Varied Recurrent Laryngeal Nerve Course Is Associated with Increased Risk of Nerve Dysfunction During Thyroidectomy: Results of the Surgical Anatomy of the Recurrent Laryngeal Nerve in Thyroid Surgery Study, an International Multicenter Prospective Anatomic and Electrophysiologic Study of 1000 Monitored Nerves at Risk from the International Neural Monitoring Study Group

Liddy, Whitney; Wu, Che‐Wei; Dionigi, Gianlorenzo; Donatini, Gianluca; Şenyürek, Yasemin Giles; Kamani, Dipti; Iwata, Ayaka J.; Wang, Bo; Okose, Okenwa; Cheung, Anthony Y.; Saito, Yoshiyuki; Casella, Claudio; Aygün, Nurcihan; Uludağ, Mehmet; Brauckhoff, Katrin; Carnaille, B.; Tunca, Fatih; Barczyński, Marcin; Kim, Hoon Yub; Favero, Emerson; Innaro, Nadia; Vamvakidis, Kyriakos; Serpell, Jonathan W.; Romanchishen, Anatoly F; Takami, Hiroshi; Chiang, Feng‐Yu; Schneider, Rick; Dralle, Henning; Shin, Jennifer J.; Ahmed, Amr H. Abdelhamid; Randolph, Gregory W.

doi:10.1089/thy.2021.0155

Cited by 24 publications

(18 citation statements)

References 34 publications

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“…In total, 30% of nerves at risk were fixed/splayed/entrapped at the level of the thyroid capsule. The rate of entrapment of the nerve by the ligament of Berry and/or vascular structure in the Berry ligament region was 41%, rate of nerve thinner than 1 mm was found in 16%, and extralaryngeal branching was detected in 28% ( 22 ).…”

Section: Discussionmentioning

confidence: 98%

“…The mechanisms of RLN injury were examined under 5 main headings; traction trauma due to medial traction and elevation of the thyroid lobe (A), blunt trauma with a surgical instrument during dissection of the nerve, contusion, accidental clamping of the nerve, pressure, compression, or suction with a surgical instrument (B), clipping or ligating during or after dissection of the nerve during the separation of small vessels or connective tissue, touching the nerve directly with electrocautery or energy-based device, or thermal injury by lateral heat spread (D), dividing the nerve due to visual misidentification (E) ( 22 , 27 ).…”

Section: Methodsmentioning

confidence: 99%

“…A prospective international multicentric study evaluating 1,000 nerves considering this classification system and its associated RLN paralysis was recently published ( 22 ).…”

Section: Introductionmentioning

confidence: 99%

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Clinical and Anatomical Factors Affecting Recurrent Laryngeal Nerve Paralysis During Thyroidectomy via Intraoperative Nerve Monitorization

et al. 2022

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BackgroundDespite all the technical developments in thyroidectomy and the use of intraoperative nerve monitorization (IONM), recurrent laryngeal nerve (RLN) paralysis may still occur. We aimed to evaluate the effects of anatomical variations, clinical features, and intervention type on RLN paralysis.MethodThe RLNs identified till the laryngeal entry point, between January 2016 and September 2021 were included in the study. The effects of RLN anatomical features considering the International RLN Anatomical Classification System, intervention and monitoring types on RLN paralysis were evaluated.ResultsA total of 1,412 neck sides of 871 patients (672 F, 199 M) with a mean age of 49.17 + 13.42 years (range, 18–99) were evaluated. Eighty-three nerves (5.9%) including 78 nerves with transient (5.5%) and 5 (0.4%) with permanent vocal cord paralysis (VCP) were detected. The factors that may increase the risk of VCP were evaluated with binary logistic regression analysis. While the secondary thyroidectomy (OR: 2.809, 95%CI: 1.302–6.061, p = 0.008) and Berry entrapment of RLN (OR: 2.347, 95%CI: 1.425–3.876, p = 0.001) were detected as the independent risk factors for total VCP, the use of intermittent-IONM (OR: 2.217, 95% CI: 1.299–3.788, 0.004), secondary thyroidectomy (OR: 3.257, 95%CI: 1.340–7.937, p = 0.009), and nerve branching (OR: 1.739, 95%CI: 1.049–2.882, p = 0.032) were detected as independent risk factors for transient VCP.ConclusionPreference of continuous-IONM particularly in secondary thyroidectomies would reduce the risk of VCP. Anatomical variations of the RLN cannot be predicted preoperatively. Revealing anatomical features with careful dissection may contribute to risk reduction by minimizing actions causing traction trauma or compression on the nerve.

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Section: Discussionmentioning

confidence: 98%

Section: Methodsmentioning

confidence: 99%

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Clinical and Anatomical Factors Affecting Recurrent Laryngeal Nerve Paralysis During Thyroidectomy via Intraoperative Nerve Monitorization

et al. 2022

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“…For malignant disease, surgeons tend to dissect a longer segment in proximal end of RLN and perform central neck dissection; and tend to dissect the most distal end of RLN near laryngeal entry to decrease the tissue remnant in malignant disease. According to a large international registry database study with 1,000 RLNs at risks enrolled, the abnormal RLN trajectory (23%) was higher than surgeon expected, and 34% of RLN with loss of signal following an abnormal trajectory, for instance, fixed/splayed/entrapped RLN at the ligament of Berry, extensive RLN dissection, cases of cancer invasion or when lateral lymph node dissection ( 26 ). In this manner, the risk of RLN mechanical and thermal injury rate can be higher in malignant disease.…”

Section: Discussionmentioning

confidence: 99%

Prognostic Indicators of Non-Transection Nerve Injury and Vocal Fold Motion Impairment After Thyroid Surgery – Correlation Between Intraoperative Neuromonitoring Findings and Perioperative Voice Parameters

Huang

Chiang

et al. 2021

Front. Endocrinol.

