Skip to main content
SpringerLink
Log in

Loss of Signal in IONM and Staged Thyroid Surgery

  • Chapter
  • First Online:
The Recurrent and Superior Laryngeal Nerves

Abstract

Intraoperative neuromonitoring (IONM) through vagus nerve (VN) stimulation in thyroid surgery provides indisputable recurrent laryngeal nerve (RLN) identification and comprehensive functional assessment of neural integrity during the process of thyroid resection. Neurostimulation of the RLN and VN generates an electromyogram with audio-tone. Relevant information regarding neural integrity using IONM is gained by observing the EMG parameters of amplitude, latency, and signal configuration. Relevant changes and corresponding surgical maneuvers must be considered to react timely and thereby possibly prevent neural injury. The hallmark of neural injury that corresponds with postoperative vocal cord dysfunction is the loss of signal (LOS) without recovery during IONM-guided thyroid surgery. Therefore, after LOS on the first side operated, staging of the planned bilateral surgery by postponing the second side until RLN function is restored is recommended. In this chapter, detailed definitions of the relevant IONM parameters and LOS are provided, and a description of IONM application with procedural recommendations is presented.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Randolph GW, Dralle H, Abdullah H, Barczynski M, Bellantone R, Brauckhoff M, Carnaille B, Cherenko S, Chiang FY, Dionigi G, Finck C, Hartl D, Kamani D, Lorenz K, Miccoli P, Mihai R, Miyauchi A, Orloff L, Perrier N, Poveda MD, Romanchishen A, Serpell J, Sitges-Serra A, Solan T, Van Slycke S, Snyder S, