Rate Of Recurrent Laryngeal Nerve Injury Research Articles

Systematic review with meta-analysis of intraoperative neuromonitoring during thyroid reoperation

Objective: Recurrent laryngeal nerve (RLN) injury is a serious complication during thyroid reoperation. Intraoperative neuromonitoring (IONM) is one of the means to reduce RLN paralysis. However, the role of IONM during thyroidectomy is still controversial. The aim of this study was to assess whether the IONM could reduce the incidence of RLN injury during thyroid reoperation. Methods: We performed a systematic review to identify studies in English language which were published between January 1, 2004, and March 25, 2023 from PubMed, EMBASE, and Cochrane Library, comparing the use of IONM and Visualization Alone (VA) during thyroid reoperation. The RLN injury rate was calculated in relation to the number of nerves at risk. All data were analyzed using Review Manger (version 5.3) software. The Cochran Q test (I2 test) was used to test for heterogeneity. Odds ratios were estimated by fixed effects model or random effects model, according to the heterogeneity level. Results: Eleven studies (3655 at-risk nerves) met criteria for inclusion. Data presented as odds ratio(OR) and their 95% confidence intervals(CI). Incidence of overall, temporary, and permanent RLN injury in IONM group were, respectively, 4.67%, 4.17%, and 2.39%, whereas for the VA group, they were 8.30%, 6.27%, and 2.88%. The summary OR of overall, temporary, and permanent RLN injury compared using IONM and VA were, respectively, 0.68 (95%CI 0.4-1.14, p=0.14), 0.82 (95%CI 0.39-1.72, p=0.60), and 0.62 (95%CI 0.4-0.96, p=0.03). Conclusions: The presented data showed benefits of reducing permanent RLN injury by using IONM, but without statistical significance for temporary RLN injury. doi: https://doi.org/10.12669/pjms.40.8.8241 How to cite this: Ji S, Hu M, Zhang C, Pei M. Systematic review with meta-analysis of intraoperative neuromonitoring during thyroid reoperation. Pak J Med Sci. 2024;40(8):---------. doi: https://doi.org/10.12669/pjms.40.8.8241 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Recurrent Laryngeal Nerve Injury After Thyroid Surgery at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia

<i>Background</i>: Recurrent laryngeal nerve (RLN) injury, a dreaded complication in thyroid surgery, remains a concern even in the hands of seasoned surgeons. It stands as a significant cause for medical malpractice claims against surgeons. <i>Objective</i>: To assess the Magnitude of RLN injury and associated factors in patients undergoing thyroid surgery at St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia, from May 1st, 2021, to April 30<sup>th</sup>, 2022. <i>Methods</i>: A facility-based, observational study was conducted at SPHMMC, Addis Ababa, Ethiopia. Data was collected using a structured questionnaire designed with Google Forms. A census sampling approach was used to select the data charts to ensure a comprehensive perspective. This method ensured a representative sample of the population under study, enhancing the reliability of the results. The information was transferred to Excel and then imported into SPSS. Descriptive statistics were employed to summarize the key characteristics within the dataset concisely. Stepwise multiple logistic regression was implemented to explore the potential relationships between the independent and dependent variables. A significance level of p < 0.05 was adopted to identify statistically meaningful results. The findings are presented through a combination of text, tables, and figures. <i>Results</i>: The study included a total of 185 patients, with a mean± SD age of 41.62 ± 12.72 and a median age of 40. Females constituted 78.9% of the participants. The study's key finding is a persistent RLN injury rate of 5.4% (10/185). After adjusting for other covariates, the odds of developing persistent RLN injury were found to be 30 times higher among patients who had central neck dissection than those who had not undergone central neck dissection (AOR=30.0, 95%CI=4.3,211.9, p-value=0.001). However, sex, substernal goiter, histologic finding, preoperative toxicity, extent of thyroidectomy, and identification of RLN intra-operatively were not associated with persistent RLN injury in bivariate logistic regression analysis. <i>Conclusion</i>: This study found a persistent, recurrent laryngeal nerve injury rate of 5.4% in patients undergoing thyroid surgery. Central neck dissection was the only factor significantly associated with an increased risk of recurrent laryngeal nerve injury. These findings suggest minimizing central neck dissection when feasible during thyroid surgery to reduce the risk of this complication.

