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Langenbeck's Archives of Surgery
Published in: Langenbeck's Archives of Surgery 6/2017

Open Access 01-09-2017 | ORIGINAL ARTICLE

Prognostic value of intraoperative neural monitoring of the recurrent laryngeal nerve in thyroid surgery

Authors: Małgorzata Stopa, Marcin Barczyński

Published in: Langenbeck's Archives of Surgery | Issue 6/2017

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Abstract

Purpose

The diagnostic accuracy of intraoperative recurrent laryngeal nerve (RLN) monitoring (IONM) remains controversial. The aim of this study was to evaluate IONM diagnostic accuracy in prognostication of postoperative nerve function in thyroid surgery.

Methods

This prospective study was conducted in 2011–2013. Five hundred consenting patients qualified for total thyroidectomy with IONM (1000 nerves at risk) using NIM 3.0 Response equipment were included. Laryngoscopy was used to evaluate and follow up RLN injury. The primary outcome was diagnostic accuracy of IONM. The receiver operating characteristics (ROC) were used for evaluation of IONM diagnostic accuracy.

Results

Loss of signal (LOS) occurred in 31 cases, including 25 patients with LOS and corresponding vocal fold paresis found in postoperative laryngoscopy (2.5 %), including 20 (2.0 %) temporary and 5 (0.5 %) permanent nerve lesions. The following diagnostic accuracy values were calculated for the criterion recommended by INMSG (V2 amplitude ≤ 100 μV): sensitivity 92.0 %, specificity 99.3 %, positive predictive value (PPV) 76.7 %, and negative predictive value (NPV) 99.8 %. The ROC curve analysis allowed for calculation of the most optimal criterion in prognostication of postoperative vocal fold paresis, namely, V2 amplitude ≤ 189 μV. For this criterion, PPV was 77.4 %, while NPV was 99.9 %.

