It is important to explain to patients that there are limitations to imaging and pathology in determining the presence of extrathyroidal extension, a contraindication to hemithyroidectomy. Understanding these limitations is absolutely critical to shared decision-making. —Eric Genden, MD
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March 2019
The group found that the cause of the loss of signal matters a great deal. Thermal and clamping injuries lead to the highest rates of permanent paralysis, while traction and compression, while they have high initial rates of paralysis, have comparatively low rates of permanent paralysis.
When performing neural monitoring, a baseline reading is essential, Dr. Randolph said. During surgery, when the amplitude and latency stay within a normative range, there is virtually no risk of vocal cord paralysis. The INMSG guideline lays out changes in signal that bring different levels of risk, underscoring the importance of respecting changes in electromyography (EMG) signal during the case as these are the warning signs of vocal cord paralysis, he said.
“A surgeon,” the group wrote, “should prioritize concern for the obvious significant medical and psychological morbidity of bilateral vocal cord paralysis and possible tracheotomy over perceived surgical convenience, the routine of doing the ‘planned procedure,’ or the potential perceived impact on surgical reputation by openly acknowledging the surgical complication of ipsilateral loss of signal.”
Gady Har-El, MD, chair of otolaryngology-head and neck surgery at Lenox Hill Hospital in New York City, said using active surveillance raises an ethical question: Since it is a new approach that departs from what has been considered standard for many years, independent review board (IRB) approval might be necessary.
“If I see tomorrow a 40-year-old lady with a small thyroid cancer who meets all of the criteria that are deemed appropriate for active surveillance—and I would like to do active surveillance—can I do it, without IRB approval?” he said. “This obviously has implications, both ethical and medical-legal.”
Dr. Wang and other panelists said IRB approval would be appropriate. “Ideally, an IRB is best for any medical intervention that is not considered standard,” she said. “The question is, is this considered standard of care? And probably not. It is a recommendation if you look in the ATA guidelines, but it’s very vague.”
Thomas R. Collins is a freelance medical writer based in Florida.