Recurrent Laryngeal Nerve Injury After Thyroid Surgery at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia

<i>Background</i>: Recurrent laryngeal nerve (RLN) injury, a dreaded complication in thyroid surgery, remains a concern even in the hands of seasoned surgeons. It stands as a significant cause for medical malpractice claims against surgeons. <i>Objective</i>: To assess the Magnitude of RLN injury and associated factors in patients undergoing thyroid surgery at St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia, from May 1st, 2021, to April 30<sup>th</sup>, 2022. <i>Methods</i>: A facility-based, observational study was conducted at SPHMMC, Addis Ababa, Ethiopia. Data was collected using a structured questionnaire designed with Google Forms. A census sampling approach was used to select the data charts to ensure a comprehensive perspective. This method ensured a representative sample of the population under study, enhancing the reliability of the results. The information was transferred to Excel and then imported into SPSS. Descriptive statistics were employed to summarize the key characteristics within the dataset concisely. Stepwise multiple logistic regression was implemented to explore the potential relationships between the independent and dependent variables. A significance level of p < 0.05 was adopted to identify statistically meaningful results. The findings are presented through a combination of text, tables, and figures. <i>Results</i>: The study included a total of 185 patients, with a mean± SD age of 41.62 ± 12.72 and a median age of 40. Females constituted 78.9% of the participants. The study's key finding is a persistent RLN injury rate of 5.4% (10/185). After adjusting for other covariates, the odds of developing persistent RLN injury were found to be 30 times higher among patients who had central neck dissection than those who had not undergone central neck dissection (AOR=30.0, 95%CI=4.3,211.9, p-value=0.001). However, sex, substernal goiter, histologic finding, preoperative toxicity, extent of thyroidectomy, and identification of RLN intra-operatively were not associated with persistent RLN injury in bivariate logistic regression analysis. <i>Conclusion</i>: This study found a persistent, recurrent laryngeal nerve injury rate of 5.4% in patients undergoing thyroid surgery. Central neck dissection was the only factor significantly associated with an increased risk of recurrent laryngeal nerve injury. These findings suggest minimizing central neck dissection when feasible during thyroid surgery to reduce the risk of this complication.

The overtreatment of papillary thyroid microcarcinoma in the community

IntroductionTotal thyroidectomy is the traditional primary approach for papillary thyroid cancer. However, recent evidence supports conservative management for low-risk tumors like papillary thyroid microcarcinomas (PTMCs). This study explores the adoption of these practices in our community, using a cancer database to analyze treatment strategies. MethodsA retrospective review of a 1433-patient institutional database identified 258 ​PTMC cases. Outcomes, including 30-day mortality, reoperation rate, postoperative hypocalcemia, and recurrent laryngeal nerve (RLN) injury, were assessed. ResultsOf PTMC patients, 63.4% underwent total thyroidectomy, with higher rates of RLN injury (8.8% vs. 2.3%) and hypocalcemia (12.4% vs. 0.0%) compared to lobectomy. Non-endocrine surgeons had higher postoperative radioactive iodine administration rates (28.6% vs. 6.1%). Subgroup analysis revealed a shift in total thyroidectomy rates based on tumor size and surgery period. ConclusionOur community favors total thyroidectomy for PTMC, despite associated complications. Enhanced awareness and adherence to PTMC best practice guidelines are warranted.

Transoral endoscopic thyroidectomy vestibular approach versus conventional open thyroidectomy for the treatment of benign thyroid tumours: A prospective cohort study.

Thyroid tumours are a common condition and open surgery is a conventional method for treating benign thyroid tumours when surgery is indicated. In this study, we evaluate the outcomes of benign thyroid tumour treatment using transoral endoscopic thyroidectomy via vestibular approach (TOETVA) and compare the results with those of conventional open thyroidectomy (COT). We conducted a prospective cohort study between 100 patients who underwent TOETVA and 100 who underwent COT surgery for benign diseases from June 2018 to December 2021 in our hospital. Outcomes between the two groups, including post-operative complications, operative time and length of stay, were compared. The surgical time in the TOETVA group was significantly longer than in the COT group. The operative time of lobectomy in the TOETVA and COT groups was 77.5 ± 13.3 and 51.5 ± 4.2 min, respectively, with a P < 0.001. The operative time of total thyroidectomy in the TOETVA and COT groups was 108.1 ± 7.0 and 65.0 ± 4.1 min, respectively, with a P < 0.001. There was no difference in post-operative length of stay between the two groups. In TOETVA group, there were no patients who converted to open surgery. Amongst all 200 patients in the study, there were no cases of post-operative bleeding. The transient hypoparathyroidism rate after surgery in the TOETVA and COT groups was 3% and 2%, respectively, with no statistically significant difference (P = 0.651). Similarly, the transient recurrent laryngeal nerve injury rate showed no difference between the two groups, with rates of 5% and 4% in the TOETVA and COT groups, respectively (P = 0.733). There were no cases of post-operative infection in either group in our study. At 3 months postoperatively, the cosmetic satisfaction were significantly higher in the endoscopic groups than in the conventional group (P < 0.001). TOETVA is a safe and effective method, with a low complication rate and optimal aesthetic results compared to traditional surgery to treat benign thyroid tumours.