Conclusions

Adherence to the standardized protocol recommended by the International Neural Monitoring Study Group allows for optimizing predictive values of IONM in prognostication of postoperative RLN function. Any changes in the cutoff values for the definition of LOS only marginally improve PPV and NPV of IONM and need to be carefully assessed in multicenter studies.
Literature
1.
Dralle H, Sekulla C, Lorenz K, Brauckhoff M, Machens A, German IONM Study Group (2008) Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg 32:1358–1366CrossRefPubMed
2.
Randolph GW, Dralle H, International Nerve Monitoring Study Group (2011) Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope 121(Suppl 1):S1–16CrossRefPubMed
3.
Barczyński M, Randolph GW, Cernea CR, Dralle H, Dionigi G, Alesina PF, Mihai R, Finck C, Lombardi D, Hartl DM, Miyauchi A, Serpell J, Snyder S, Volpi E, Woodson G, Kraimps JL, Hisham AN, International Neural Monitoring Study Group (2013) External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: international neural monitoring study group standards guideline statement. Laryngoscope 123(Suppl 4):S1–14CrossRefPubMed
4.
Randolph GW, Kamani D (2014) Intraoperative neural monitoring in thyroid cancer surgery. Langenbecks Arch Surg 399:199–207CrossRefPubMed
5.
Sturgeon C, Sturgeon T, Angelos P (2009) Neuromonitoring in thyroid surgery: attitudes, usage patterns, and predictors of use among endocrine surgeons. World J Surg 33:417–425CrossRefPubMed
6.
Chan WF, Lo CY (2006) Pitfalls of intraoperative neuromonitoring for predicting postoperative recurrent laryngeal nerve function during thyroidectomy. World J Surg 30:806–812CrossRefPubMed
7.
Barczyński M, Konturek A, Cichoń S (2009) Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg 96:240–246CrossRefPubMed
8.
Barczyński M, Konturek A, Pragacz K, Papier A, Stopa M, Nowak W (2014) Intraoperative nerve monitoring can reduce prevalence of recurrent laryngeal nerve injury in thyroid reoperations: results of a retrospective cohort study. World J Surg 38:599–606CrossRefPubMed
9.
Dionigi G, Frattini F (2013) Staged thyroidectomy: time to consider intraoperative neuromonitoring as standard of care. Thyroid 23:906–908CrossRefPubMed
10.
Melin M, Schwarz K, Lammers BJ, Goretzki PE (2013) IONM-guided goiter surgery leading to two-stage thyroidectomy—indication and results. Langenbecks Arch Surg 398:411–418CrossRefPubMed
11.
Dralle H, Sekulla C, Lorenz K, Nguyen Thanh P, Schneider R, Machens A (2012) Loss of the nerve monitoring signal during bilateral thyroid surgery. Br J Surg 99:1089–1095CrossRefPubMed
12.
Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig L, Lijmer JG, Moher D, Rennie D, de Vet HC, Kressel HY, Rifai N, Golub RM, Altman DG, Hooft L, Korevaar DA, Cohen JF, STARD Group (2015) STARD 2015: an updated list of essential items for reporting diagnostic accuracy studies. BMJ 351, h5527CrossRefPubMedPubMedCentral
13.
Randolph GW, Kobler JB, Wilkins J (2004) Recurrent laryngeal nerve identification and assessment during thyroid surgery: laryngeal palpation. World J Surg 28:755–760CrossRefPubMed
14.
DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44:837–845CrossRefPubMed
15.
Schneider R, Bures C, Lorenz K, Dralle H, Freissmuth M, Hermann M (2013) Evolution of nerve injury with unexpected EMG signal recovery in thyroid surgery using continuous intraoperative neuromonitoring. World J Surg 37:364–368CrossRefPubMed
16.
Schneider R, Randolph GW, Sekulla C, Phelan E, Thanh PN, Bucher M, Machens A, Dralle H, Lorenz K (2013) Continuous intraoperative vagus nerve stimulation for identification of imminent recurrent laryngeal nerve injury. Head Neck 35:1591–1598CrossRefPubMed
17.
Phelan E, Schneider R, Lorenz K, Dralle H, Kamani D, Potenza A, Sritharan N, Shin J, Randolph GW (2014) Continuous vagal IONM prevents recurrent laryngeal nerve paralysis by revealing initial EMG changes of impending neuropraxic injury: a prospective, multicenter study. Laryngoscope 124:1498–1505CrossRefPubMed
18.
Schneider R, Sekulla C, Machens A, Lorenz K, Nguyen Thanh P, Dralle H (2015) Postoperative vocal fold palsy in patients undergoing thyroid surgery with continuous or intermittent nerve monitoring. Br J Surg 102:1380–1387CrossRefPubMed
19.
Genther DJ, Kandil EH, Noureldine SI, Tufano RP (2014) Correlation of final evoked potential amplitudes on intraoperative electromyography of the recurrent laryngeal nerve with immediate postoperative vocal fold function after thyroid and parathyroid surgery. JAMA Otolaryngol Head Neck Surg 140:124–128CrossRefPubMedPubMedCentral
20.
Goretzki PE, Schwarz K, Brinkmann J, Wirowski D, Lammers BJ (2010) The impact of intraoperative neuromonitoring (IONM) on surgical strategy in bilateral thyroid diseases: is it worth the effort? World J Surg 34:1274–1284CrossRefPubMed
21.
Sadowski SM, Soardo P, Leuchter I, Robert JH, Triponez F (2013) Systematic use of recurrent laryngeal nerve neuromonitoring changes the operative strategy in planned bilateral thyroidectomy. Thyroid 23:329–333CrossRefPubMed
22.
Barczyński M, Randolph GW, Cernea C, International Neural Monitoring Study Group in Thyroid and Parathyroid Surgery (2016) International survey on the identification and neural monitoring of the EBSLN during thyroidectomy. Laryngoscope 126:285–91CrossRefPubMed
23.
Sitges-Serra A, Fontané J, Dueñas JP, Duque CS, Lorente L, Trillo L, Sancho JJ (2013) Prospective study on loss of signal on the first side during neuromonitoring of the recurrent laryngeal nerve in total thyroidectomy. Br J Surg 100:662–666CrossRefPubMed
24.
Dionigi G, Boni L, Rovera F, Rausei S, Castelnuovo P, Dionigi R (2010) Postoperative laryngoscopy in thyroid surgery: proper timing to detect recurrent laryngeal nerve injury. Langenbecks Arch Surg 395:327–331CrossRefPubMed
25.
Dionigi G, Bacuzzi A, Boni L, Rausei S, Rovera F, Dionigi R (2012) Visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy: what about the costs? World J Surg 36:748–754CrossRefPubMed
26.
Dralle H, Lorenz K, Machens A (2012) Verdicts on malpractice claims after thyroid surgery: emerging trends and future directions. Head Neck 34:1591–1596CrossRefPubMed
Metadata
Title
Prognostic value of intraoperative neural monitoring of the recurrent laryngeal nerve in thyroid surgery
Authors
Małgorzata Stopa
Marcin Barczyński
Publication date
01-09-2017
Publisher
Springer Berlin Heidelberg
Published in
Langenbeck's Archives of Surgery / Issue 6/2017
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI
https://doi.org/10.1007/s00423-016-1441-0

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