The identification of laryngeal nerves during thyroidectomy procedures is considered the safest method to prevent variations in the motility of the vocal cords. However, the only visualization of the laryngeal nerves in many situations is not enough to ensure the result. In fact, anatomical wholeness does not always ensure the functional integrity. The number of endocrine surgery centers that use intraoperative neuromonitoring (IONM) is constantly increasing. Neuromonitoring techniques are currently considered safe methods; however, although infrequently, some complications and side effects related to the use of these methods have been reported. Recently, international guidelines on the use of IONM have been drafted and published to improve quality and safety. The aim of this work is to evaluate the safety of IONM by analyzing the complications reported in literature.
{"title":"Safety of intraoperative neuromonitoring","authors":"E. Caruso, A. Pino, G. Dionigi, Alessandro Pontin","doi":"10.21037/AOT.2019.04.01","DOIUrl":"https://doi.org/10.21037/AOT.2019.04.01","url":null,"abstract":"The identification of laryngeal nerves during thyroidectomy procedures is considered the safest method to prevent variations in the motility of the vocal cords. However, the only visualization of the laryngeal nerves in many situations is not enough to ensure the result. In fact, anatomical wholeness does not always ensure the functional integrity. The number of endocrine surgery centers that use intraoperative neuromonitoring (IONM) is constantly increasing. Neuromonitoring techniques are currently considered safe methods; however, although infrequently, some complications and side effects related to the use of these methods have been reported. Recently, international guidelines on the use of IONM have been drafted and published to improve quality and safety. The aim of this work is to evaluate the safety of IONM by analyzing the complications reported in literature.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-05-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/AOT.2019.04.01","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46958522","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Vilaça, S. Graça, L. Lencastre, A. Boa, Hugo Louro
Bulky complex cystic thyroid lesions are common, and an endoscopic approach can be a challenge due to technical limitations. Trans-axillary lobectomy is a current practice in our team. Big lobes can be very difficult to mobilize and remain still an indication for cervicotomy. Whenever there is a large cystic component, we manage these cases with trans-axillary intra-operative ultrasound (IOUS) and trans-axillary endoscopic drainage, in order to perform a safer thyroid lobectomy. As far as we are concern this issue has not yet been published in scientific papers. We describe the technique and the results of a series of three cases.
{"title":"Trans-axillary intra-operative ultrasound cystic drainage and thyroid lobectomy: a new endoscopic approach","authors":"J. Vilaça, S. Graça, L. Lencastre, A. Boa, Hugo Louro","doi":"10.21037/AOT.2019.03.01","DOIUrl":"https://doi.org/10.21037/AOT.2019.03.01","url":null,"abstract":"Bulky complex cystic thyroid lesions are common, and an endoscopic approach can be a challenge due to technical limitations. Trans-axillary lobectomy is a current practice in our team. Big lobes can be very difficult to mobilize and remain still an indication for cervicotomy. Whenever there is a large cystic component, we manage these cases with trans-axillary intra-operative ultrasound (IOUS) and trans-axillary endoscopic drainage, in order to perform a safer thyroid lobectomy. As far as we are concern this issue has not yet been published in scientific papers. We describe the technique and the results of a series of three cases.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/AOT.2019.03.01","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48198522","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Alessandro Pontin, A. Pino, Giulia Pinto, G. Dionigi, E. Caruso
The recurrent laryngeal nerve (RLN) injury represents one of the most feared complications during thyroidectomy (1). These injuries may cause a temporary or permanent palsy of the RLN and occur, more frequently, monolaterally. If only one side is involved, the palsy results in voice changes, hoarseness, or breathing trouble; in bilateral cases, instead, patients can undergo a potentially fatal airway obstruction needing an urgent tracheostomy (1). This complication, affects the quality of life of the patients, increases the charges for health care, and is the most frequent plea of lawsuits against thyroid surgeons.