Intraoperative Neuromonitoring Does Not Reduce the Risk of Temporary and Definitive Recurrent Laryngeal Nerve Damage during Thyroid Surgery: A Systematic Review and Meta-Analysis of Endoscopic Findings from 73,325 Nerves at Risk.

While intraoperative neuromonitoring (IONM) helps the early identification of recurrent laryngeal nerve (RLN) damage, IONM's role in RLN damage prevention is not defined, given the lack of large studies on the subject. In a PRISMA-compliant framework, all original thyroid surgery prospective studies providing early postoperative endoscopic data for all patients were pooled in a random-effects meta-analysis. We compared the temporary (and definitive where available) RLN damage rates according to IONM use and IONM type (intermittent, I-IONM, or continuous, C-IONM). We identified 2358 temporary and 257 definitive RLN injuries in, respectively, 73,325 and 66,476 nerves at risk. The pooled temporary and definitive RLN injury rates were, respectively, 3.15% and 0.422% considering all procedures, 3.29% and 0.409% in cases using IONM, and 3.16% and 0.463 in cases not using IONM. I-IONM and C-IONM, respectively, showed a pooled temporary RLN injury rate of 2.48% and 2.913% and a pooled definitive injury rate of 0.395% and 0.4%. All pooled rates had largely overlapping 95% confidence intervals. Our data suggest that IONM does not affect the temporary or definitive RLN injury rate following thyroidectomy, though its use can be advised in selected cases and for bilateral palsy prevention.

Initial experience with modified en bloc robot-assisted minimally invasive oesophagectomy for thoracic oesophageal squamous cell carcinoma.

The feasibility and safety of en bloc robot-assisted minimally invasive oesophagectomy (RAMIE) need to be verified. Forty-seven patients who received conventional RAMIE and 31 who received modified en bloc RAMIE at Henan Cancer Hospital were included in the study cohort. We compared the perioperative outcomes of conventional RAMIE and modified en bloc RAMIE. Compared with the conventional RAMIE group, the en bloc RAMIE group yielded a higher total number of lymph nodes (p=0.001), especially thoracic lymph nodes (p=0.025) and left recurrent laryngeal nerve (RLN) lymph nodes (p=0.005). No notable differences were found in the rate of total complications (p=0.663) or RLN injury (p=0.891) between the two groups. The preoperative and postoperative serological indicators were comparable between the two groups. Modified en bloc RAMIE was safe and feasible for patients with oesophageal squamous cell carcinoma and improved lymph node dissection, especially thoracic and left RLN lymph node dissection.

Effect of Intraoperative Neuromonitoring on the Risks of Recurrent Laryngeal Nerve Injury During Thyroidectomy: A Doubly Robust Approach.

To evaluate the relationship between the use intraoperative neuromonitoring (IONM) during thyroidectomy and the risk of recurrent laryngeal nerve (RLN) injury. The role of IONM in reducing RLN injury during thyroidectomy remains controversial. Several studies on this topic apply conventional multivariable regression to adjust for confounding. However, estimates from this method may be biased due to model misspecification, especially with a rare outcome such as RLN injury. We used a pooled dataset created by linking the 2016-2019 National Surgical Quality Improvement Project General Participant User File with the corresponding Targeted-Thyroidectomy file. The primary outcome was RLN injury rates, and the secondary outcomes were operating time and postoperative length of stay. A doubly robust (DR) estimator, in the form of an inverse-probability-weighted regression adjustment model, was used to estimate the effect of the use of IONM on the risk of RLN injury. Sensitivity analyses was performed. Twenty-four thousand three hundred seventy patients were evaluated, out of which 15,836 (70%) patients had IONM during thyroidectomy, and RLN injury occurred in 1498 (6.2%) cases. Rates of RLN injury increase with increasing age and BMI and are higher in patients with a cancer diagnosis, previous neck operation, total thyroidectomy, and node dissection. Doubly robust model suggests that the use of IONM was associated with a significant reduction in overall rate of RLN injury [risk ratio 0.77, confidence interval (CI), 0.68-0.87, P <0.001], and postoperative length of stay [-2.5 hours (CI, -4.18 to -0.81h), P =0.004]. However, IONM use was associated with an increase in operating time [15.41 minutes (CI, 13.29-17.54 minutes), P <0.0001]. Sensitivity analyses revealed that our estimates are largely robust to confounding. In a balanced cohort of patients undergoing thyroidectomy from multiple sites and surgeons participating in National Surgical Quality Improvement Project, the use of IONM during thyroidectomy was associated with reduction in RLN injury.

