Archives of Head and Neck Surgery
Archives of Head and Neck Surgery
Original Article Thyroid diseases and tumors

Effectiveness of intraoperative neuromonitoring of the recurrent laryngeal nerve with intermittent vagal nerve stimulation

Marco Aurélio Vamondes Kulcsar, Felipe Toyama Aires, Danielli Matsuura, Lenine Garcia Brandão, Claudio Roberto Cernea

Downloads: 0
Views: 74


Introduction: Vocal fold paralysis due to recurrent laryngeal nerve (RLN) injury during thyroidectomy occurs in 1-5% of patients, but it can reach up to 15% in reoperations. Intraoperative neuromonitoring (IONM) during thyroidectomy was first described in 1970, and has been widely used by surgeons. However, data on the IONM capacity to predict inferior laryngeal nerve function are still lacking. Objective: To evaluate the effectiveness of IONM of the RLN using intermittent stimulation of the vagus nerve during thyroidectomy to predict post-operative vocal fold function. Methods: Retrospective cohort analysis of 104 patients undergoing thyroidectomy with IONM of the RLN through intermittent vagal nerve stimulation. IONM response and vocal fold mobility were evaluated utilizing the McNemar’s test associated with the Kappa agreement coefficient. Results: The final response of RLN stimulation showed 69.23% sensitivity and 93.79% specificity (p=0.180). Conclusion: IONM of the RLN through intermittent vagal nerve stimulation during thyroidectomy is effective to predict post-operative vocal fold function.


intraoperative neuromonitoring; laryngoscopy; thyroidectomy.


1. Cernea CR, Brandão LG, Brandão J. Neuromonitoring in thyroid surgery. Curr Opin Otolaryngol Head Neck Surg. 2012;20(2):125-9. PMid:22327789.

2. Hermann M, Hellebart C, Freissmuth M. Neuromonitoring in thyroid surgery: prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury. Ann Surg. 2004;240(1):9-17. PMid:15213612.

3. Pisanu A, Porceddu G, Podda M, Cois A, Uccheddu A. Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy. J Surg Res. 2014;188(1):152-61. PMid:24433869.

4. Rulli F, Ambrogi V, Dionigi G, Amirhassankhani S, Mineo TC, Ottaviani F, Buemi ADI, Stefano P, Mourad M. Meta-analysis of recurrent laryngeal nerve injury in thyroid surgery with or without intraoperative nerve monitoring. Acta Otorhinolaryngol Ital. 2014;34(4):223-9. PMid:25210215.

5. Siegel S, Castellan NJ Jr. Nonparametric statistics for the behavioral sciences. 2nd ed. New York: McGraw-Hill Humanities; 1988.

6. Randolph GW, Dralle H, Abdullah H, Barczynski M, Bellantone R, Brauckhoff M, Carnaille B, Cherenko S, Chiang FY, Dionigi G, Finck C, Hartl D, Kamani D, Lorenz K, Miccolli P, Mihai R, Miyauchi A, Orloff L, Perrier N, Poveda MD, Romanchishen A, Serpell J, Sitges-Serra A, Sloan T, Van Slycke S, Snyder S, Takami H, Volpi E, Woodson G. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope. 2011;121(Suppl 1):S1-16. PMid:21181860.

7. Tschopp KP, Gottardo C. Comparison of various methods of electromyographic monitoring of the recurrent laryngeal nerve in thyroid surgery. Ann Otol Rhinol Laryngol. 2002;111(9):811-6. PMid:12296336.

8. Otto RA, Cochran CS. Sensitivity and specificity of intraoperative recurrent laryngeal nerve stimulation in predicting postoperative nerve paralysis. Ann Otol Rhinol Laryngol. 2002;111(11):1005-7. PMid:12450175.

9. Snyder SK, Hendricks JC. Intraoperative neurophysiology testing of the recurrent laryngeal nerve: plaudits and pitfalls. Surgery. 2005;138(6):1183-91, discussion 1191-2. PMid:16360407.

10. Chan WF, Lang BH, Lo CY. The role of intraoperative neuromonitoring of recurrent laryngeal nerve during thyroidectomy: a comparative study on 1000 nerves at risk. Surgery. 2006;140(6):866-72, discussion 872-3. PMid:17188132.

11. Loch-Wilkinson TJ, Stalberg PL, Sidhu SB, Sywak MS, Wilkinson JF, Delbridge LW. Nerve stimulation in thyroid surgery: is it really useful? ANZ J Surg. 2007;77(5):377-80. PMid:17497981.

12. Barczyński M, Konturek A, Cichoń S. Cichon’ S randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg. 2009;96(3):240-6. PMid:19177420.

13. Cernea CR, Brandão LG, Hojaij FC, Carlucci D Jr, Brandão J, Cavalheiro B, Sondermann A. Negative and positive predictive values of nerve monitoring in thyroidectomy. Head Neck. 2012;34(2):175-9. PMid:21413099.

