Preoperative Vocal Cord Paralysis Research Articles

Surgical management and outcomes of T4a papillary thyroid carcinoma: a single-centre study of 602 cases.

This study aimed to investigate the clinical characteristics and risk factors associated with the disease progression of T4a papillary thyroid carcinoma (PTC). In all, 602 patients (230 males; 372 females), aged 8-82 years, with T4a PTC who were admitted for initial surgery between April 2010 and September 2022 were retrospectively analysed. Tracheal invasion was observed in 271 (45.0%), oesophageal invasion in 190 (31.6%), recurrent laryngeal nerve (RLN) invasion in 516 (85.7%), and larynx invasion in 22 (3.7%) patients. The 5-year progression-free survival was 89.8%, and disease-specific survival was 96.0%, with a postoperative disease progression rate of 9.6% (54 patients) and mortality rate of 5.17% (29 patients). Disease recurrence was most likely to occur at the initial surgical site. Age ≥55 years, preoperative vocal cord paralysis, microvascular invasion, trachea invasion, and metastases to >5 cervical lymph nodes were independent risk factors for disease progression in patients with M0 stage. Male sex, preoperative vocal cord paralysis, microvascular invasion, specific pathological type, and laryngeal invasion were associated with an increased risk of disease progression for all T4a patients, while lobectomy, total thyroidectomy, tumour shaving on the RLN surface, total RLN resection, and absence of radioactive iodine therapy were not. Surgery was the primary treatment for patients with stage T4a PTC and most patients had a satisfactory prognosis. Surgeons should comprehensively evaluate each patient before deciding the surgical approach.

Outcomes of Immediate Total Thyroidectomy in First-Side Loss of Neuromonitoring Signal

Use of intraoperative neuromonitoring (IONM) during thyroidectomy can nearly eliminate the risk of postoperative bilateral vocal cord palsy (VCP) by indicating staged surgery in cases of loss of signal (LOS) on the first side of planned total thyroidectomy. However, aborting planned total thyroidectomy may lead to persistence of symptoms, delay in adjuvant treatment, and patient inconvenience and distress. There are few data to guide a selective approach to total thyroidectomy in patients with first-side LOS. To investigate outcomes of immediate bilateral surgery in patients undergoing total thyroidectomy with first-side LOS. This cohort study was a retrospective review of outcomes for patients undergoing thyroidectomy between January 2016 and July 2023 at an academic tertiary referral center for thyroid surgery. Consecutive patients scheduled for total thyroidectomy using IONM were included. Exclusion criteria were preoperative VCP, deliberate sacrifice of recurrent laryngeal nerve (RLN), inadvertent RLN resection, and surgery performed without IONM. Total thyroidectomy performed using IONM. Vocal mobility on first postoperative day as assessed by flexible laryngoscopy; secondary outcome measures included subjective voice assessment, other postoperative complications, and long-term vocal mobility. Among 400 patients undergoing planned total thyroidectomy (mean age, 50.5 years [range, 4-88 years]; 318 female [79.5%]), 51 (12.8%) had first-side LOS, of whom 37 (9.3%) had persistent LOS. Twenty-nine patients (56% of procedures with first-side LOS, including 18 with persistent LOS) proceeded to immediate total thyroidectomy. Postoperatively, 16 patients (55% of patients undergoing total thyroidectomy following first-side LOS, including 14 of 18 with persistent LOS) had impaired vocal mobility. One patient had bilateral VCP that did not require tracheostomy, and 2 had postoperative hypoparathyroidism. Of those whose surgery was aborted after first-side LOS, 8 of 22 (36%) underwent completion thyroidectomy at a later stage. In those undergoing completion thyroidectomy, 2 of 8 (25%) had temporary VCP after the second surgery, 2 (25%) had permanent hypoparathyroidism, and 1 (12.5%) developed inoperable cancer. Postoperative VCP was fully reversible in all but 1 patient. Among patients planned for total thyroidectomy who develop first-side LOS, immediate total thyroidectomy may be considered among those who have pressing reasons for same, and where surgical difficulties might be anticipated in a secondary surgery.

Surgical and Biochemical Outcomes in Nerve Monitored Reoperation Surgery for Recurrent Papillary Thyroid Carcinoma.