{"title":"Cost analysis of intraoperative neural monitoring","authors":"Alessandro Pontin, A. Pino, Giulia Pinto, G. Dionigi, E. Caruso","doi":"10.21037/AOT.2019.03.03","DOIUrl":"https://doi.org/10.21037/AOT.2019.03.03","url":null,"abstract":"The recurrent laryngeal nerve (RLN) injury represents one of the most feared complications during thyroidectomy (1). These injuries may cause a temporary or permanent palsy of the RLN and occur, more frequently, monolaterally. If only one side is involved, the palsy results in voice changes, hoarseness, or breathing trouble; in bilateral cases, instead, patients can undergo a potentially fatal airway obstruction needing an urgent tracheostomy (1). This complication, affects the quality of life of the patients, increases the charges for health care, and is the most frequent plea of lawsuits against thyroid surgeons.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-03-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/AOT.2019.03.03","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46888815","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
R. Ranganath, Vaninder K. Dhillon, J. Russell, R. Tufano
Intraoperative nerve monitoring is a well validated technology for use in thyroid surgery. Intermittent intraoperative nerve monitoring is commonly used. Unfortunately, it helps detect injury only after it occurs limiting its usefulness. Continuous intraoperative nerve monitoring appears to be the emerging technology which has the ability to overcome this disadvantage. In this review, we discuss the utility of continuous nerve monitoring and its application in open and remote access thyroidectomy and the role of surgeon’s role in the use of these new technologies.
{"title":"Future directions of neural monitoring in thyroid surgery","authors":"R. Ranganath, Vaninder K. Dhillon, J. Russell, R. Tufano","doi":"10.21037/AOT.2019.03.04","DOIUrl":"https://doi.org/10.21037/AOT.2019.03.04","url":null,"abstract":"Intraoperative nerve monitoring is a well validated technology for use in thyroid surgery. Intermittent intraoperative nerve monitoring is commonly used. Unfortunately, it helps detect injury only after it occurs limiting its usefulness. Continuous intraoperative nerve monitoring appears to be the emerging technology which has the ability to overcome this disadvantage. In this review, we discuss the utility of continuous nerve monitoring and its application in open and remote access thyroidectomy and the role of surgeon’s role in the use of these new technologies.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/AOT.2019.03.04","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"68297027","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The close proximity of the recurrent and external superior laryngeal nerves to the thyroid bed places them at risk of injury during neck endocrine procedures. Intra-operative nerve visual identification with structural preservation does not equate with the preservation of nerve functional integrity and the morbidity of neural injury resulting in post-operative vocal fold paralysis or voice change can be significant. As such, intraoperative neuromonitoring strategies for the recurrent laryngeal and, more recently, the external branch of the superior laryngeal nerve have evolved and have gained increasing attention from surgeons performing neck endocrine procedures worldwide. Currently, many head and neck and general surgeons use neural monitoring in at least some of their surgical cases. The support for intraoperative nerve monitoring (IONM) continues to grow at both an individual and organization level as the guidelines for standardization are published, prospective randomized controlled trials are reported, and structured training courses are established. This article will discuss the evolution and recent progress of standard procedures for intraoperative neuromonitoring of laryngeal nerves in thyroid and parathyroid surgeries.
{"title":"The evolution and progress of standard procedures for intraoperative nerve monitoring","authors":"C. Sinclair, D. Kamani, G. Randolph","doi":"10.21037/AOT.2018.12.01","DOIUrl":"https://doi.org/10.21037/AOT.2018.12.01","url":null,"abstract":"The close proximity of the recurrent and external superior laryngeal nerves to the thyroid bed places them at risk of injury during neck endocrine procedures. Intra-operative nerve visual identification with structural preservation does not equate with the preservation of nerve functional integrity and the morbidity of neural injury resulting in post-operative vocal fold paralysis or voice change can be significant. As such, intraoperative neuromonitoring strategies for the recurrent laryngeal and, more recently, the external branch of the superior laryngeal nerve have evolved and have gained increasing attention from surgeons performing neck endocrine procedures worldwide. Currently, many head and neck and general surgeons use neural monitoring in at least some of their surgical cases. The support for intraoperative nerve monitoring (IONM) continues to grow at both an individual and organization level as the guidelines for standardization are published, prospective randomized controlled trials are reported, and structured training courses are established. This article will discuss the evolution and recent progress of standard procedures for intraoperative neuromonitoring of laryngeal nerves in thyroid and parathyroid surgeries.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/AOT.2018.12.01","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48258429","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Nowadays thyroid surgery is the widely endocrine procedures performed worldwide. Since ancient times to 21th century the clinicians developed a lot of researches to reduce complications related to thyroid gland surgery. The postoperative challenges are haematoma, infections, hypocalcemia, tracheal injury and recurrent laryngeal nerve injury. The progress in technology with haemostatic instrument and the standardization of surgical technique reduced surgical related complications, while the introduction of intraoperative neuromonitoring (IONM) permitted to identify nerves and to preserve the functional activity of vocal cords avoiding postoperative complications such as dysphonia and vocal cords palsy. In this manuscript, we discuss the anesthesiological perspective about IONM evolution during thyroid surgery.