The value of intraoperative nerve monitoring against recurrent laryngeal nerve injury in thyroid reoperations.

Reoperative thyroidectomy is challenging for surgeons because of the higher incidence of recurrent laryngeal nerve (RLN) palsy. RLN identification is the gold standard during thyroidectomy; however, it is sometimes difficult to perform thyroid reoperations. In recent years, intraoperative nerve monitoring (IONM) has gained increased acceptance, and the use of IONM can be a valuable adjunct to visual identification. The aim of this study was to evaluate the value of IONM during thyroid reoperation.A total of 109 patients who met our criteria at the Affiliated Hospital of Hangzhou Normal University from January 2010 to June 2020 were retrospectively analyzed and divided into the IONM group and the visualization-alone group (VA group) according to whether neuromonitoring was used during the operation. The patients’ characteristics, perioperative data, and intraoperative information including the RLN identification, time of RLNs confirmation, operative time, intraoperative blood loss, and the rate of RLN injury were collected.Sixty-five procedures (94 RLNs at risk) were performed in the IONM group, whereas 44 (65 RLNs at risk) were in the VA group. The rate of RLN identification was 96.8% in the IONM group and 75.4% in the VA group (P < .05). The incidence of RLN injury was 5.3% in the IONM group and 13.8% in the VA group (P > .05). The incidence of surgeon-related RLN injury rate was 0% in the IONM group compared to 7.7% in the VA group (P < .05), but the tumor-related or scar-related RLN injury rate between the 2 groups were not significantly different (4.3% vs 3.1%, 1.1% vs 3.1%, P > .05).IONM in thyroid reoperation was helpful in improving the RLN identification rate and reducing the surgeon-related RLN injury rate, but was ineffective in reducing the tumor-related and scar-related RLN injury rate. In the future, multicenter prospective studies with large sample sizes may be needed to further assess the role of IONM in thyroid reoperations.

Recurrent Nerve Injury After Total Thyroidectomy: Risk Factor Analysis of a Targeted NSQIP Data Set.

Recurrent laryngeal nerve (RLN) injury is a significant complication after thyroidectomy. Understanding risk factors for RLN injury and the associated postoperative complications may help inform quality improvement initiatives. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) thyroidectomy-targeted database was utilized for patients undergoing total thyroidectomy between 2016 and 2017. Univariable and multivariable regression were used to identify factors associated with RLN injury. A total of 6538 patients were identified. The overall rate of RLN injury was 7.1% (467/6538). Of these, 4129 (63.1%) patients had intraoperative neuromonitoring (IONM), with an associated RLN injury rate of 6.5% (versus 8.2% without). African American and Asian race, non-elective surgery, parathyroid auto-transplantation, and lack of RLN monitoring were all significantly associated with nerve injury on multivariable analysis (P<.05). Patients with RLN injury were more likely to experience cardiopulmonary complications, re-intubation, longer length of stay, readmission, and reoperation. Patients who had IONM and sustained RLN injury remained at risk for developing significant postoperative complications, although the extent of cardiopulmonary complications was less severe in this cohort. Recurrent laryngeal nerve injury is common after thyroidectomy and is associated with significant morbidity, despite best practices. Attention to preoperative characteristics may help clinicians to further risk stratify patients prior to thyroidectomy. While IONM does not mitigate all complications, use of this technology may decrease severity of postoperative complications.

Bilateral and Ipsilateral Central Neck Dissection in Total Thyroidectomy: a Long Term Comparison of Complications.

