The use of thyroid cartilage needle electrodes in intraoperative neuromonitoring during thyroidectomy: C<scp>ase–control</scp> study

Türk, Yiğit; Kıvratma, Göktuğ; Özdemir, Murat; İçöz, Gökhan; Makay, Özer

doi:10.1002/hed.26810

Cited by 12 publications

(13 citation statements)

References 21 publications

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“…In this study, we used the trans-thyroid cartilage EMG signal recording method (19,(27)(28)(29). The EMG amplitude will not be influenced by EMG tube displacement and the elicited signals remain high and stable during the entire course of operation that is important to monitor the actual status of RLN function.…”

Section: Discussionmentioning

confidence: 99%

Necessity of Routinely Testing the Proximal and Distal Ends of Exposed Recurrent Laryngeal Nerve During Monitored Thyroidectomy

et al. 2022

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ObjectivesIntraoperative neuromonitoring (IONM) is a useful tool to evaluate the function of recurrent laryngeal nerve (RLN) in thyroid surgery. This study aimed to determine the necessity and value of routinely testing the proximal and distal ends of RLN.MethodsIn total, 796 patients undergoing monitored thyroidectomies with standardized procedures were enrolled. All 1346 RLNs with visual integrity of anatomical continuity were routinely stimulated at the most proximal (R2p signal) and distal (R2d signal) ends after complete RLN dissection. The EMG amplitudes between R2p and R2d signals were compared. If the amplitude of R2p/R2d ratio reduction (RPDR) was over 10% or loss of signal (LOS) occurred, the exposed RLN was mapped to identify the injured point. Pre- and post-operative vocal cord (VC) mobility was routinely examined with video-laryngofiberscope.ResultsNerve injuries were detected in 108 (8%) RLNs, including 94 nerves with incomplete LOS (RPDR between 13%-93%) and 14 nerves with complete LOS. The nerve injuries were caused by traction in 80 nerves, dissecting trauma in 23 nerves and lateral heat spread of energy-based devices in 5 nerves. Symmetric VC mobility was found in 72 nerves with RPDR ≤50%. The occurrence of abnormal VC mobility (weak or fixed) was 14%, 67%, 100%, and 100% among the different RPDR stratifications of 51%-60%, 61%-70%, 71%-80%, and 81-93%, respectively. Of the 14 nerves with complete LOS, all showed fixed VC mobility. Permanent VC palsy occurred in 2 nerves with thermal injury.ConclusionRoutinely testing the proximal and distal ends of exposed RLN helps detect unrecognized partial nerve injury, elucidate the injury mechanism and determine injury severity. The procedure provides accurate information for evaluating RLN function after nerve dissection and should be included in the standard IONM procedure.

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Section: Discussionmentioning

confidence: 99%

Necessity of Routinely Testing the Proximal and Distal Ends of Exposed Recurrent Laryngeal Nerve During Monitored Thyroidectomy

et al. 2022

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“…Two fundamental elements of successful neuromonitoring are a proper recording of electrode position and NMB recovery. With respect to electrode position, in this study, we used a pair of outer thyroid cartilage electrodes to ensure stable EMG signals (34)(35)(36)(37)(38)(39) instead of electrodes of an EMG endotracheal tube, which was susceptible to rotational or depth changes (18,38,40). Regarding NMB management, several feasible regimens have been proposed to facilitate tracheal intubation and functional IONM (8).…”

Section: Discussionmentioning

confidence: 99%

A Surgeon-Centered Neuromuscular Block Protocol Improving Intraoperative Neuromonitoring Outcome of Thyroid Surgery

Hsu

Chang

et al. 2022

Front. Endocrinol.

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BackgroundNeuromuscular blocking agents provide muscular relaxation for tracheal intubation and surgery. However, the degree of neuromuscular block may disturb neuromuscular transmission and lead to weak electromyography during intraoperative neuromonitoring. This study aimed to investigate a surgeon-friendly neuromuscular block degree titrated sugammadex protocol to maintain both intraoperative neuromonitoring quality and surgical relaxation during thyroid surgery.MethodsA total of 116 patients were enrolled into two groups and underwent elective thyroid surgery with intraoperative neuromonitoring. All patients followed a standardized intraoperative neuromonitoring protocol with continuous neuromuscular transmission monitoring and received 0.6 mg/kg rocuronium for tracheal intubation. Patients were allocated into two groups according to the degree of neuromuscular block when the anterior surface of the thyroid gland was exposed. The neuromuscular block degree was assessed by the train-of-four (TOF) count and ratio. Patients in group I received sugammadex 0.25 mg/kg for non-deep neuromuscular block degree (TOF count = 1~4). Patients in group II were administered sugammadex 0.5 mg/kg for deep neuromuscular block degree (TOF count = 0). The quality of the intraoperative neuromonitoring was measured using the V1 electromyography (EMG) amplitude. An amplitude less than 500 μV and greater than 500 μV was defined as weak and satisfactory, respectively.ResultsThe quality of the intraoperative neuromonitoring was not different between groups I and II (satisfactory/weak: 75/1 vs. 38/2, P = 0.14). The quality of surgical relaxation was acceptable after sugammadex injection and showed no difference between groups [55/76 (72.3%) in group I vs. 33/40 (82.5%) in group II, P = 0.23].ConclusionsThis surgeon-centered sugammadex protocol guided by neuromuscular block degree (0.5 mg/kg for deep block and 0.25 mg/kg for others) showed comparably high intraoperative neuromonitoring quality and adequate surgical relaxation. The results expanded the practicality of sugammadex for precise neuromuscular block management during monitored thyroidectomy.