To study the surgical and biochemical outcomes in nerve-monitored reoperation or revision surgery for recurrent thyroid cancers. A single-center retrospective study. Tertiary center. We identified patients with recurrent papillary thyroid carcinoma (PTC) who underwent reoperation/revision surgery. Study outcomes were surgical complications frequency, recurrence, distant metastasis, and biological complete response (BCR) by comparing preoperative and postoperative thyroglobulin (Tg) levels. Out of 227 patients, 33.9% presented for ≥2 reoperation surgeries. Nineteen (8.4%) had permanent preoperative hypoparathyroidism while 22 patients (9.7%) had preoperative vocal cord paralysis (VCP). Following reoperation surgery, there were 12 cases (5.3%) of permanent hypocalcemia and no cases of unexpected postoperative VCP. BCR was achieved in 31 patients (35.2%) with complete Tg data. Mean preoperative Tg was 47.7 ng/mL and was 19.7 ng/mL postoperatively (p = .003). The cervical nodal recurrence rate after final surgery was 7.0% (n = 16). Reoperation surgery for recurrent PTC may help achieve biochemical remission regardless of age or the number of prior surgeries.

Artificial Nerve Conduit for Recurrent Laryngeal Nerve Reconstruction in Thyroid Surgery.

Oncological reconstruction of the recurrent laryngeal nerve (RLN) is sometimes necessary for RLN invaded by thyroid cancer. There have been no case reports of RLN reconstruction using artificial nerve conduits, which are often used for peripheral nerves. In this study, we retrospectively evaluate the feasibility, safety, and efficacy of a collagen conduit with collagen filaments for RLN reconstruction cases at our hospital. Artificial nerve conduits were used in seven cases of RLN reconstruction. Two patients had preoperative unilateral vocal cord paralysis with severe vocal cord atrophy, and two had vocal cord paresis without atrophy. The remaining three patients had functional vocal cords before surgery that had to be resected via surgery due to thyroid cancer infiltration of the RLN. Reconstruction was performed using RENERVE®, which is a collagen conduit. Voice examination and laryngeal endoscopy were performed 1, 3, and 12 months after surgery. There was no improvement in the phonetics of the two patients with vocal cord atrophy before surgery. In the remaining five cases, three with functional vocal cords improved to preoperative values, and two with vocal cord paresis improved to greater than preoperative values. We report the first case series using an artificial nerve conduit for human RLN reconstruction. In cases of RLN resection when the patient has good voice quality pre-operatively, reconstruction of the RLN using an artificial nerve may be a favorable option in cases where direct anastomosis or ansa cervicalis to RLN anastomosis cannot be performed. 4 Laryngoscope, 133:1773-1779, 2023.

Predictive factors and risk analysis of recurrent laryngeal nerve invasion in papillary thyroid carcinoma ≤ 1 cm.

The recurrent laryngeal nerve (RLN) may be involved by papillary thyroid carcinoma ≤ 1 centimeter (PTC ≤ 1 cm). Current study investigated the predictive factors of RLN invasion in PTC ≤ 1 cm, the risk factors of disease recurrence in RLN invaded cases and the results of surgical management for RLN invasion. Data of 374 PTC ≤ 1 cm patients were retrospectively collected. We performed univariate and multivariate analysis to identify predictive factors of RLN invasion and risk factors of disease recurrence. The abilities of factors in predicting RLN invasion were evaluated. Surgical outcomes and recurrence free survival (RFS) of patients were analyzed. A total of 28 patients suffered RLN invasion, among which seven had disease recurrence. Preoperative vocal cord palsy (VCP), gross extrathyroidal extension, larger tumor size and tumor on the dorsal side of thyroid were verified as predictive factors of RLN invasion. RLN involved patients had poorer RFS, but better than those who also had upper-aerodigestive tract invasion. Upper-aerodigestive tract invasion, lateral neck lymph nodes metastasis (LNM) and BRAF V600E mutation were independent risk factors of disease recurrence in RLN invaded cases. Tumor shaving showed better RLN function preservation without increasing recurrent risk. Current study confirmed the rarity of RLN invasion in PTC ≤ 1 cm. Various aggressive features were verified as predictive factors of RLN invasion. Tumor shaving showed superiority in preserving nerve function without increasing recurrent risk. Special attentions should be paid for disease recurrence when RLN invasion accompanied by upper-aerodigestive tract invasion, lateral neck LNM or BRAF V600E mutation.

