Role of Intraoperative Nerve Monitoring During Parathyroidectomy to Prevent Recurrent Laryngeal Nerve Injury

Abstract

Injury to the recurrent laryngeal nerve (RLN) is a well known, though less frequent, complication of parathyroid surgery. In recent years, the use of intraoperative nerve monitoring (IONM) has gained popularity amongst surgeons when operating on thyroid gland; however, its utilization in parathyroid surgery is not established. This trend continues to rise, despite multiple studies documenting no statistically significant difference that IONM decreases the incidence of RLN injury. Most surgeons use this technology as an adjunct to visualization alone for identification of RLN. The purpose of this review is to discuss the possible role of IONM in parathyroid surgery with regards to the accuracy, efficacy, and recent trends in the utilization of this technology. There is insufficient evidence that IONM reduces the risk of RLN injury in parathyroidectomy. Although IONM may decrease the likelihood of nerve injury by helping to identify and map the RLN during thyroidectomy, we did not find studies exclusive to parathyroid surgery to see if its use can be supported for parathyroidectomy. Despite this lack of evidence, we believe that IONM is a promising adjunct to visualization alone in detecting nerve structures during neck dissection, but more clinical trials are warranted to establish its role in preventing nerve injury in parathyroid surgery.

Secondary and Tertiary Hyperparathyroidism: A Narrative Review

“…As the RLN is at risk, it should ideally always be identified and carefully handled during parathyroid surgery. Surgical adjuncts such as RLN monitoring may be used to assist the surgeon in preservation of the RLN (61). The clinical benefit of RLN monitoring during PTx for secondary or tertiary HPT is not well established.…”

“…The clinical benefit of RLN monitoring during PTx for secondary or tertiary HPT is not well established. Snyder et al found that the use of RLN monitoring for thyroid and parathyroid tissue did lead to a decline in injury rates of the RLN, but other studies could not replicate this finding (61–63). RLN monitoring might especially be of assistance during difficult cases such as re-operative setting.…”

Thyroid Gland Flap for Minimally Invasive Reconstructive Head and Neck Surgery

“…When elevating a larger flap, monitoring the nerve intraoperatively might be necessary for its preservation. 21 …”

Surgical Management of Secondary Hyperparathyroidism

“…Intraoperative nerve monitoring is frequently used in various neck procedures to help identify and preserve the recurrent laryngeal nerves. 67 Studies on PTX patients specifically have been conflicted on whether intraoperative nerve monitoring actually prevents recurrent laryngeal nerve injury, which can cause permanent voice changes and airway complications. 67 Although its results may not be generalizable, a recent large meta-analysis of bilateral thyroidectomy patients showed a significantly decreased risk of both transient (risk ratio = 0.71) and permanent (risk difference = −0.0026) recurrent laryngeal nerve injury with intraoperative nerve monitoring.…”

“… 67 Studies on PTX patients specifically have been conflicted on whether intraoperative nerve monitoring actually prevents recurrent laryngeal nerve injury, which can cause permanent voice changes and airway complications. 67 Although its results may not be generalizable, a recent large meta-analysis of bilateral thyroidectomy patients showed a significantly decreased risk of both transient (risk ratio = 0.71) and permanent (risk difference = −0.0026) recurrent laryngeal nerve injury with intraoperative nerve monitoring. 68 Use of this technology varies by institution and, to our knowledge, has not been studied in SHPT patients specifically.…”