Elsevier

Surgery

Volume 136, Issue 6, December 2004, Pages 1310-1322
Surgery

American Association of Endocrine Surgeon
Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery

https://doi.org/10.1016/j.surg.2004.07.018Get rights and content

Background

Recurrent laryngeal nerve monitoring (RLNM) has been suspected to reduce postoperative RLN paralysis (RLNP). However, functional outcome of RLNM in comparison with no nerve identification and visual nerve identification only has not been analyzed.

Methods

Analysis of 16,448 consecutive multi-institutional operations resulted in 29,998 nerves at risk. Three groups of different RLN treatment were compared: group 1, no RLN identification; group 2, visual RLN identification; and group 3, visual RLN identification and electromyographic monitoring. RLNM was performed with a bipolar needle electrode that was placed through the cricothyroid ligament into the vocal muscle.

Results

Risk factors for permanent RLNP were recurrent benign and malignant goiter (odds ratios, [ORs]), 4.7, and 6.7, respectively), primary surgery in thyroid malignancy (OR, 2.0), lobectomy (OR, 1.8), no nerve identification (OR, 1.4), low or medium volume hospital (OR, 1.3), and low volume surgeons (OR, 1.2).

Conclusions

Based on these data, visual nerve identification was identified to be the gold standard of RLN treatment in thyroid surgery. RLNM is a promising tool for nerve identification and protection in extended thyroid resection procedures. However, because of the overall low frequency of RLNP, no statistical difference compared with visual nerve identification only was reached in the setting of this study.

Section snippets

Study design

From January 1, 1998, to January 15, 2001, a total of 16,448 consecutive operations with 29,998 operated thyroid sites (29,998 nerves at risk [NAR]) were evaluated prospectively; 15,412 (93.7%) of interventions were due to benign goiter and 1036 (6.3%) because of thyroid malignancies. A total of 8471 patients (51.5%) received bilateral subtotal thyroidectomy; 3698 patients (22.5%) underwent total resection on 1 site (hemithyroidectomy) and subtotal resection on the contralateral site.

Study group

Baseline characteristics of the entire cohort of patients were grouped according to the type of RLN treatment (groups 1-3; Table II).

Discussion

RLNP is the most striking stigma of postoperative thyroid morbidity. It is followed by enormous economic and health care burden, an increasing number of medicolegal proceedings, and significant disruption of socioeconomic outcome for the afflicted patients.7., 8. For approximately 4 decades, several methods have been developed to overcome the dilemma of RLN protection during surgery (ie, the fact that functional impairment could not be proved before removal of the endotracheal tube after the

References (24)

  • K.A. Kern

    Medicolegal analysis of errors in diagnosis and treatment of surgical endocrine disease

    Surgery

    (1993)
  • J.A. Sosa et al.

    The importance of surgeon experience for clinical and economic outcomes from thyroidectomy

    Ann Surg

    (1998)
  • Cited by (511)

    View all citing articles on Scopus

    Presented at the 25th Annual Meeting of the American Association of Endocrine Surgeons, Charlottesville, Virginia, April 4-6, 2004.

    Logistic support for the study was provided by Henning Berlin GmbH & Co KG, Berlin, Germany, and by Inomed GmbH, Teningen, Germany.

    View full text