The role of prophylactic central compartment neck dissection (CCND) in total thyroidectomy (TT) is controversial in patients without clinically evident lymph nodes metastasis (cN0) because of association with transient and permanent hypoparathyroidism (HPT) as well as transient and permanent recurrent laryngeal nerve (RLN) injury. Instead of bilateral central neck dissection (bCCND), ipsilateral central compartment neck dissection (iCCND) has recently been proposed as a safer, alternative treatment for selected patients. The aim of this study is to characterize the morbidity that CCND (ipsilateral and bilateral) adds to TT. We enrolled 453 patients: Group A (316 patients) underwent TT alone, Group B (86 patients) underwent TT + iCCND, Group C (51 patients) underwent TT + bCCND. We compared the rates of RLN injury and HPT in three groups and data analysis showed that iCCND was associated with increased rate of transient HPT but not permanent HPT and bCCND was associated with increased rate of transient and permanent HPT, when compared with TT alone. Further studies are needed to evaluate the clear advantages of CCND (both ipsilateral and bilateral), but this should be considered in the context of an higher risk of surgical complications (especially transient and permanent hypoparathyroidism), in comparison with TT alone.

Selecting the Right Plane of Dissection in Thyroidectomy: Along the Recurrent Laryngeal Nerve or the Thyroid Capsule? A Retrospective Analysis.

Introduction Total thyroidectomy remains highly technical, with a significant risk of recurrent laryngeal nerve (RLN) compromise and hypoparathyroidism. After identifying RLN, at the level of the ligament of Berry, local factors may compel the surgeon to either dissect along the nerve or the thyroid capsule. Objective The objective of the present study is to compare these two approaches in terms of outcomes and complication rates. Methods This is a retrospective analysis from September, 2013 to April 2019 of 511 consecutive patients undergoing thyroidectomy. General demographics and disease parameters were recorded. At the discretion of the surgeon and according to the demands of the local operative factors, the patients either had dissection along the RLN or along the thyroid capsule. Perioperative and postoperative parameters such as blood loss, duration of surgery, hospital stay, pain scores, analgesia requirements and complications were recorded. The groups were compared with the Pearson chi-squared test or with the Fisher exact test. A p-value < 0.05 was considered statistically significant. Results The incidence of transient hypocalcaemia and transient RLN compromise were higher when dissection was performed along the nerve as opposed to the plane along the thyroid capsule. Other parameters including operative time, hospital stay, pain scores, analgesia requirement, wound infection, seroma, hemorrhage, and recurrence did not differ between the groups. Subgroup analysis of the patients who presented with complications showed that local factors, malignancy, and extent of surgery correlated positively with complications when dissected along the RLN. Conclusion Dissection along the capsule of the thyroid during thyroidectomy is a safer plane in terms of low rate of transient RLN injury and hypoparathyroidism as opposed to dissection along the nerve.

Intraoperative Recurrent Laryngeal Nerve Monitoring During Pediatric Cardiac and Thoracic Surgery: A Mini Review.

Objective: Review techniques for intraoperative recurrent laryngeal nerve (RLN) monitoring during pediatric surgery for esophageal atresia, tracheoesophageal fistula, tracheobronchomalacia, and cardiac surgery.Summary Background Data: Literature was reviewed for reports of intraoperative recurrent laryngeal nerve monitoring in cervical, thoracic, and cardiac surgical procedures which place the RLNs at risk for injury.Methods: Review paper.Results: The RLN is at risk during pediatric surgery for esophageal atresia, tracheoesophageal fistula, tracheobronchomalacia, and cardiac surgery. Intraoperative nerve monitoring has decreased rates of RLN injury in thyroid surgery. Intraoperative RLN monitoring techniques appropriate for pediatric surgery are discussed, including endotracheal tubes with integrated surface electrodes, adhesive surface electrodes for smaller endotracheal tubes, endolaryngeal electrodes, and automatic periodic continuous intra-operative stimulation.Conclusions: Multiple techniques exist to monitor the RLN in children undergoing cervical, cardiac, and thoracic surgery. Monitoring the RLN during procedures that place the RLNs at risk may help decrease the rate of RLN injury.

Transoral Thyroidectomy: Safety and Outcomes of 200 Consecutive North American Cases.