Clinical characteristics and prognosis in papillary thyroid carcinoma patients with recurrent laryngeal nerve invasion

Objective: To investigate the clinical characteristics and risk factors of postoperative recurrence in papillary thyroid carcinoma (PTC) patients with recurrent laryngeal nerve (RLN) invasion. Methods: The data of PTC patients with recurrent laryngeal nerve invasion treated in Beijing Tongren Hospital, Capital Medical University from January 2006 to December 2019 were retrospectively analyzed. The acoustic parameters were compared between different subgroups. Kaplan-Meier method was used to calculate the overall survival (OS) and the recurrence-free rate (RFS), and univariate and multivariate Cox regression analyses were performed to determine the risk factors for postoperative recurrence. Results: A total of 150 PTC patients were enrolled in the final analysis, including 102 females and 48 males, with an average age of (53.5±13.7) years, and 62 patients (41.3%) aged over 55 years. There were 88 cases with stage Ⅰ, and 62 cases with stage Ⅲ. Fifty-five patients presented with preoperative vocal cord paralysis. There were 75 cases appearing adhesion between tumor or lymph node and recurrent laryngeal nerve while 75 cases presented with direct invasion. The comparisons of acoustic parameters showed that patients with RLN invasion had higher jitter compared with patients without RLN invasion [2.3% (1.4%, 3.2%) vs 1.8% (0.8%, 2.6%), P<0.001]. Moreover, patients with preoperative vocal cord paralysis (VCP) had higher jitter[3.1% (2.2%, 4.6%) vs 2.0% (1.1%, 2.8%), P<0.001] and shimmer [7.1% (4.9%, 9.9%) vs 5.5% (4.2%, 7.3%), P<0.001] and shorter maximum phonation time (MPT) [8.0 (6.0, 10.0) s vs 12.0 (10.0, 15.3) s, P<0.001] compared with patients without preoperative VCP. However, there was no statistical difference in acoustic parameters between cases with RLN adhesion and RLN invasion (all P>0.05). Postoperative follow-up time ranged between 12-196 months, with an average of (65.0±35.9) months. Sixteen patients (10.7%) had recurrence or metastasis, and 8 cases (5.3%) died of recurrence or metastasis. The 5-year OS rate was 95.1%, and the 10-year OS rate was 92.8%. The 5-year RFS rate was 88.9%, and the 10-year RFS rate was 86.2%. Univariate Cox analysis showed that age of onset ≥ 55 years, preoperative recurrent laryngeal nerve palsy, laryngeal, trachea or esophageal invasion were the risk factors for postoperative recurrence of PTC with RLN invasion (all P<0.05). Multivariate Cox analysis showed that age of onset ≥ 55 years (OR=1.060, 95%CI: 1.011-1.110, P=0.015) was an independent risk factor. Conclusions: Age of onset ≥ 55 years is an independent risk factor for postoperative recurrence in PTC patients with RLN invasion. Preoperative acoustic parameters may provide reference for evaluation of RLN function.

Preoperative voice analysis and survival outcomes in papillary thyroid cancer with recurrent laryngeal nerve invasion.

To investigate the clinicopathological characteristics of papillary thyroid cancer (PTC) and identify risk factors for postoperative recurrence of PTC with recurrent laryngeal nerve (RLN) involvement. In total, 171 patients (112 women and 59 men, age: 18-80 years, and 65 patients aged ≥ 55) with T4a PTC with RLN involvement, treated at Beijing Tongren Hospital, Capital Medical University, from January 2006 to December 2020, were retrospectively examined. Clinicopathological characteristics, including voice analysis results, and survival outcomes were assessed. The Mann-Whitney U and Kruskal-Wallis H tests were used to analyze differences in acoustic parameters. The Kaplan-Meier method was used to calculate the overall survival (OS) and recurrence-free (RFS) rates. Univariate and multivariate Cox regression analyses were performed of the clinical data. The postoperative follow-up period ranged from 12 to 196 months (mean: 66.18 months). Of the 171 patients, 16 had recurrence and 8 died of thyroid-related diseases. The 5-year OS rate was 95.22%. The 5-year RFS rate was 89.38%. Jitter and shimmer were higher and maximum phonation time was shorter in patients with preoperative vocal cord paralysis (VCP) than in those without RLN involvement, and in those with RLN involvement but without preoperative VCP. Acoustic parameters were similar in patients with no preoperative VCP and those without RLN involvement. Voice analysis results did not differ between cases with RLN adhesion and RLN invasion. Univariate analysis showed that age at onset ≥ 55 years, preoperative RLN palsy, and esophageal invasion were risk factors for postoperative recurrence of PTC with RLN involvement. Multivariate analysis showed that onset age ≥ 55 years (OR 4.52, 95% confidence interval: 1.44-14.19, P = 0.010) was an independent risk factor for recurrence. PTC patients with RLN invasion can achieve good outcomes. Preoperative voice analysis may offer insights into RLN function. Age of onset ≥ 55 years is an independent risk factor for postoperative recurrence in T4a PTC patients.