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ObjectivesIn patients with recurrent laryngeal nerve (RLN) injury after thyroid surgery, unrecovered vocal fold motion (VFM) and subjective voice impairment cause extreme distress. For surgeons, treating these poor outcomes is extremely challenging. To enable early treatment of VFM impairment, this study evaluated prognostic indicators of non-transection RLN injury and VFM impairment after thyroid surgery and evaluated correlations between intraoperative neuromonitoring (IONM) findings and perioperative voice parameters.Methods82 adult patients had postoperative VFM impairment after thyroidectomy were enrolled. Demographic characteristics, RLN electromyography (EMG), and RLN injury mechanism were compared. Multi-dimensional voice program, voice range profile and Index of voice and swallowing handicap of thyroidectomy (IVST) were administered during I-preoperative; II-immediate, III-short-term and IV-long-term postoperative periods. The patients were divided into R/U Group according to the VFM was recovered/unrecovered 3 months after surgery. The patients in U Group were divided into U1/U2 Group according to total IVST score change was <4 and ≥4 during period-IV.ResultsCompared to R Group (42 patients), U Group (38 patients) had significantly more patients with EMG >90% decrease in the injured RLN (p<0.001) and thermal injury as the RLN injury mechanism (p=0.002). Voice parameter impairments were more severe in U Group compared to R Group. Compared to U1 group (19 patients), U2 Group (19 patients) had a significantly larger proportion of patients with EMG decrease >90% in the injured RLN (p=0.022) and thermal injury as the RLN injury mechanism (p=0.017). A large pitch range decrease in period-II was a prognostic indicator of a moderate/severe long-term postoperative subjective voice impairment.ConclusionThis study is the first to evaluate correlations between IONM findings and voice outcomes in patients with VFM impairment after thyroid surgery. Thyroid surgeons should make every effort to avoid severe type RLN injury (e.g., thermal injury or injury causing EMG decrease >90%), which raises the risk of unrecovered VFM and moderate/severe long-term postoperative subjective voice impairment. Using objective voice parameters (e.g., pitch range) as prognostic indicators not only enables surgeons to earlier identify patients with low voice satisfaction after surgery, and also enable implementation of interventions sufficiently early to maintain quality of life.

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“…However, Arulalan Mathialagan et al [ 36 ] reported that in patients undergoing selective neck dissection for primary oral malignancy, nerve injury was less, and spinal accessory nerve function recovery was better in harmonic scalpel group as compared to the electro cautery group. Intraoperative nerve monitoring (IONM) has been applied in many operations, such as thyroid surgery [ 37 , 38 ], esophageal cancer surgery for recurrent laryngeal nerve protection [ 39 , 40 ], and craniocerebral surgery [ 41 ]; however, it is rarely used in pulmonary surgery. The reason might be that cough in patients after surgery had a good long-term recovery, while researchers ignored cough that may have troubled patients in the short term, or even persistent long-term cough of some patients.…”

Section: Discussionmentioning

confidence: 99%

Lymph Node Dissection Is a Risk Factor for Short-Term Cough after Pulmonary Resection

Xing

Chen

et al. 2022

Current Oncology

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Cough is a common complication after pulmonary resection. However, the factors associated with cough that develop after pulmonary resection are still controversial. In this study, we used the Simplified Cough Score (SCS) and the Leicester Cough Questionnaire (LCQ) score to investigate potential risk factors for postoperative cough. Between January 2017 and June 2021, we collected the clinical data of 517 patients, the SCS at three days after surgery and the LCQ at two weeks and six weeks after surgery. Then, univariate and multivariate analyses were used to identify the independent risk factors for postoperative cough. The clinical baseline data of the cough group and the non-cough group were similar. However, the cough group had longer operation time and more blood loss. The patients who underwent lobectomy were more likely to develop postoperative cough than the patients who underwent segmentectomy and wedge resection, while the patients who underwent systematic lymph node dissection were more likely to develop postoperative cough than the patients who underwent lymph node sampling and those who did not undergo lymph node resection. When the same lymph node management method was applied, there was no difference in the LCQ scores between the patients who underwent wedge resection, lobectomy and segmentectomy. The lymph node resection method was an independent risk factor for postoperative cough (p < 0.001). Conclusions: Lymph node resection is an independent risk factor for short-term cough after pulmonary resection with video-assisted thoracoscopic surgery, and damage to the vagus nerve and its branches (particularly the pulmonary branches) is a possible cause of short-term cough. The mechanism of postoperative cough remains to be further studied.

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Cited by 24 publications

References 34 publications

Clinical and Anatomical Factors Affecting Recurrent Laryngeal Nerve Paralysis During Thyroidectomy via Intraoperative Nerve Monitorization

Clinical and Anatomical Factors Affecting Recurrent Laryngeal Nerve Paralysis During Thyroidectomy via Intraoperative Nerve Monitorization

Prognostic Indicators of Non-Transection Nerve Injury and Vocal Fold Motion Impairment After Thyroid Surgery – Correlation Between Intraoperative Neuromonitoring Findings and Perioperative Voice Parameters

Lymph Node Dissection Is a Risk Factor for Short-Term Cough after Pulmonary Resection

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