{"title":"The evolution and progress of anesthesia for intraoperative neuromonitoring during thyroid surgery","authors":"L. Guzzetti, G. Dionigi, S. Cuffari, A. Bacuzzi","doi":"10.21037/aot.2018.11.03","DOIUrl":"https://doi.org/10.21037/aot.2018.11.03","url":null,"abstract":"Nowadays thyroid surgery is the widely endocrine procedures performed worldwide. Since ancient times to 21th century the clinicians developed a lot of researches to reduce complications related to thyroid gland surgery. The postoperative challenges are haematoma, infections, hypocalcemia, tracheal injury and recurrent laryngeal nerve injury. The progress in technology with haemostatic instrument and the standardization of surgical technique reduced surgical related complications, while the introduction of intraoperative neuromonitoring (IONM) permitted to identify nerves and to preserve the functional activity of vocal cords avoiding postoperative complications such as dysphonia and vocal cords palsy. In this manuscript, we discuss the anesthesiological perspective about IONM evolution during thyroid surgery.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2018-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/aot.2018.11.03","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42197078","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
R. Uehara, Junichi Okada, Eijiro Yamada, A. Ozawa, Yasuyo Nakajima, S. Okada, M. Yamada
We describe the first reported case of painless thyroiditis induced by an abrupt cessation of a dipeptidyl peptidase-4 (DPP-4) inhibitor. A 38-year-old man who had type 2 diabetes mellitus, hypertension, hyperuricemia, and pruritus, was treated with metformin, glimepiride, dapagliflozin, sitagliptin, azelnidipine, trichlormethiazide, febuxostat, and fexofenadine. One year previously, his thyroid-stimulating hormone (TSH) was 1.59 (reference range, 0.34–4.94 U/mL). As his HbA1c value reached to 13%, sitagliptin was switched to dulaglutide. One month later, the HbA1c was 12.3%, TSH was <0.05, FT4 was 3.16 (0.7–1.48 ng/dL), FT3 was 7.79 (1.71–3.71 pg/mL), anti-TSH receptor antibody was 0.7 (0–1.99 IU/L), and thyroglobulin was 159.5 (0–32.6 ng/mL). Additionally, his anti-thyroglobulin and anti-thyroid microsomal antibodies were negative. Thyroid ultrasonography revealed a heterogeneous, hypoechogenic, normal-sized thyroid gland with decreased doppler flow. He was diagnosed with painless thyroiditis and was kept under observation without any change in current medication. One month later, the HbA1c was 12.4%, TSH was 9.06, FT4 was 0.81, FT3 was 2.26, and thyroglobulin was 86.7. Additionally, 2 months later, the HbA1c was 9.8%, TSH was 4.2, FT4 was 1, FT3 was 2.55, and thyroglobulin was 21.92. He continued taking dulaglutide once a week. His thyrotoxicosis disappeared within 3 months without specific drug therapy. Anti-TSH receptor antibody was negative throughout his clinical course. We speculate that the cessation of a DPP-4 inhibitor maybe one of the triggers of painless thyroiditis. However, glucagon-like peptide-1 is not likely a cause for painless thyroiditis because he continues taking dulaglutide once a week to date. Our findings indicate that it is important to examine thyroid function after termination of a DPP-4 inhibitor.