A large-scale study of patients with preoperative vocal cord paralysis associated with thyroid disease and related clinicopathological features.

The performance of thyroidectomies has been increasing over the last decade due to the growing prevalence of thyroid diseases. The purpose of this study was to investigate the clinical significance of preoperative vocal cord paralysis (VCP) associated with thyroid disease and other incidences of malignant or benign lesions, as well as different thyroid pathological features. Additionally, the epidemiological changes of thyroid diseases with preoperative VCP were investigated. Ninety-nine out of 12,530 patients with preoperative VCP who had undergone thyroid surgery for various diseases in the Zhejiang Cancer Hospital from January 2007 to December 2015 were identified. Their clinicopathological data was recorded and case distributions from different years and intraoperative recurrent laryngeal nerve statuses were retrospectively analyzed. The incidence of preoperative VCP in 2007 was reported to be 1.53% (9/590) and had decreased to 0.53% (12/2,247) by 2015 (P < 0.05). Among the 99 patients with preoperative VCP, 81 had malignancies (81.82%), while 18 (18.18%) had benign thyroid diseases. The incidences of preoperative VCP in malignant and benign diseases were 1.13% (81/7,159) and 0.35% (18/5,371), respectively (P < 0.05). There were only 5 (0.04%, 5/12,530) cases of papillary thyroid microcarcinoma with preoperative VCP. There was no statistical difference between the incidence of preoperative hoarseness in malignant 69.14% (56/81) and benign diseases 61.11% (11/18) with preoperative VCP. The preoperative VCP incidence rate had gradually decreased with an increased proportion of papillary thyroid cancer. Preoperative voice symptoms do not necessarily suggest a malignancy. Selective rather than routine preoperative laryngoscopic examinations should be performed on papillary thyroid microcarcinomas. The probability of preoperative VCP in malignancy was significantly higher than in benign lesions.

Recurrent Laryngeal Nerve Invasion by Thyroid Cancer: Laryngeal Function and Survival Outcomes.

Recurrent laryngeal nerve (RLN) invasion by thyroid carcinoma represents an advanced disease status with potentially significant co-morbidity. In a retrospective single-center study, we included patients with invaded RLNs operated on while using nerve monitoring techniques. We studied pre-, intra-, and postoperative parameters associated with postoperative vocal cord paralysis (VCP); 5-year recurrence-free survival (RFS); and 5-year overall survival (OS) in addition to two subgroup analyses of postoperative VCP in patients without preoperative VCP and based on source of RLN invasion. Of 65 patients with 66 nerves-at-risk, 39.3% reported preoperative voice complaints. Preoperative VCP was documented in 43.5%. The RLN was invaded by primary tumor in 59.3% and nodal metastasis in 30.5%. Papillary thyroid carcinoma was the most common pathologic subtype (80%). After 6 months, 81.8% had VCP. Complete tumor resection of the RLN was not associated with 5-year RFS (p=0.24) or 5-year OS (p=0.9). Resecting the RLN did not offer statistically significant benefit on 5-year RFS (p=0.5) or 5-year OS (p=0.38). Radioactive Iodine (RAI) administration was associated with improvement in 5-year RFS (p=0.006) and 5-year OS (p=0.004). Patients without preoperative VCP had higher IONM amplitude compared with patients with VCP. After a mean follow-up of 65.8 months, 35.9% of patients had distant metastases, whereas 36.4% had recurrence. Preoperative VCP accompanies less than half of patients with RLN invasion. Invaded RLNs may have existent electrophysiologic stimulability. Complete tumor resection and RLN resection were not associated with better 5-year RFS or OS, but postoperative RAI was. 4 Laryngoscope, 132:2285-2292, 2022.

