was 41.9±8.1 years ranged from 10 to 60 years. Data were collected in a prescribed data collection sheet. Then all data were compiled and analyzed.Result: 12% of the patients had transient hypoparathyroidism, 4% had haemorrhage, 2% had permanent hypoparathyroidism, 4% had temporary recurrent laryngeal nerve (RLN) palsy and 2% had permanent recurrent laryngeal nerve palsy. Other rare complications were superior laryngeal nerve palsy, hematoma, and wound infection.Conclusion: Improved surgical techniques and proper management of complications reduce the postoperative morbidity and mortality of thyroid surgery. In spite of all measures, keen observation in postoperative period is very important to find out the complications for early intervention.Anwer Khan Modern Medical College Journal Vol. 6, No. 2: July 2015, P 15-19

Transoral endoscopic thyroidectomy: current state of the art—a systematic literature review and results of a bi-center study

Transoral endoscopic approaches for thyroidectomy (TOET) have been developing since 2008. To date, single centers have gained great experience and patients treated worldwide (477 by February 2016) have resulted in complication rates [transient recurrent laryngeal nerve palsy (RLNP) 2.5%, permanent RLNP 0.4%, transient mental paraesthesia 5.9%, local or neck site infections 1.2%] comparable to conventional open and other endoscopic or robotic approaches. The conversion rate from TOET to open surgery is very low (0.6%). This data is based on a systematic literature review (PubMed search) and the results of a bi-centric study in Xiamen, P.R. China and Borna, Germany. TOET was performed on thyroid nodules or cervical masses in 93 patients. Isthmus resections, hemi, subtotal and total thyroidectomies were performed. A learning curve could be shown and cut-suture-times approached those of conventional thyroid surgery. One permanent RLNP was observed and a transient mental paraesthesia, which resolved within 3–4 weeks, was noted in 15 cases. In conclusion, TOET has left the stage of infancy and has proven to be a good alternative to conventional open or endoscopic/robotic-assisted thyroidectomy with the advantage of decreased postoperative pain and diminished swallowing disorders following thyroid surgery. Lastly, it secures an optimal cosmetic result since TOET leaves no visible scars even at the access points in the mouth.

Transoral endoscopic thyroidectomy: current state of the art—a systematic literature review and results of a bi-center study

: Transoral endoscopic approaches for thyroidectomy (TOET) have been developing since 2008. To date, single centers have gained great experience and patients treated worldwide (477 by February 2016) have resulted in complication rates [transient recurrent laryngeal nerve palsy (RLNP) 2.5%, permanent RLNP 0.4%, transient mental paraesthesia 5.9%, local or neck site infections 1.2%] comparable to conventional open and other endoscopic or robotic approaches. The conversion rate from TOET to open surgery is very low (0.6%). This data is based on a systematic literature review (PubMed search) and the results of a bi-centric study in Xiamen, P.R. China and Borna, Germany. TOET was performed on thyroid nodules or cervical masses in 93 patients. Isthmus resections, hemi, subtotal and total thyroidectomies were performed. A learning curve could be shown and cut-suture-times approached those of conventional thyroid surgery. One permanent RLNP was observed and a transient mental paraesthesia, which resolved within 3–4 weeks, was noted in 15 cases. In conclusion, TOET has left the stage of infancy and has proven to be a good alternative to conventional open or endoscopic/robotic-assisted thyroidectomy with the advantage of decreased postoperative pain and diminished swallowing disorders following thyroid surgery. Lastly, it secures an optimal cosmetic result since TOET leaves no visible scars even at the access points in the mouth.

An original technique for lymph node dissection along the left recurrent laryngeal nerve after stripping the residual esophagus during video-assisted thorocoscopic surgery of esophagus.

