Intraoperative neuromonitoring in thyroid and parathyroid surgery: indications and method

Intraoperative neuromonitoring finds widespread application in thyroid and parathyroid surgery, as a preventive method against laryngeal nerves injuries. Today it is possible to monitor the laryngeal nerve function in real time during an operation. In this article based on experience of 1065 thyroid and parathyroid operations with intraoperative neuromonitoring, we describe in details the procedure of intraoperative neuromonitoring of laryngeal nerves: features of anaesthesia, endotracheal tube position, algorythm of trouble shooting in case of loss of electromyographical sygnal. Besides that, there is an explanation of electromyographical indices, such as: signal amplitude, latency, threshold, LOS (loss of signal); there are main literature sources on this problem.

1. Дедов И.И., Кузнецова Н.С., Мельниченко Г.А. Эндокринная хирургия. – М.: Литтерра, 2011. – 352 с. [Dedov II, Kuznetsovа NS, Меl’nichenko GА. Endocrine surgery. – Мoscow: Litterrа; 2011. 352 p. (In Russ.)]

2. Черников Р.А., Воробьев С.Л., Слепцов И.В., и др. Результаты хирургического этапа лечения папиллярного рака щитовидной железы // Клиничеcкая и экспериментальная тиреоидология. – 2014. – Т. 10. – №2 – С. 38–42. [Chernikov RA, Vorobjev SL, Sleptsov IV, et al. Results of surgical treatment of papillary thyroid cancer. Clinical and experimental thyroidology. 2014;10(2):38-42. (In Russ.)] doi: 10.14341/CET201410238-42.

3. Каприн А.Д., Старинский В.В., Петрова Г.В. Злокачественные новообразования в России в 2014 году (заболеваемость и смертность). – М., 2016. – 250 c. [Kaprin АD, Starinskiy VV, Petrovа GV. Malignant tumors in Russia in 2014 (morbidity and fatality). Мoscow; 2016. 250 p. (In Russ.)]

4. Гагаркин Г.Н., Ужва В.П., Гагаркин И.Г. Повреждения возвратного нерва во время выполнения операции на щитовидной железе // Клиническая хирургия. – 1991. – №12. – С. 47–48. [Gagarkin GN, Uzhva VP, Gagarkin IG. Povrezhdeniya vozvratnogo nerva vo vremya vypolneniya operatsii na shchitovidnoy zheleze. Klinicheskaya khirurgiya. 1991;(12):47-48. (In Russ.)]

5. Бондаренко В.О. Возвратный гортанный нерв в хирургии щитовидной и паращитовидной желез. – М., 2006. – 120 с. [Bondarenko VO. Vozvratnyy gortannyy nerv v khirurgii shchitovidnoy i parashchitovidnoy zhelez. Moscow; 2006. 120 p. (In Russ.)]

6. Мустафаев Д.М., Свистушкин В.М., Осипенко Е.В., и др. Алгоритм клинического обследования при односторонних парезах и параличах гортани неясного генеза // Российская оториноларингология. – 2010. – № 2. – С. 84–90. [Mustafaev DM, Svistushkin VM, Osipenko EV, et al. Algorithm of clinical tests in indeterminate unilaterally vocal fold paresis and paralysis. Russian otorhinolaryngology. 2010;(2):84-90. (In Russ.)]

7. Готовяхина Т.В. Хирургические вмешательства на щитовидной железе как одна из причин дисфоний в раннем послеоперационном периоде // Российская оториноларингология. – 2010. – №1. – С. 12–17.[Gotovyakhina TV. Surgical interventions on a thyroid gland as one of the reasons of dysphonia in the early postoperative period. Russian otorhinolaryngology. 2010;(1):12-17. (In Russ.)]

8. Sancho JJ, Pascual-Damieta M, Pereira JA, et al. Risk factors for transient vocal cord palsy after thyroidectomy. Br J Surg. 2008;95(8):961-967. doi: 10.1002/bjs.6173.

9. Василенко Ю.С., Романенко С.Г. Клинико-функциональное обследование больных с односторонним параличом гортани // Вестник оториноларингологии. – 2000. – №5. – С. 50–53. [Vasilenko YS, Romanenko SG. Kliniko-funktsional’noe obsledovanie bol’nykh s odnostoronnim paralichom gortani. Vestnik otorinolaringologii. 2000;(5): 50-53. (In Russ.)]