Total thyroidectomy for 147 cases of thyroid cancer with preoperative vocal cord paralysis

Total thyroidectomy for 147 cases of thyroid cancer with preoperative vocal cord paralysis

Efficacy and safety of preoperative preparation with Lugol's iodine solution in euthyroid patients with Graves’ disease (LIGRADIS Trial): Study protocol for a multicenter randomized trial

BackgroundCurrently, both the American Thyroid Association and the European Thyroid Association recommend preoperative preparation with Lugol's Solution (LS) for patients undergoing thyroidectomy for Graves’ Disease (GD), but their recommendations are based on low-quality evidence. The LIGRADIS trial aims to provide evidence either to support or refute the systematic use of LS in euthyroid patients undergoing thyroidectomy for GD. MethodsA multicenter randomized controlled trial will be performed. Patients ≥18 years of age, diagnosed with GD, treated with antithyroid drugs, euthyroid and proposed for total thyroidectomy will be eligible for inclusion. Exclusion criteria will be prior thyroid or parathyroid surgery, hyperparathyroidism that requires associated parathyroidectomy, thyroid cancer that requires adding a lymph node dissection, iodine allergy, consumption of lithium or amiodarone, medically unfit patients (ASA-IV), breastfeeding women, preoperative vocal cord palsy and planned endoscopic, video-assisted or remote access surgery.Between January 2020 and January 2022, 270 patients will be randomized for either receiving or not preoperative preparation with LS. Researchers will be blinded to treatment assignment. The primary outcome will be the rate of postoperative complications: hypoparathyroidism, recurrent laryngeal nerve injury, hematoma, surgical site infection or death. Secondary outcomes will be intraoperative events (Thyroidectomy Difficulty Scale score, blood loss, recurrent laryngeal nerve neuromonitoring signal loss), operative time, postoperative length of stay, hospital readmissions, permanent complications and adverse events associated to LS. ConclusionsThere is no conclusive evidence supporting the benefits of preoperative treatment with LS in this setting. This trial aims to provide new insights into future Clinical Practice Guidelines recommendations. Trial registrationClinicalTrials.gov identifier: NCT03980132.

Clinical outcomes of T4a papillary thyroid cancer with recurrent laryngeal nerve involvement: a retrospective analysis

Preoperative vocal cord palsy (VCP) may indicate locally invasive papillary thyroid cancer (PTC); using this relationship, we evaluated the clinical outcomes and risk factors for recurrence in post-thyroidectomy T4a PTC patients with recurrent laryngeal nerve (RLN) involvement. We retrospectively investigated thyroidectomy patients, recorded their clinical factors, recurrence rate, and pathological findings, and analysed the relationship between recurrence rate and clinical factors. Of 72 patients, 37 (51%) had preoperative VCP and 35 (49%) had normal preoperative vocal cord movement with confirmed intraoperative RLN invasion. Tracheal and esophageal invasion was observed in 13 (18%) and 15 (21%) patients, respectively. Thyroid cancer recurred in 18 (25%) patients over 58 months, resulting in 2 (3%) deaths. Recurrence was not associated with surgical extent, organ invasion, enlarged tumour size, or lymph node infiltration (p > 0.05). The recurrence rate was significantly higher in patients with positive resection margins (p < 0.05). T4a PTC patients with RLN involvement showed a poor prognosis. The recurrence rate was not affected by preoperative VCP, intraoperative detection of RLN invasion, nerve resection, nerve preservation by shaving, lymph node metastasis, or tracheal or esophageal invasion. The most important prognostic factor for recurrence was a positive resection margin.

Development and validation of the nomogram for predicting preoperative vocal cord palsy in thyroid cancer patients.

Low incidence of preoperative vocal cord palsy (VCP) promotes a diagnosis model to eliminate patients without the necessity of preoperative laryngoscopy assessments, avoiding medical costs and discomfort. However, previous studies lacked a comprehensive strategy and external validation data to effectively detect VCP in thyroid cancer patients. This study aimed to develop a VCP scoring system that could calculate cumulative VCP risks and determine preoperative laryngeal examinations based on the clinical characteristics of VCP patients from the Union Hospital, Tongji Medical College of Huazhong University of Science and Technology. A retrospective study recruited 5,354 thyroid cancer patients was performed. Preoperative VCP incidence was recorded, and a prediction table was constructed using independent, significant risk factors for preoperative VCP. The visualized nomogram, including five parameters, was proportionally assigned 0 to 100 points. Finally, the diagnostic performance was confirmed by verifying the nomogram in the internal and external cohort. The incidence of preoperative VCP by preoperative laryngoscopy assessment was 1.57%. Age at diagnosis (OR: 1.04; P=0.006), history of neck surgery (OR: 11.57; P<0.001), voice symptoms (OR: 32.75; P<0.001), large nodule diameter (OR: 1.04; P<0.001) and suspicious neck lymph nodes (OR: 3.25; P<0.001) were identified as independent risk factors. The nomogram was proven to be acceptable discrimination in internal and external sets, and the cut-off value was 94.7. We identified clinical risk factors related to preoperative VCP and established a nomogram for VCP clinical discrimination with an excellent performance in the external cohort.