14. Calò PG, Pisano G, Medas F, Tatti A, Pittau MR, Demontis R, Favoriti P, Nicolosi A. Intraoperative recurrent laryngeal nerve monitoring in thyroid surgery: is it really useful? Clin Ter. 2013;164(3):e193-8. PMid:23868637.

15. Thomusch O, Sekulla C, Machens A, Neumann HJ, Timmermann W, Dralle H. Validity of intra-operative neuromonitoring signals in thyroid surgery. Langenbecks Arch Surg. 2004;389(6):499-503. PMid:14722777.

16. Goretzki PE, Schwarz K, Brinkmann J, Wirowski D, Lammers BJ. The impact of intraoperative neuromonitoring (IONM) on surgical strategy in bilateral thyroid diseases: is it worth the effort? World J Surg. 2010;34(6):1274-84. PMid:20143072.

17. Sadowski SM, Soardo P, Leuchter I, Robert JH, Triponez F. Systematic use of recurrent laryngeal nerve neuromonitoring changes the operative strategy in planned bilateral thyroidectomy. Thyroid. 2013;23(3):329-33. PMid:23249377.

18. Melin M, Schwarz K, Lammers BJ, Goretzki PE. IONM-guided goiter surgery leading to two-stage thyroidectomy--indication and results. Langenbecks Arch Surg. 2013;398(3):411-8. PMid:23179319.

19. Shindo M, Chheda NN. Incidence of vocal cord paralysis with and without recurrent laryngeal nerve monitoring during thyroidectomy. Arch Otolaryngol Head Neck Surg. 2007;133(5):481-5. PMid:17520762.

20. Cavicchi O, Caliceti U, Fernandez IJ, Macrì G, Di Lieto C, Marcantoni A, Ceroni AR, Piccin O. The value of neurostimulation and intraoperative nerve monitoring of inferior laryngeal nerve in thyroid surgery. Otolaryngol Head Neck Surg. 2009;140(6):866-70. PMid:19467405.

21. Alesina PF, Rolfs T, Hommeltenberg S, Hinrichs J, Meier B, Mohmand W, Hofmeister S, Walz MK. Intraoperative neuromonitoring does not reduce the incidence of recurrent laryngeal nerve palsy in thyroid reoperations: results of a retrospective comparative analysis. World J Surg. 2012;36(6):1348-53. PMid:22411090.

22. Duclos A, Lifante JC, Ducarroz S, Soardo P, Colin C, Peix JL. Influence of intraoperative neuromonitoring on surgeons’ technique during thyroidectomy. World J Surg. 2011;35(4):773-8. PMid:21267565.

23. Chiang FY, Lu IC, Kuo WR, Lee KW, Chang NC, Wu CW. The mechanism of recurrent laryngeal nerve injury during thyroid surgery - The application of intraoperative neuromonitoring. Surgery. 2008;143(6):743-9. PMid:18549890.

24. Donnellan KA, Pitman KT, Cannon CR, Replogle WH, Simmons JD. Intraoperative laryngeal nerve monitoring during thyroidectomy. Arch Otolaryngol Head Neck Surg. 2009;135(12):1196-8. PMid:20026815.

25. Dionigi G, Bacuzzi A, Boni L, Rovera F, Rausei S, Frattini F, Dionigi R. The technique of intraoperative neuromonitoring in thyroid surgery. Surg Technol Int. 2010;19:25-37. PMid:20437342.

26. Frattini F, Mangano A, Boni L, Rausei S, Biondi A, Dionigi G. Intraoperative neuromonitoring for thyroid malignancy surgery: technical notes and results from a retrospective series. Updates Surg. 2010;62(3-4):183-7. PMid:21153003.

27. Barczynski M, Konturek A, Stopa M, Hubalewska-Dydejczyk A, Richter P, Nowak W. Clinical value of intraoperative neuromonitoring of the recurrent laryngeal nerves in improving outcomes of surgery for well-differentiated thyroid cancer. Pol Przegl Chir. 2011;83(4):196-203. PMid:22166358.

28. Silva IC, Pedro I No, Vartanian JG, Kowalski LP, Carrara-de Angelis E. Prevalence of upper aerodigestive symptoms in patients who underwent thyroidectomy with and without the use of intraoperative laryngeal nerve monitoring. Thyroid. 2012;22(8):814-9. PMid:22780215.

29. Dionigi G, Chiang FY, Dralle H, Boni L, Rausei S, Rovera F, Piantanida E, Mangano A, Barczyński M, Randolph GW, Dionigi R, Ulmer C. Safety of neural monitoring in thyroid surgery. Int J Surg. 2013;11(Suppl 1):S120-6. PMid:24380543.

Submitted date:

Accepted date:

5fd2140a0e8825c041014ba4 archives Articles
Links & Downloads

Arch. Head Neck Surg.

Share this page
Page Sections