10. Sinclair IS. The risk to the recurrent laryngeal nerves in thyroid and parathyroid surgery. J R Coll Surg Edinb. 1994;39(4): 253-257.

11. Мышкин К.И., Амирова Н.М. Выбор операции у больных раком щитовидной железы // Вопросы онкологии. – 1991. – Т. 37. – №2. – С. 219–223. [Myshkin KI, Amirova NM. Vybor operatsii u bol’nykh rakom shchitovidnoy zhelezy. Problems in oncology. 1991;37(2):219-223. (In Russ.)]

12. Черенько М.П. Обоснование показаний и опыт хирургического лечения больных с патологией щитовидной железы // Клиническая хирургия. – 1987. – №5. – С. 76. [Cheren’ko MP. Obosnovanie pokazaniy i opyt khirurgicheskogo lecheniya bol’nykh s patologiey shchitovidnoy zhelezy. Klinicheskaya khirurgiya. 1987;(5):76. (In Russ.)]

13. Caragacianu D, Kamani D, Randolph GW. Intraoperative monitoring: normative range associated with normal postoperative glottic function. Laryngoscope. 2013;123(12): 3026-3031. doi: 10.1002/lary.24195.

14. Anuwong A, Lavazza M, Kim HY, et al. Recurrent laryngeal nerve management in thyroid surgery: consequences of routine visualization, application of intermittent, standardized and continuous nerve monitoring. Updates Surg. 2016. doi: 10.1007/s13304-016-0393-9.

15. Hayward NJ, Grodski S, Yeung M, et al. Recurrent laryngeal nerve injury in thyroid surgery: a review. ANZ J Surg. 2013; 83(1-2):15-21. doi: 10.1111/j.1445-2197.2012.06247.x.

16. Chiang FY, Lu IC, Kuo WR, et al. The mechanism of recurrent laryngeal nerve injury during thyroid surgery – the application of intraoperative neuromonitoring. Surgery. 2008;143(6): 743-749. doi: 10.1016/j.surg.2008.02.006.

17. Snyder SK, Lairmore TC, Hendricks JC, Roberts JW. Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy. J Am Coll Surg. 2008;206(1):123-130. doi: 10.1016/j.jamcollsurg.2007.07.017.

18. Dionigi G, Wu CW, Kim HY, et al. Severity of recurrent laryngeal nerve injuries in thyroid surgery. World J Surg. 2016;40(6):1373-1381. doi: 10.1007/s00268-016-3415-3.

19. Tschopp K, Probst R. New aspects in surgery of the thyroid gland with intraoperative monitoring of the recurrent laryngeal nerve. Laryngorhinootologie. 1994;73(11):568-572. doi: 10.1055/s-2007-997197.

20. Dralle H, Sekulla C, Lorenz K, et al. Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg. 2008;32(7):1358-1366. doi: 10.1007/s00268-008-9483-2.

21. Dionigi G, Barczynski M, Chiang FY, et al. Why monitor the recurrent laryngeal nerve in thyroid surgery? J Endocrinol Invest. 2010;33(11):819-822. doi: 10.1007/BF03350349.

22. Dralle H, Sekulla C, Lorenz K, et al. Loss of the nerve monitoring signal during bilateral thyroid surgery. Br J Surg. 2012;99(8):1089-1095. doi: 10.1002/bjs.8831.

23. Schneider R, Randolph GW, Sekulla C, et al. Continuous intraoperative vagus nerve stimulation for identification of imminent recurrent laryngeal nerve injury. Head Neck. 2013;35(11):1591-1598. doi: 10.1002/hed.23187.

24. Phelan E, Schneider R, Lorenz K, et al. Continuous vagal IONM prevents recurrent laryngeal nerve paralysis by revealing initial EMG changes of impending neuropraxic injury: a prospective, multicenter study. Laryngoscope. 2014;124(6): 1498-1505. doi: 10.1002/lary.24550.

25. Henry L, Helou L, Solomon N, et al. Current practice patterns regarding the conduct of thyroidectomy and parathyroidectomy amongst surgeons – a survey study. J Cancer. 2012;3:207-216. doi: 10.7150/jca.4452.