Relation of Superior Laryngeal Nerve and Superior Thyroid Artery with Superior Pole of Thyroid During Thyroid Surgery.

The purpose of this study was to evaluate relation between superior thyroid vessels, external branch of superior laryngeal nerve and superior pole of thyroid based on Cernea classification in Jammu population. The present study was conducted on 50 patients in Department of ENT & Head and Neck Surgery, SMGS Hospital, Government Medical College Jammu during a time period of January 2018 to March 2020. Patients undergoing selective thyroid surgeries for various pathologies were included in the study. Patients with preoperative vocal cord palsy and patients with malignant thyroid neoplasms were excluded from the study. All patients were operated under general anaesthesia, with supine neck extended position. The bifurcation and the branches of STA were meticulously dissected preserving all the branches and any anastomoses if present. Once visualization of the nerve was attained, various measurements were taken to assess Cernea classification type. Depending on extent of lesion appropriate surgical procedure was done so as remove all the diseased tissue. Out of total 62 lobes, Cernea's Type 1 pattern was seen in 33 (53.2%) of patients, Cernea's Type 2a was seen in 11 patients (17.7%) and Cernea's Type 2b was seen in 14 patients (22.5%). No specific pattern was seen in 4 (6.4%) of patients. Cernea classification system is a simple and reliable guide to identify and preserve the nerve.

Is Vocal Cord Assessment before Total Thyroidectomy Required for All Patients?

We investigated whether laryngoscopy should be performed before total thyroidectomy on all patients without a history of neck surgery. A total of 2523 patients who underwent total thyroidectomy between January 1, 2013, and March 18, 2018, were retrospectively examined. Preoperative vocal cord examination was performed on 2070 of these patients by the otorhinolaryngology department using indirect laryngoscopy. Patients with a history of neck or thyroid surgery were not included in the study. The patients were evaluated in terms of age, gender, symptom (hoarseness/dyspnea), comorbidity, surgical history, biopsy, nodule diameter, pathological diagnosis, and tracheal deviation. Preoperative vocal cord paralysis was detected in 0.8 per cent of the patients (17/2070). Four patients (23.5%) were male and 13 patients (76.5%) were female. The mean age was 62 (range, 25-82) years. Seven of the 17 patients (41%) were symptomatic, with complaints of dyspnea in five and hoarseness in two. The univariate analysis revealed that a nodule diameter >30 mm and the presence of dyspnea were associated with vocal cord damage. Furthermore, the multivariate analysis showed that dyspnea alone was an independent variable (P = 0.011). It is recommended that preoperative vocal cord evaluation should be performed only in patients with severe symptoms, such as dyspnea.

Routine Preoperative Laryngoscopy for Thyroid Surgery Is Not Necessary Without Risk Factors.

Background: Routine preoperative vocal cord (VC) assessment with laryngoscopy in patients undergoing thyroidectomy allows clear documentation of baseline VC function, aids in surgical planning in patients with palsies, and facilitates interpretation of intraoperative neuromonitoring (IONM) findings. We aimed to determine the incidence of preoperative vocal cord palsy (VCP); to evaluate the associated risk factors for preoperative VCP; and to calculate the cost-savings potential of implementing a selective approach. Methods: Patients with a pre-thyroidectomy VC assessment by fiberoptic laryngoscopy were retrospectively recruited from the Monash University Endocrine Surgery Unit database from 2000 to 2018. Cases with preoperative VCP were reviewed for potential contributing factors and compared with a non-palsy cohort. Results: Of the 5987 patients who had preoperative laryngoscopy, VCP was documented in 41 (0.68%) patients. Four clinical parameters were found to be potential indicators of VCP, including: age (p < 0.001), nodule ≥3.5 cm recorded on ultrasound imaging (p = 0.01), presence of voice symptoms (p < 0.001), and previous neck surgery (p < 0.001). Malignant cytology (p = 0.5) and exposure to head and neck irradiation were not different between the groups. Utilizing these risk factors, 2354 (39%) patients had at least one feature that may raise suspicion for preoperative VCP. By performing preoperative laryngoscopy only on this subset of patients, the potential cost savings exceeds 400 Australian Dollars per patient. Conclusions: Using this large dataset, we have established that a VCP is rare in the absence of a large nodule, hoarseness, or previous neck surgery. Therefore, in the era of IONM, we support a selective approach to preoperative laryngoscopy by using the aforementioned criteria.