{"title":"Painless thyroiditis induced by the cessation of a dipeptidyl peptidase-4 inhibitor","authors":"R. Uehara, Junichi Okada, Eijiro Yamada, A. Ozawa, Yasuyo Nakajima, S. Okada, M. Yamada","doi":"10.21037/AOT.2018.10.06","DOIUrl":"https://doi.org/10.21037/AOT.2018.10.06","url":null,"abstract":"We describe the first reported case of painless thyroiditis induced by an abrupt cessation of a dipeptidyl peptidase-4 (DPP-4) inhibitor. A 38-year-old man who had type 2 diabetes mellitus, hypertension, hyperuricemia, and pruritus, was treated with metformin, glimepiride, dapagliflozin, sitagliptin, azelnidipine, trichlormethiazide, febuxostat, and fexofenadine. One year previously, his thyroid-stimulating hormone (TSH) was 1.59 (reference range, 0.34–4.94 U/mL). As his HbA1c value reached to 13%, sitagliptin was switched to dulaglutide. One month later, the HbA1c was 12.3%, TSH was <0.05, FT4 was 3.16 (0.7–1.48 ng/dL), FT3 was 7.79 (1.71–3.71 pg/mL), anti-TSH receptor antibody was 0.7 (0–1.99 IU/L), and thyroglobulin was 159.5 (0–32.6 ng/mL). Additionally, his anti-thyroglobulin and anti-thyroid microsomal antibodies were negative. Thyroid ultrasonography revealed a heterogeneous, hypoechogenic, normal-sized thyroid gland with decreased doppler flow. He was diagnosed with painless thyroiditis and was kept under observation without any change in current medication. One month later, the HbA1c was 12.4%, TSH was 9.06, FT4 was 0.81, FT3 was 2.26, and thyroglobulin was 86.7. Additionally, 2 months later, the HbA1c was 9.8%, TSH was 4.2, FT4 was 1, FT3 was 2.55, and thyroglobulin was 21.92. He continued taking dulaglutide once a week. His thyrotoxicosis disappeared within 3 months without specific drug therapy. Anti-TSH receptor antibody was negative throughout his clinical course. We speculate that the cessation of a DPP-4 inhibitor maybe one of the triggers of painless thyroiditis. However, glucagon-like peptide-1 is not likely a cause for painless thyroiditis because he continues taking dulaglutide once a week to date. Our findings indicate that it is important to examine thyroid function after termination of a DPP-4 inhibitor.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2018-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41514419","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pregnancy has a profound impact on the thyroid economy and function, and may result in hypothyroidism in women with limited thyroid reserves or iodine deficiency. Well established overt hypothyroidism and hyperthyroidism have deleterious effects on pregnancy. In addition, maternal subclinical hypothyroidism and subclinical hyperthyroidism have the potential to impact maternal and fetal health. The association between miscarriage and preterm delivery in euthyroid TPOAb positive women has also been documented. Therefore, early detection and proper management of thyroid alterations before and during pregnancy could help to prevent unwanted adverse effects of thyroid dysfunction on pregnant women and their fetuses.
{"title":"“Pregnancy and Thyroid Disease”: early detection and optimized management","authors":"F. Azizi","doi":"10.21037/AOT.2018.10.03","DOIUrl":"https://doi.org/10.21037/AOT.2018.10.03","url":null,"abstract":"Pregnancy has a profound impact on the thyroid economy and function, and may result in hypothyroidism in women with limited thyroid reserves or iodine deficiency. Well established overt hypothyroidism and hyperthyroidism have deleterious effects on pregnancy. In addition, maternal subclinical hypothyroidism and subclinical hyperthyroidism have the potential to impact maternal and fetal health. The association between miscarriage and preterm delivery in euthyroid TPOAb positive women has also been documented. Therefore, early detection and proper management of thyroid alterations before and during pregnancy could help to prevent unwanted adverse effects of thyroid dysfunction on pregnant women and their fetuses.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45732239","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Thyroid surgery has always been closely involved with the recurrent laryngeal nerve (RLN) and the external branch of the superior laryngeal nerve (EBSLN). The goal of thyroid surgery is to remove all pathological thyroid tissue while preserving the parathyroid glands and both laryngeal nerves to ensure patients the highest quality of life after the operation. The goal of this paper was to assess the evolution and progress of studies of the anatomy & electrophysiology of the laryngeal nerves in thyroid surgery. Our knowledge of the anatomy and electrophysiology of laryngeal nerves in relation to thyroid operations has evolved over the centuries from visual RLN identification to the functional RLN identification with intraoperative neural monitoring (IONM). The progress in RLN identification has changed the surgical technic, surgical strategy in order to minimize the rate of complications. Now the thyroid surgery is safe procedure with the high quality of voice after this operation.