26. Thomusch O, Sekulla C, Walls G, et al. Intraoperative neuromonitoring of surgery for benign goiter. Am J Surg. 2002;183(6):673-678.

27. Hopkins C, Khemani S, Terry RM, Golding-Wood D. How we do it: nerve monitoring in ENT surgery: current UK practice. Clin Otolaryngol. 2005;30(2):195-198. doi: 10.1111/j.1365-2273.2004.00933.x.

28. Румянцев П.О. Интраоперационный нейромониторинг как метод функциональной визуализации двигательных нервов // Опухоли головы и шеи. – 2012. – №4. – С. 49–52. [Rumyantsev PO. Intraoperative neuromonitoring as a method of motor nerves functional visualization. Head and neck tumors (HNT). 2012;(4):49-52. (In Russ.)] doi: 10.17650/2222-1468-2012-0-4-49-52

29. Румянцев П.О. Интраоперационный нейромониторинг при операциях на щитовидной железе // Эндокринная хирургия. – 2012. – Т. 6. – №2 – C. 42–47. [Rumyantsev PO. Intraoperative neuromonitoring in thyroid surgery. Endocrine Surgery. 2012;6(2):42-47. (In Russ.)]. doi: 10.14341/2306-3513-2012-2-42-47.

30. Dionigi G, Bacuzzi A, Boni L, et al. What is the learning curve for intraoperative neuromonitoring in thyroid surgery? Int J Surg. 2008;6(Suppl 1):S7-12. doi: 10.1016/j.ijsu.2008.12.023.

31. White WM, Randolph GW, Hartnick CJ, Cunningham MJ. Recurrent laryngeal nerve monitoring during thyroidectomy and related cervical procedures in the pediatric population. Arch Otolaryngol Head Neck Surg.2009;135(1):88-94. doi: 10.1001/archoto.2008.520.

32. Randolph GW. Surgical anatomy of the recurrent laryngeal nerve. In: Randolph GW, ed. Surgery of the Thyroid and Parathyroid Glands. Philadelphia, PA: Saunders; 2003: 300-349.

33. Mihai R., Randolph GW. Thyroid surgery, voice and the laryngeal examination time for increased awareness and accurate evaluation. World J Endocr Surg. 2009;1(1):1-5.

34. Randolph GW, Kamani D. The importance of preoperative laryngoscopy in patients undergoing thyroidectomy: voice, vocal cord function, and the preoperative detection of invasive thyroid malignancy. Surgery.2006;139(3):357-362. doi: 10.1016/j.surg.2005.08.009.

35. Gavilan J, Gavilan C. Recurrent laryngeal nerve. Identification during thyroid and parathyroid surgery. Arch Otolaryngol Head Neck Surg. 1986;112(12):1286-1288.

36. Echeverri A, Flexon PB. Electrophysiologic nerve stimulation for identifying the recurrent laryngeal nerve in thyroid surgery: review of 70 consecutive thyroid surgeries. Am Surg. 1998;64(4):328-333.

37. Riddell V. Thyroidectomy: Prevention of bilateral recurrent nerve palsy, results of identification of the nerve over 23 consecutive years (1946-69) with a description of an additional safety measure. Br J Surg. 1970;57(1):1-11. doi: 10.1002/bjs.1800570102.

38. Premachandra DJ, Radcliffe GJ, Stearns MP. Intraoperative identification of the recurrent laryngeal nerve and demonstration of its function. Laryngoscope. 1990;100(1):94-96. doi: 10.1288/00005537-199001000-00019.

39. Woltering EA, Dumond D, Ferrara J, et al. A method for intraoperative identification of the recurrent laryngeal nerve. Am J Surg. 1984;148(4):438-440. doi: 10.1016/0002-9610(84)90365-9.

40. Lipton RJ, McCaffrey TV, Litchy WJ. Intraoperative electrophysiologic monitoring of laryngeal muscle during thyroid surgery. Laryngoscope. 1988;98(12):1292-1296. doi: 10.1288/00005537-198812000-00003.

41. Hamelmann WH, Meyer T, Timm S, Timmermann W. A critical estimation of intraoperative neuromonitoring (IONM) in thyroid surgery. Zentralbl Chir. 2002;127(5):409-413. doi: 10.1055/s-2002-31982.