Increased prevalence of neural monitoring during thyroidectomy: Global surgical survey.

To investigate intraoperative nerve monitoring (IONM) use among thyroid surgeons. A 25-question survey was used to assess attitudes regarding IONM use. Surveys were sent to surgeons registered to the American Academy of Otolaryngology-Head and Neck Surgery, International Association of Endocrine Surgeons, and American Head and Neck Society. Among 1,015 respondents, 83% reported using IONM (65.1% always using IONM and 18.1% reporting selective use). For selective users, a majority reported using IONM for reoperative cases (95.1%) and in cases with preoperative vocal cord paralysis (59.8%). When comparing location, there was a significant difference in IONM implementation (P < 0.001), with 70.4% of North American responders using it ubiquitously compared to 27.4% of non-North American responders. Preoperative laryngeal exam was performed more universally by North American surgeons and more selectively by non-North American surgeons (P < 0.001). Other attitudes toward their implementation and the postoperative laryngeal exam were similar. Surgeons ≤45 years of age and those with ≤15 years of practice used IONM more than their peers (P < 0.001). Thyroid surgery volume, fellowship training, and type of practice had no bearing on IONM use. The prevalence of IONM in thyroid and parathyroid surgeries has increased significantly over the past decade, with 83% of surgeons using IONM in some or all cases. Although IONM use may be more ubiquitous in North America, attitudes toward its implementation and pre- and postoperative laryngeal exams are fairly uniform. IONM use is more prevalent among younger surgeons, whereas its use has no correlation with thyroid surgery volume or type of practice. 4 Laryngoscope, 130:1097-1104, 2020.

The utility of surgeon performed transcutaneous laryngeal ultrasound for the assessment of vocal cords in post-thyroidectomy patients

Background: Post-thyroidectomy vocal cord palsy is a significant procedure associated complication and a notable contributor for medico-legal litigation. The standard technique for vocal cord evaluation and the most commonly used tool is direct laryngoscopy. Endocrine surgeons generally address the patients to otolaryngologist for laryngoscopy, leading to extra expense and time loss. Laryngoscopy causes patient annoyance and could potentially contribute to poor patient compliance. Ultrasonography is a non-invasive technique that is regularly used by endocrine surgeons to examine the thyroid region.Methods: A prospective study conducted on patients who underwent thyroidectomy between September 2016 and August 2017 at endocrine surgery department in a tertiary care institute (South India), Surgeon performed ultrasound (SPU) and Video laryngoscopy (VDL) was performed before and after elective thyroidectomy.Results: 155 patients who consented were categorized in the study, 2 of the patients included in the study had preoperative vocal cord palsy and 12 of them had unilateral postoperative vocal cord palsy detected using VDL. In general, the postoperative vocal cord palsy rate was 6.45%. Postoperative SPU was ineffective in assessing vocal cords in 16(10.32%) of patients. SPU had a sensitivity of 83.33% and negative predictive value of 97.90%, for the visualization of vocal cords in the postoperative period.Conclusions: SPU is convenient and non-invasive technique which could provide our speciality with cheap yet powerful diagnostic tool for vocal cord assessment in post-thyroidectomy patients and can potentially decrease the requirement of difficult and cumbersome VDL.