{"title":"The evolution and progress of studies of the anatomy & electrophysiology of the laryngeal nerves in thyroid surgery","authors":"Beata Wojtczak, M. Barczyński","doi":"10.21037/AOT.2018.09.03","DOIUrl":"https://doi.org/10.21037/AOT.2018.09.03","url":null,"abstract":"Thyroid surgery has always been closely involved with the recurrent laryngeal nerve (RLN) and the external branch of the superior laryngeal nerve (EBSLN). The goal of thyroid surgery is to remove all pathological thyroid tissue while preserving the parathyroid glands and both laryngeal nerves to ensure patients the highest quality of life after the operation. The goal of this paper was to assess the evolution and progress of studies of the anatomy & electrophysiology of the laryngeal nerves in thyroid surgery. Our knowledge of the anatomy and electrophysiology of laryngeal nerves in relation to thyroid operations has evolved over the centuries from visual RLN identification to the functional RLN identification with intraoperative neural monitoring (IONM). The progress in RLN identification has changed the surgical technic, surgical strategy in order to minimize the rate of complications. Now the thyroid surgery is safe procedure with the high quality of voice after this operation.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/AOT.2018.09.03","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46631096","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Hypoparathyroidism and recurrent laryngeal nerve (RLN) damage are the most frequent reported morbidity in thyroid surgery whereas damage of the external branch of the superior laryngeal nerve (EBSLN) has been considered to be the most neglected sequel. EBSLN injury results in subtle changes in voice as a result of dysfunction of the cricothyroid muscle (CTM): changed basic voice frequency, deterioration of voice quality in the production of high frequency sounds and reduced voice projection. Symptoms of this dysfunction are usually more notable for professional voice users and can be difficult to diagnose. EBSLN injury can happen during dissection of the vessels of the upper thyroid pole due to proximity between the nerve and these vessels. Several maneuvers can minimize the risk of injury to the EBSLN including visual identification of the nerve before ligation of the upper thyroid pole vessels and use of either a nerve stimulator or intraoperative neuromonitoring (IONM) for neuromapping and evidence of the EBSLN identification. The EBSLN monitoring is relied on evaluation of CTM twitch (present in all patients) and electromyographic curve traced by the monitor using surface tube electrodes within the vocal folds which present in the majority but not all individuals (70–80% of patients using standard EMG tubes) or approaching to 100% of patients (using NIM TriVantage tubes). IONM has a potential to increase the rate of the EBSLNs identification, diminish prevalence of neural damage, and decrease prevalence of postoperative voice impairment which has been repeatedly supported by recently published data. It is advised that at the end of upper thyroid lobe dissection the EBSLN should be stimulated at the most cranial arc of dissection to confirm not only anatomical but what is even more important functional preservation of intact neural function.
{"title":"The evolution and progress of intraoperative monitoring of the external branch of the superior laryngeal nerve in thyroid surgery","authors":"M. Barczyński, Beata Wojtczak, A. Konturek","doi":"10.21037/AOT.2018.10.01","DOIUrl":"https://doi.org/10.21037/AOT.2018.10.01","url":null,"abstract":"Hypoparathyroidism and recurrent laryngeal nerve (RLN) damage are the most frequent reported morbidity in thyroid surgery whereas damage of the external branch of the superior laryngeal nerve (EBSLN) has been considered to be the most neglected sequel. EBSLN injury results in subtle changes in voice as a result of dysfunction of the cricothyroid muscle (CTM): changed basic voice frequency, deterioration of voice quality in the production of high frequency sounds and reduced voice projection. Symptoms of this dysfunction are usually more notable for professional voice users and can be difficult to diagnose. EBSLN injury can happen during dissection of the vessels of the upper thyroid pole due to proximity between the nerve and these vessels. Several maneuvers can minimize the risk of injury to the EBSLN including visual identification of the nerve before ligation of the upper thyroid pole vessels and use of either a nerve stimulator or intraoperative neuromonitoring (IONM) for neuromapping and evidence of the EBSLN identification. The EBSLN monitoring is relied on evaluation of CTM twitch (present in all patients) and electromyographic curve traced by the monitor using surface tube electrodes within the vocal folds which present in the majority but not all individuals (70–80% of patients using standard EMG tubes) or approaching to 100% of patients (using NIM TriVantage tubes). IONM has a potential to increase the rate of the EBSLNs identification, diminish prevalence of neural damage, and decrease prevalence of postoperative voice impairment which has been repeatedly supported by recently published data. It is advised that at the end of upper thyroid lobe dissection the EBSLN should be stimulated at the most cranial arc of dissection to confirm not only anatomical but what is even more important functional preservation of intact neural function.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/AOT.2018.10.01","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47583615","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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