North American adoption of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been limited due to concerns regarding the generalizability of published outcomes, as data are predominantly from Asian cohorts with a different body habitus. We describe our experience with TOETVA in a North American population in the context of the conventional transcervical approach thyroidectomy (TCA). Cases of TOETVA and TCA were reviewed from August 2017 to March 2020 at a tertiary care center. Outcomes included operative time, major (permanent recurrent laryngeal nerve (RLN) injury, permanent hypoparathyroidism, hematoma, conversion to open surgery), and minor complications. The TOETVA cohort was stratified into body mass index (BMI) classes of underweight/normal < 25kg/m2, overweight 25-29.9kg/m2, and obese ≥ 30kg/m2 for comparative analysis. Multivariable logistic regression analyses were performed for odds of cumulative complication. Two hundred TOETVA and 333 TCA cases were included. There was no difference in incidence of major complications between the TOETVA and TCA cohorts (1.5% vs. 2.1%, p = 0.75). No difference was found in the rate of temporary RLN injury (4.5% vs. 2.1%, p = 0.124) or temporary hypoparathyroidism (18.2% vs. 12.5%, p = 0.163) for TOETVA and TCA, respectively. Surgical technique (TOETVA vs TCA) did not alter the odds of cumulative complication (OR 0.69 95% CI [0.26-1.85]) on logistic regression analysis. In the TOETVA cohort, higher BMI did not lead to a significantly greater odds of cumulative complication, 0.52 (95% CI [0.17-1.58]) and 1.69 (95% CI [0.74-3.88]) for the overweight and obese groups, respectively. TOETVA can be performed in a North American patient population without a difference in odds of complication compared to TCA. Higher BMI is not associated with greater likelihood of complication with TOETVA.

Role of intraoperative recurrent laryngeal nerve monitoring for pediatric thyroid surgery: Comparative analysis.

The data on the advantages of intraoperative nerve monitoring (IONM) during pediatric thyroid surgeries are limited. We aimed to study the role of IONM by comparing between children who underwent thyroid surgery with and without IONM. A retrospective study of all children who underwent thyroid surgery between 2001 and 2019. The study included 113 patients with 183 recurrent laryngeal nerve (RLN) at risk. Transient paralysis rate was more than 5-fold lower in the IONM group compared to the control group (1.5% vs 8%; P = .114). Permanent paralysis was documented only in the control group (2.5% vs 0%; P = .552). Children <10 years and those who underwent central neck dissection had significantly higher rates of RLN injury. IONM was associated with decreased rate of RLN injury during pediatric thyroid surgery and should be considered especially in children under 10 years of age and those undergoing concomitant central neck dissection.

Intraoperative nerve monitoring is associated with a lower risk of recurrent laryngeal nerve injury: A national analysis of 17,610 patients

BackgroundBased on current evidence, the benefit of intraoperative nerve monitoring (IONM) in thyroid surgery is equivocal. MethodsAll patients who underwent planned thyroid surgery in the 2016–2018 ACS NSQIP procedure-targeted thyroidectomy dataset were included. Multivariable regression analyses were performed to examine the association between nerve monitoring and recurrent laryngeal nerve (RLN) injury while adjusting for patient demographics, extent of surgery, and perioperative variables. ResultsIn total, 17,610 patients met inclusion criteria: 77.8% were female, and the median age was 52 years. IONM was used in 63.9% of cases. Of the entire cohort, 6.1% experienced RLN injury. Cases with IONM use had a lower rate of RLN injury compared to those that did not use IONM (5.7% vs. 6.8%, p = 0.0001). After adjustment, IONM was associated with reduced risk of RLN injury (OR 0.69, 95% CI 0.59–0.82, p < 0.0001). ConclusionsNationally, IONM is used in nearly two thirds of thyroid surgeries. IONM is associated with a lower risk of recurrent laryngeal nerve injury.

Mechanisms of recurrent laryngeal nerve injury near the nerve entry point during thyroid surgery: A retrospective cohort study.