42. Kunath M, Marusch F, Horschig P, Gastinger I. The value of intraoperative neuromonitoring in thyroid surgery – a prospective observational study with 926 patients. Zentralbl Chir. 2003;128(3):187-190. doi: 10.1055/s-2003-38529.

43. Dackiw AP, Rotstein LE, Clark OH. Computer-assisted evoked electromyography with stimulating surgical instruments for recurrent/external laryngeal nerve identification and preservation in thyroid and parathyroid operation. Surgery. 2002; 132(6):1100-1106; discussion 1107-1108. doi: 10.1067/msy.2002.128483.

44. Eisele DW. Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve. Laryngoscope. 1996;106(4): 443-449.

45. Barwell J, Lytle J, Page R, Wilkins D. The NIM-2 nerve integrity monitor in thyroid and parathyroid surgery. Br J Surg. 1997;84(6):854-854. doi: 10.1046/j.1365-2168.1997.02674.x.

46. Rea JL, Khan A. Clinical evoked electromyography for recurrent laryngeal nerve preservation: Use of an endotracheal tube electrode and a postcricoid surface electrode. Laryngoscope. 1998;108(9):1418-1420. doi: 10.1097/00005537-199809000-00032.

47. Starczewska A, Brol M, Żołnowska A. Advantages of rocuronium bromide in thyroid surgery with neuromonitoring. Proceedings of the 1st World Congress on Neural Monitoring in Thyroid and Parathyroid Surgery. Cracow; 2015. P. 26.

48. Chu KS, Wu SH, Lu IC, et al. Feasibility of intraoperative neuromonitoring during thyroid surgery after administration of nondepolarizing neuromuscular blocking agents. World J Surg. 2009;33(7):1408-1413. doi: 10.1007/s00268-009-0049-8.

49. Lu IC, Tsai CJ, Wu CW, et al. A comparative study between 1 and 2 effective doses of rocuronium for intraoperative neuromonitoring during thyroid surgery. Surgery. 2011;149(4): 543-548. doi: 10.1016/j.surg.2010.11.006.

50. Sugammadex for the reversal of neuromuscular blockade in adult patients: a review of clinical effectiveness and cost-effectiveness. Canadian Agency for Drugs and Technologies in Health; 2016. PMID: 27336121.

51. Randolph GW, Dralle H, International Intraoperative Monitoring Study. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope. 2011; 12(Suppl 1):S1-16. doi: 10.1002/lary.21119.

52. Han YD, Liang F, Chen P. Dosage effect of rocuronium on intraoperative neuromonitoring in patients undergoing thyroid surgery. Cell Biochem Biophys. 2015;71(1):143-146. doi: 10.1007/s12013-014-0176-1.

53. Tsai CJ, Tseng KY, Wang FY, et al. Electromyographic endotracheal tube placement during thyroid surgery in neuromonitoring of recurrent laryngeal nerve. Kaohsiung J Med Sci. 2011;27(3):96-101. doi: 10.1016/j.kjms.2010.08.002.

54. Blitzer A, Crumley RL, Dailey SH, et al. Recommendations of the Neurolaryngology Study Group on laryngeal electromyography. Otolaryngol Head Neck Surg. 2009;140(6):782-793. doi: 10.1016/j.otohns.2009.01.026.

55. Sritharan N, Chase M, Kamani D, et al. The vagus nerve, recurrent laryngeal nerve, and external branch of the superior laryngeal nerve have unique latencies allowing for intraoperative documentation of intact neural function during thyroid surgery. Laryngoscope. 2015;125(2):E84-89. doi: 10.1002/lary.24781.

56. Snyder SK, Lairmore TC, Hendricks JC, Roberts JW. Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy. J Am Coll Surg. 2008;206(1):123-130. doi: 10.1016/j.jamcollsurg.2007.07.017.

57. Schneider R, Randolph G, Dionigi G, et al. Prospective study of vocal fold function after loss of the neuromonitoring signal in thyroid surgery: The International Neural Monitoring Study Group's POLT study. Laryngoscope. 2016;126(5): 1260-1266. doi: 10.1002/lary.25807.