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“…Regarding the basis of anatomy, there are many innovative hypotheses and possible solutions including novel electrodes designs have been proposed. For example, many experimental (14)(15)(16)(17)(18) and clinical studies (19)(20)(21)(22)(23)(24)(25)(26)(27)(28) have confirmed the hypothesis that needle or adhesive surface recording electrodes attached to the thyroid cartilage (transcartilage or percutaneous recordings) or attached to the overlying neck skin (transcutaneous recording) can function like ET electrodes by enabling access to the EMG response of the vocal fold muscles (vocalis muscle and thyroarytenoid muscle) originating from the inner TC surface (Table 1, Figure 1). These studies have also demonstrated that transcutaneous or transcartilage anterior laryngeal (AL) recording electrodes are as accurate as ET-based surface electrodes in depicting RLN stress during IONM.…”

Section: Alternative Electrode Systems That Circumvent the Factors Affecting Et Recordingmentioning

confidence: 91%

New Developments in Anterior Laryngeal Recording Technique During Neuromonitored Thyroid and Parathyroid Surgery

Liu

Huang

et al. 2021

Front. Endocrinol.

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A recurrent laryngeal nerve (RLN) injury resulting in vocal fold paralysis and dysphonia remains a major source of morbidity after thyroid and parathyroid surgeries. Intraoperative neural monitoring (IONM) is increasingly accepted as an adjunct to the standard practice of visual RLN identification. Endotracheal tube (ET) surface recording electrode systems are now widely used for IONM; however, the major limitation of the clinical use of ET-based surface electrodes is the need to maintain constant contact between the electrodes and vocal folds during surgery to obtain a high-quality recording. An ET that is malpositioned during intubation or displaced during surgical manipulation can cause a false decrease or loss of electromyography (EMG) signal. Since it may be difficult to distinguish from an EMG change caused by a true RLN injury, a false loss or decrease in EMG signal may contribute to inappropriate surgical decision making. Therefore, researchers have investigated alternative electrode systems that circumvent common causes of poor accuracy in ET-based neuromonitoring. Recent experimental and clinical studies have confirmed the hypothesis that needle or adhesive surface recording electrodes attached to the thyroid cartilage (transcartilage and percutaneous recording) or attached to the overlying neck skin (transcutaneous recording) can provide functionality similar to that of ET-based electrodes, and these recording methods enable access to the EMG response of the vocalis muscle that originates from the inner surface of the thyroid cartilage. Studies also indicate that, during surgical manipulation of the trachea, transcartilage, percutaneous, and transcutaneous anterior laryngeal (AL) recording electrodes could be more stable than ET-based surface electrodes and could be equally accurate in depicting RLN stress during IONM. These findings show that these AL electrodes have potential applications in future designs of recording electrodes and support the use of IONM as a high-quality quantitative tool in thyroid and parathyroid surgery. This article reviews the major recent developments of newly emerging transcartilage, percutaneous, and transcutaneous AL recording techniques used in IONM and evaluates their contribution to improved voice outcomes in modern thyroid surgery.

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The use of thyroid cartilage needle electrodes in intraoperative neuromonitoring during thyroidectomy: Case–control study

Cited by 12 publications

References 21 publications

Necessity of Routinely Testing the Proximal and Distal Ends of Exposed Recurrent Laryngeal Nerve During Monitored Thyroidectomy

Necessity of Routinely Testing the Proximal and Distal Ends of Exposed Recurrent Laryngeal Nerve During Monitored Thyroidectomy

A Surgeon-Centered Neuromuscular Block Protocol Improving Intraoperative Neuromonitoring Outcome of Thyroid Surgery

New Developments in Anterior Laryngeal Recording Technique During Neuromonitored Thyroid and Parathyroid Surgery

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