A clear operative view of the middle and lower mediastinum is possible in prone position during video-assisted thorocoscopic surgery of esophagus (VATS-E), but the working space in the upper mediastinum is limited and lymph node dissection along the left recurrent laryngeal nerve (RLN) is difficult in this position. Esophagectomy and lymph node dissection are performed for pneumothorax by maintaining CO2 insufflation in the prone position. Working space in the left upper mediastinal area for lymph node dissection around RLN is limited in this position. To create space, the residual esophagus is stripped in the reverse direction and retracted toward the neck after the stomach tube is removed through the nose. Lymph node dissection is performed after stripping the residual esophagus. We could obtain a clear operative field in the upper left mediastinum by stripping the residual esophagus in the prone position, enabling safe and straightforward lymph node dissection along the left RLN. The rate of permanent RLN paralysis was 1.2%. Lymph node dissection along the left RLN after esophageal stripping is possible in the prone position during VATS-E.

Can we consider immediate complications after thyroidectomy as a quality metric of operation?

Permanent recurrent laryngeal nerve palsy and hypoparathyroidism are 2 major complications after thyroid operation. Assuming that the rate of immediate complications can predict the permanent complication rate, some authors consider these complications as a valid metric for assessing the performance of individual surgeons. This study aimed to determine the correlation between rates of immediate and permanent complications after thyroidectomy at the surgeon level. We conducted a prospective, cross-sectional study in 5 academic hospitals between April 2008 and December 2009. The correlation between the rates of immediate and permanent complications for each of the 22 participating surgeons was calculated using the Pearson correlation test (r). The study period included 3,605 patients. There was a fairly good correlation between rates of immediate and permanent recurrent laryngeal nerve palsy (r=0.70, P=.004), but no correlation was found for immediate and permanent hypoparathyroidism (r=0.18, P=.427). The immediate hypoparathyroidism rate does not reflect the permanent hypoparathyroidism rate. Consequently, immediate hypoparathyroidism should not be used to assess the quality of thyroidectomy or to monitor the performance of surgeons.

Modified minimally invasive video-assisted lateral neck dissection for papillary thyroid carcinoma: a series of 130 cases

Objective: To discuss the feasibility, safety and oncologic completeness of modified minimally invasive video-assisted lateral neck dissection (MIVALND) for papillary thyroid carcinoma. Methods: Data of 130 patients from Department of Head and Neck Surgery, Sir Run Run Shaw Hospital, Medical School, Zhejiang University undergoing MIVALND from January 2013 to September 2015 were reviewed retrospectively. There were 31 male and 99 female patients with the mean age of (39±11) years. The thyroidectomy and central compartment dissection were performed under a direct visual field or video-assisted (VA) approach, lateral neck dissection was performed via the VA approach. Serum thyroglobulin and thyroglobulin antibody levels were measured every 6 months after surgery. Ulrasonography was performed to assess the thyroid bed and lateral neck compartment every 6 months after surgery. The mean operation time for MIVALND, mean postoperative hospital stay, size of primary tumor, number of retrieved lymph nodes, complication rates, and postoperative serum thyroglobulin levels were analyzed retrospectively. The patients were followed up by outpatient review and until March 2016. Results: Beside 1 case was converted to open procedure, 129 (99.2%) patients successfully underwent MIVALND. The mean operative time was (74±17) min (ranging from 40 to 120 min) for MIVALND. The mean postoperative hospital stay was (4.9±2.1) days (range 2 to 14 days). The mean size of primary tumor was (1.3±0.7) cm (range 0.3 to 4.0 cm). The mean number of lymph nodes removed was 42±13 (range 15 to 79) in lateral compartment. Postoperative complications included 19 transient hypoparathyroidism, 7 transient recurrent laryngeal nerve (RLN) palsy and 3 permanent RLN palsy (tumor invasion and the RLN was resected en bloc with the tumor in 2 cases), 2 (1.5%) transient palsy of spinal accessory nerve, 1 (0.8%) transient palsy of marginal mandibular branch of the facial nerve, 1 (0.8%) seroma, and 4 (3.1%) minor chyle leak. The mean follow-up period was (19±10) months (ranged 6 to 36 months). The mean serum thyroglobulin level was 0.10 μg/L during follow-up. No evidence of local residual or recurrent disease was observed at postoperative follow-up. Conclusion: The modified MIVALND is a safe and feasible approach in selected papillary thyroid carcinoma patients.

