Recurrent laryngeal nerve injury with incomplete loss of electromyography signal during monitored thyroidectomy—evaluation and outcome

Percutaneous probe stimulation for intraoperative neuromonitoring in total endoscopic thyroidectomy: A preliminary experience

“…This finding also suggested that the percentage reduction in EMG amplitude compared to baseline EMG might reflect the severity of nerve injury and might correlate with postoperative vocal cord function. 17,18 Based on the results of this study and our clinical experience, we recommend using IONM via percutaneous probe stimulation during total endoscopic thyroidectomy to detect RLN distress and minimize the severity of injury early. When EMG shows a progressive decrease in amplitude larger than 50% and/or a latency increase to more than 10% of baseline, 16,19 we suggest pausing the surgical maneuver immediately to observe further EMG changes, especially at vulnerable points, such as the intersection of the RLN with the ITA and in the Berry's ligament region during RLN dissection.…”

“…Although the other 8 injured nerves that had poorer recoveries (final amplitude reduction, 65% to 80%) developed vocal cod palsy postoperatively, all vocal palsies were temporary and recovered in 3 months. This finding also suggested that the percentage reduction in EMG amplitude compared to baseline EMG might reflect the severity of nerve injury and might correlate with postoperative vocal cord function …”

Neuromuscular blockade management for intraoperative neural monitoring

“…RLN injury may result in hoarseness, dysphonia, dysphagia, and fatal aspiration . The incidence of temporary and permanent RLN paralysis after thyroid surgery ranged from 0.2 to 3.5 and 0 to 1.6%, respectively . In recent decades, much effort has been made to reduce the possibility of RLN injury.…”

“…1,2 The incidence of temporary and permanent RLN paralysis after thyroid surgery ranged from 0.2 to 3.5 and 0 to 1.6%, respectively. [3][4][5][6][7] In recent decades, much effort has been made to reduce the possibility of RLN injury. Intraoperative neural monitoring (IONM) is a noninvasive adjuvant developed to assist standard visualization, and detect variation, intraoperative management, and injury mechanism analysis of the RLN during thyroid and parathyroid surgery.…”

In response to Reversal of rocuronium‐induced neuromuscular blockade by sugammadex allows for optimization of neural monitoring of the recurrent laryngeal nerve

“…2 Second, a higher initial EMG signal is also crucial as 1) it can be as a reference to be compared with the final signal to predict the outcome of vocal cord function, 2) it is helpful to map the path of the recurrent laryngeal nerve intraoperatively, and 3) it is useful to detect early adverse signal change to prevent imminent nerve injury, particularly for continuous IONM. 3,4 Third, because sugammadex is currently an expensive product, a selective reversal approach may be more cost-effective. However, we have to emphasize that when a standard dose of rocuronium (0.6 mg/kg) is used for tracheal intubation, the recovery from neuromuscular blockade after rocuronium varies widely between subjects and may lead to a false-negative IONM result.…”