Is intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) during thyroidectomy better than identification alone at reducing the risk of true vocal fold palsy (TVFP)?
Background: TVFP is one of the most feared complications of thyroidectomy and is, along with hypoparathyroidism, one of the leading causes for litigation after thyroidectomy. Additionally, some individuals with unilateral TVFP have significant swallowing and aspiration problems. IONM of the RLN has been advocated by some as a tool to help limit this complication.
Explore this issue:May 2011
Study design: Literature and data review, with a meta-analysis.
Setting: A systematic literature search.
Synopsis: In a search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, clinicaltrials.gov and the National Guideline Clearinghouse database, the authors evaluated 64,699 nerves-at-risk.
The overall incidence of TVFP was 3.52% for IONM versus 3.12% for nerve identification alone. Limitations of the study included sample size restrictions, no mention of unintentional RLN injury, multiple biases such as selection, technology and publication and no distinction between partial and full paralysis.
Bottom line: Although IONM is a tool that surgeons can consider using to assist in identification of the RLN during thyroidectomy, IONM should not be considered the standard of care, nor should it supplant anatomical identification of the RLN.
Citation: Higgins TS, Gupta R, Ketcham AS, et al. Recurrent laryngeal nerve monitoring versus identification alone on post-thyroidectomy true vocal fold palsy: a meta-analysis. Laryngoscope. 2011;121(5):1009-1017.
—Reviewed by Sue Pondrom