Implementation of Intraoperative Neuromonitoring for Transoral Endoscopic Thyroid Surgery: A Preliminary Report.

Transoral endoscopic approach is the natural orifice surgery applied in thyroidectomy to achieve an excellent cosmetic result. Recurrent laryngeal nerve (RLN) injury is the most common complication and little advancement was achieved in the previous clinical studies of transoral thyroid surgery. Herein, we introduced the method of intraoperative neuromonitoring (IONM) for transoral endoscopic thyroid surgery. Patients with thyroid carcinoma received transoral endoscopic thyroid surgery through vestibular approach (TOETVA) for thyroidectomy and central node dissection (CND). IONM was implemented to identify whether the RLN benefited from oral tracheal intubation. The laryngeal electromyography (EMG) response, operation time, number of CND, drainage volume, hospital duration, surgical complications, and cosmetic results were evaluated. From August to October 2015, 10 cases were performed with TOETVA and IONM. All EMG responses were recorded intraoperatively, and no case experienced transient or permanent RLN palsy. The operation time ranged from 130 to 215 minutes in ipsilateral lobectomy with CND, whereas bilateral lobectomy with ipsilateral CND lasted 345 minutes. The number of CNDs ranged from three to eight. The average time of drainage extubation and discharge was 4 days (3-5 days) postoperatively. All patients were satisfied with the cosmetic results, and no infection was observed at lip wound or in the anterior neck region. IONM system implemented in transoral thyroid surgery was feasible and serviceable in preventing RLN injury. The method of TOETVA shows promise for thyroidectomy with CND due its ideal cosmetic results.

Comparative characteristics of primary hyperparathyroidism in pediatric and young adult patients

Primary hyperparathyroidism is rare in pediatric patients. Our study aim was to compare primary hyperparathyroidism in pediatric (<19years) and young adult (19-29years) patients. A prospectively collected database from a single, high-volume institution was queried for all patients age <30years who had initial parathyroidectomy for primary hyperparathyroidism yielding 126/4,546 (2.7%) primary hyperparathyroidism patients representing 39 pediatric and 87 young adult patients. Presenting symptoms, operative data, and postoperative course were compared for patients age 0-19years and 20-29years. Sporadic primary hyperparathyroidism was present in 81.7% and occurred less often in pediatric patients than young adult patients (74.4% vs 86.2%, P=.12). Among patients with hereditary primary hyperparathyroidism, multiple endocrine neoplasia type 1 was the most common type. Multiglandular disease was common in both pediatric (30.7%) and young adult (21.8%) patients. Following parathyroidectomy, 3 (2.3%) patients had permanent hypoparathyroidism and none had permanent recurrent laryngeal nerve paralysis. Biochemical cure at 6months was equally likely in pediatric and young adult patients (97.1% vs 93.6%, P=.44) with comparable follow-up (78.4months vs 69.1months, P=.66) and rates of recurrent disease (5.9% vs 10.3%, P=.46). Recurrence was due to multiple endocrine neoplasia 1-related primary hyperparathyroidism in all cases. Although primary hyperparathyroidism is sporadic in most patients <19years, they are more likely to have multiple endocrine neoplasia type 1-associated primary hyperparathyroidism (23%). Parathyroidectomy for primary hyperparathyroidism can be performed safely in pediatric patients with a high rate of cure. Follow-up for patients with hereditary disease is necessary.

Intraoperative Neuromonitoring in Thyroid Surgery: A Systematic Review.