The use of intraoperative neuromonitoring (IONM) for visual identification of recurrent laryngeal nerve (RLN) has decreased the rates of RLN injury (RLNI) during thyroid surgery. However, little attention has been paid to RLNI near the nerve entry point (NEP), where most injuries occur. The aim of this study was to determine the mechanism of RLNI near the NEP and to describe the recovery of nerve function. Patients undergoing thyroid surgery were analyzed to identify true loss of signal (LOS) by IONM. Follow-up for vocal cord palsy (VCP) was confirmed by a postoperative laryngoscopy. The risk factors for RLNI, the type of RLNI, the prevalence of VCP and the time for VCP recovery were all recorded and analyzed. We analyzed 3582at-risk nerves in 2257 surgical patients. The overall rate of RLNI near the NEP in at-risk nerves was 3.2%. RLNI was more likely to occur in nerves with extralaryngeal bifurcation (p=0.013). The distribution of RLNI types, in order of frequency, was traction (52.6%; n=61), compression (38.8%; n=45), thermal (7.8%; n=9), and nerve transection (0.9%; n=1). Complete recovery from VCP was documented in 93.1% (n=108) of RLNI. Patients with a bifurcated RLN were at a higher risk of RLNI near the NEP than those without bifurcation. Traction and compression injuries occurred most frequently, but would eventually recover. Excessive stretching of the thyroid lobe played a role in RLNIs near the NEP.

Thyroidectomy Audit: Effects of Specialised, High Volume Work on Key Performance Indicators

We conducted this audit to assess and improve the quality of care for patients undergoing thyroid surgery at our institution. The audit process began in 2012. Key performance indicators assessed were rates of hypocalcemia (immediate postoperative, temporary and permanent), recurrent laryngeal nerve (RLN) injury, chyle leak rate, re-exploration for chyle leak and post-thyroidectomy haemorrhage. Data of patients undergoing thyroidectomy from 1st January to 31st December 2011 was retrospectively collected from the electronic database. Performance indicators were assessed and compared to international standards. Actions to correct the short falls were implemented and retrospective re-audits were performed on prospectively collected data in subsequent years until 2015. The data was analysed using STATA IC/13.1. There has been a steady increase in the number of thyroidectomies performed/year from 357 in 2011 to 577 in 2015. The most common procedure performed was total thyroidectomy (~70%) and histopathology revealed thyroid malignancy in the majority of patients. Over 5 years, a significant improvement in the rates of post-thyroidectomy immediate and temporary hypocalcemia was witnessed (p < 0.001) as well as a near significant fall in permanent hypocalcemia and RLN injury rate (p = 0.06). In 2014 and 2015, no patients were re-explored for a chyle leak. The rate of post-thyroidectomy haemorrhage (1.2–1.8%) has remained static over 5 years. This audit portrays specialisation in endocrine surgery and high volumes of patients treated have resulted in a significant improvement in outcomes for patients following thyroid surgery that meet international standards.

Prophylactic Central Neck Dissection for Papillary Thyroid Carcinoma with Clinically Uninvolved Central Neck Lymph Nodes: A Systematic Review and Meta-analysis.

Central neck dissection and total thyroidectomy are standard treatments for patients with papillary thyroid carcinoma (PTC) with clinically involved central nodes. However, prophylactic central neck dissection (pCND) in patients with clinically uninvolved cN0 has been beneficial in some studies but ineffective in others. We conducted a meta-analysis to evaluate the efficacy and safety of pCND in patients with central neck lymph nodes cN0 PTC. The PubMed, EMBASE, Cochrane Library, and Scopus databases and the ClinicalTrials.gov registry were electronically searched for studies published until September 2017. The meta-analysis was conducted to calculate the pooled effect size by using random-effects model. Treatment efficacies were measured by determining locoregional recurrence (LRR). Secondary outcomes included transient recurrent laryngeal nerve (RLN) injury, permanent RLN injury, transient hypocalcemia, and permanent hypocalcemia. Twenty-three retrospective and prospective cohort studies involving 18,376 patients were reviewed. Patients who underwent pCND had significantly lower LRR (odds ratio [OR] 0.65; 95% confidence interval [CI] 0.48-0.88) but significantly higher incidence rates of transient RLN injury (OR 2.03; 95% CI 1.32-3.13), transient hypocalcemia (OR 2.23; 95% CI 1.84-2.70), and permanent hypocalcemia (OR 2.22; 95% CI 1.58-3.13) than that of no pCND group. Compared with no pCND, pCND significantly reduces LRR but is accompanied by numerous adverse effects. The clinical decision should be made after the shared decision-making process of clinicians and patients.

Recurrent laryngeal nerve function after central neck dissection

It is generally accepted that central compartment neck dissection (CCND) improves locoregional recurrence rates in cases of known central compartment lymph node involvement, however the practice of prophylactic CCND is somewhat more controversial. It is often quoted anecdotally that the risk of damage to the recurrent laryngeal nerve is higher during CND than in thyroidectomy only. The aim of this study was to evaluate recurrent laryngeal nerve injury rates following CND in thyroid cancer patients.