PS01.138: EXPERIENCE FROM 102 PATIENTS WITH CONTINUOUS INTRAOPERATIVE VAGUS NERVE STIMULATION DURING MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background The incidence of recurrent laryngeal nerve (RLN) injury after esophagectomy can be as high as 60–70% especially when lymphadenectomy is performed along bilateral RLN. Vocal cord paralysis is associated with increased pulmonary complication rate, longer hospital stay, and impaired quality-of-life. The authors have modified the Continuous Intraoperative Nerve Monitoring (CIONM) method for minimally invasive esophagectomy. This study reviews our experience in the first 102 patients. Methods From May 2014 to January 2018, patients who underwent thoracoscopic esophagectomy were recruited. CIONM and intermittent nerve stimulation were routinely used during left RLN lymphadenectomy. For right RLN dissection, only intermittent nerve stimulation was used because of much lower chance of nerve injury. Routine direct laryngoscopy was performed on postoperative day one to assess the vocal cord status. Patients with RLN palsy are referred to otorhinolaryngologist for assessment and treatment. Surgical outcome, especially RLN palsy and recovery rates were documented. Results 102 patients were recruited and 73 patients had more than one year follow up. Twenty-two patients had RLN palsy (21.6%); right side in 3, left side in 18, and bilateral in one. Thirty-eight patients (37%) had only unilateral or no RLN dissection performed. This was because of R2 resection negating the benefits of RLN dissection (15.6%), poor pulmonary exposure (9.8%), other technical difficulties (7.8%), preoperative vocal cord palsy (2%), intraoperative complications (1%) and uncertain contralateral nerve integrity (1%). For those 90 patients with successful CIONM, 20 RLN palsy (22.2%), 10 of whom underwent injection thyroplasty within 2–80 days. Thyroplasty was not performed in 12 patients as they had good compensation from the contralateral cord (58.3%), early recovery within 2 weeks (16.7%) tracheostomized status (16.7%) or refusal (8.3%). Thirteen patients (59%) recovered within 2–72 weeks (Median 6 weeks). For the 73 patients with more than 1 year follow up, only 4 has residual vocal cord paralysis, making a genuine cord palsy rate of 5.5%. Conclusion Lymphadenectomy along bilateral RLN is technically demanding. CIONM is a sensitive tool to guide surgeons for safer dissection. Proper patient selection, postoperative assessment and treatment protocol can reduce the morbidity of RLN injury. Majority of the vocal cord paralysis is temporary Disclosure All authors have declared no conflicts of interest.

A Review of Methods for the Preservation of Laryngeal Nerves During Thyroidectomy.

The recurrent laryngeal nerve (RLN) provides motor innervation to the abductor and adductor muscles of the vocal cord, whereas the external branch of the superior laryngeal nerve (EBSLN) provides motor innervation to the cricothyroid muscle, which is the tensor muscle of the vocal cord. Both the RLN and the EBSLN are anatomically close to the thyroid and are therefore at risk of injury during thyroidectomy. These 2 laryngeal nerves must be carefully preserved during surgery to ensure that the function of the vocal cord is not impaired. Currently, complete exposure of the RLN during thyroidectomy is accepted as the gold standard method for the preservation of RLN. Sufficient knowledge of surgical anatomy, clinical experience, and meticulous surgical techniques are key factors in the identification and safe dissection of the RLN. During a thyroidectomy, the RLN can be identified using four different approaches, depending on the type of thyroid growth and choice of the surgeon: There are lateral, inferior, superior, and medial approaches.The lateral approach is the most commonly used technique in primary thyroid surgery. The RLN is usually found by dissection around the inferior thyroid artery at the level of the middle lobe of the thyroid. RLN is generally found at the site of its entry into the neck region devoid of scar formation when the inferior approach is used especially in cases with secondary surgery. The superior approach is recommended for patients with an huge goiter or large substernal goiter. In this approach, the upper pole of the thyroid is first released and then pulled forward and laterally, and the RLN is exposed on the nerve’s entry point (NEP), into the larynx, under the cricopharyngeus muscle. The medial approach is preferred for patients with substernally or retropharyngeally enlarged goiters. In this approach, the isthmus is first dissected and divided, and then the isthmus and the medial part of the lobe are dissected away from the trachea to reveal the anterolateral part of the trachea. The fibers between the lateral aspect of the second or third tracheal rings and the thyroid, and the fibers of the Berry ligament are gradually dissected cranially, to allow RLN to enter into the field of view lateral to the trachea. The preservation of the anatomical integrity of the RLN does not indicate that its functional integrity is also preserved. IONM is a tool for the functional assessment of RLN, and so this method is an addition to visually identifying RLN, which is the gold standard. IONM significantly contributes to visual identification of the RLN, determination of its anatomical variations, intraoperative recognition of RLN injury, prevention of bilateral vocal cord paralysis, and detection and preservation of electrical activity in the nerve in patients with preoperative vocal cord paralysis.Although there is no standardized method for the preservation of the EBSLN, 3 methods have been defined during the release of the upper pole of the thyroid. These methods involve dividing the branches of the superior thyroidal artery one by one on the capsule without visually identifying the EBSLN, searching and visually identifying the EBSLN before the dissection of the upper pole vessels, or detecting the EBSLN and dissecting the upper pole under the guidance of IONM. IONM also significantly contributes to the detection and confirmation of the EBSLN and dissection and preservation of the upper pole of the thyroid gland.