This study aimed to assess the efficacy of intraoperative neurophysiologic monitoring (IONM) in preventing recurrent laryngeal nerve palsy (RLNP) during thyroid surgery. When IONM results in false positives, it seeks to evaluate contributing factors. A systematic review was conducted gauging the predictive power of neuromonitoring in determining RLN function intraoperatively, its reductions of temporary and permanent RLNP rates, and surgeons' response to the technology. MEDLINE, EMBASE, and PubMed were searched for RLN monitoring in thyroid surgery following a set of inclusion/exclusion criteria. Seventeen studies comparing thyroid surgery with and without IONM were reviewed, including 30,926 patients. Selected studies were pooled to gage the predictive power. Mean specificity of IONM in identifying functional nerves was 90.24% among 7366 nerves at risk (NAR). However, mean positive predictive power (PPP) was low, and both specificity and PPP varied substantially when stratified by risk levels. Among the pooled studies focusing on IONM efficacy-there were 44,575 NAR, of which (57.98%) were operated on with IONM and 18,732 (42.02%) without (control). The rates of overall RLNP per NAR were 3.18 and 3.83% for the IONM group and control, respectively. There is no statistically significant difference between IONM and control, a conclusion supported by qualitative analysis from many individual studies. IONM is not recommended as the standard of care for thyroidectomies. Low PPP of IONM and complications associated with IONM-assisted thyroidectomies may be attributed to either the absence of a standardized negative-signal cutoff value or injury from intubation.

Intermittent Intraoperative Neural Monitoring Technology in Minimally Invasive Video-Assisted Thyroidectomy: A Preliminary Study

ABSTRACTPurpose: Intraoperative neural monitoring (IONM) technology was applied in minimally invasive video-assisted thyroidectomy (MIVAT) to explore its safety and effectiveness. Materials and Methods: Data were collected retrospectively from October 2009 to August 2011. Inclusion criteria included the following: (1) benign thyroid nodule with maximum diameter less than 4.0 cm by preoperative ultrasound evaluation; (2) no previous thyroid surgeries; (3) no cervical radiation history; (4) normal function of recurrent laryngeal nerve (RLN) examined by preoperative laryngoscopy; (5) patients who did not accept to take a “wait and see” follow-up strategy. Enrolled patients were randomly allocated into NIM group and control group. Results: 46 patients were enrolled in NIM group, and 51 patients were enrolled in control group. All surgeries in NIM group were performed successfully, and majority of tracheal intubations were placed with one attempt. 47 RLNs in NIM group and 60 RLNs in control group were exposed. The time of RLN locating was 6.06 ± 1.48 min in NIM group and 6.92 ± 1.34 min in control group (p = .02). The time of RLN tracing and exposing was 28.96 ± 4.75 min in NIM group and 32.17 ± 5.56 min in control group (p = .02). 1 case of temporary RLN paralysis was observed in both groups, and no permanent RLN paralysis was reported. Conclusions: The application of intermittent IONM in MIVAT is feasible. Intermittent IONM can help reduce the time of RLN locating and the time of RLN tracing and exposing.

Intermittent intraoperative nerve monitoring in thyroid reoperations: Preliminary results of a randomized, single-surgeon study.

The purpose of this study was to evaluate whether intermittent intraoperative nerve monitoring (IONM) could reduce the incidence of recurrent laryngeal nerve (RLN) paralysis in thyroid reoperations. Enrolled patients were randomly assigned into the nerve integrity monitor (NIM) group and the control group. The incidence of temporary RLN paralysis and permanent RLN paralysis was 12.2% and 4.9% in the NIM group compared with 7.0% and 2.3% in the control group (p = .658 and p = .966, respectively). The incidence of surgeon-related paralysis, tumor-related paralysis, and scar-related paralysis was 4.9%, 7.3%, and 4.9% in the NIM group compared with 4.7%, 2.3%, and 2.3% in the control group, respectively (p = 1, p = .575, and p = .966, respectively). Intermittent IONM could not provide additional benefits to reduce the incidence of temporary RLN paralysis and permanent RLN paralysis in thyroid reoperations. It could not reduce the incidence of paralysis caused by unintentional injuries. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1993-E1997, 2016.