Continuous Laryngeal Adductor Reflex Versus Intermittent Nerve Monitoring in Neck Endocrine Surgery

ABSTRACT Background Various approaches can be employed when teaching thyroidectomy. Delivery of the gland prior to complete dissection and identification of the recurrent laryngeal nerve (RLN) is sometimes utilized in the absence of laryngeal nerve monitoring (LNM), while identification and dissection of the RLN from the gland is more feasible in the presence of LNM. We hypothesized that teaching RLN dissection technique to residents as primary surgeons (using loupes and nerve monitoring) did not increase postoperative morbidity in head and neck endocrine surgery. Materials and methods In 101 consecutive patients who underwent thyroidectomies/parathyroidectomies, we have modified our technique to teach our residents consistent early identification of the RLN in the paratracheal region by direct visualization (loupe magnification) and nerve stimulation. All patients had preoperative fiberoptic laryngoscopy and a repeat laryngoscopy 1 week after surgery. Presence or absence of true vocal fold paralysis/paresis was documented. Results One hundred and nineteen surgical procedures were available for study. One patient developed a permanent vocal fold paralysis (1/119 or 0.84%). There was another patient with a vocal fold paresis which recovered in 4 weeks (1/119 or 0.84%). Conclusion The RLN dissection technique with early identification, dissection and preservation of the nerve using magnification combined with nerve monitoring has emerged as an important resident teaching tool. The morbidity rate is acceptable. Notably in light of the increasing rates of thyroid surgery and LNM utilization, resident physicians may benefit from exposure to this technique as a component of their training. How to cite this article Sundaram K, Aynehchi BB. Teaching Recurrent Laryngeal Nerve Dissection to Residents in Head and Neck Endocrine Surgery. Int J Head and Neck Surg 2012;3(1):5-7.

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Critical Review and Consensus Statement for Neural Monitoring in Otolaryngologic Head, Neck, and Endocrine Surgery

Otolaryngology ◽

10.1177/01945998211011062 ◽

2021 ◽

pp. 019459982110110

Author(s):

Joseph Scharpf ◽

Jeffrey C. Liu ◽

Catherine Sinclair ◽

Michael Singer ◽

Whitney Liddy ◽

...

Keyword(s):

Head And Neck ◽

Patient Outcomes ◽

Cranial Nerve ◽

Consensus Statement ◽

Task Force ◽

Cranial Nerves ◽

Endocrine Surgery ◽

Nerve Monitoring ◽

Modified Delphi ◽

Head Neck

Background Enhancing patient outcomes in an array of surgical procedures in the head and neck requires the maintenance of complex regional functions through the protection of cranial nerve integrity. This review and consensus statement cover the scope of cranial nerve monitoring of all cranial nerves that are of practical importance in head, neck, and endocrine surgery except for cranial nerves VII and VIII within the temporal bone. Complete and applied understanding of neurophysiologic principles facilitates the surgeon’s ability to monitor the at-risk nerve. Methods The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) identified the need for a consensus statement on cranial nerve monitoring. An AAO-HNS task force was created through soliciting experts on the subject. Relevant domains were identified, including residency education, neurophysiology, application, and various techniques for monitoring pertinent cranial nerves. A document was generated to incorporate and consolidate these domains. The panel used a modified Delphi method for consensus generation. Results Consensus was achieved in the domains of education needs and anesthesia considerations, as well as setup, troubleshooting, and documentation. Specific cranial nerve monitoring was evaluated and reached consensus for all cranial nerves in statement 4 with the exception of the spinal accessory nerve. Although the spinal accessory nerve’s value can never be marginalized, the task force did not feel that the existing literature was as robust to support a recommendation of routine monitoring of this nerve. In contrast, there is robust supporting literature cited and consensus for routine monitoring in certain procedures, such as thyroid surgery, to optimize patient outcomes. Conclusions The AAO-HNS Cranial Nerve Monitoring Task Force has provided a state-of-the-art review in neural monitoring in otolaryngologic head, neck, and endocrine surgery. The evidence-based review was complemented by consensus statements utilizing a modified Delphi method to prioritize key statements to enhance patient outcomes in an array of surgical procedures in the head and neck. A precise definition of what actually constitutes intraoperative nerve monitoring and its benefits have been provided.

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Noninvasive Continuous Vagal-Nerve Monitoring, Harnessing the Primitive Laryngeal Adductor Reflex, Is on the Horizon

Clinical Thyroidology ◽

10.1089/ct.2019;31.490-492 ◽

2019 ◽

Vol 31 (11) ◽

pp. 490-492

Author(s):

Lisa A. Orloff

Keyword(s):

Vagal Nerve ◽

Nerve Monitoring ◽

Laryngeal Adductor Reflex

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Continuous Intraoperative Recurrent Laryngeal Nerve Monitoring: Techniques, Applications, and Controversies

Current Otorhinolaryngology Reports ◽

10.1007/s40136-021-00353-7 ◽

2021 ◽

Author(s):

Julia I. Staubitz ◽

Thomas J. Musholt

Keyword(s):

Recurrent Laryngeal Nerve ◽

Recurrent Laryngeal Nerve Palsy ◽

Vocal Cord Palsy ◽

Laryngeal Nerve ◽

Vagal Nerve ◽

Direct Stimulation ◽

Nerve Monitoring ◽

Current State ◽

Laryngeal Adductor Reflex ◽

Recurrent Laryngeal Nerve Monitoring

Abstract Purpose of Review Purpose of the present review is to illustrate the current state of the art concerning continuous intraoperative recurrent laryngeal nerve monitoring (cIONM) for thyroid surgery. Recent Findings cIONM potentially leads to an improved postoperative vocal cord palsy rate, compared to the intermittent technique. There are currently two main approaches for cIONM: either conventional cIONM based on vagal nerve stimulation or experimental methods, which do not require the positioning of a vagal nerve electrode. One of these methods is the recently described technique “LAR-cIONM,” which utilizes the laryngeal adductor reflex. Summary cIONM represents an advancement of intermittent nerve monitoring, which allows for an immediate reaction to signal changes. Threshold values and guidelines to prevent recurrent laryngeal nerve palsy were validated for the direct stimulation of the vagal nerve and require verification for alterative cIONM methods, including LAR-cIONM.

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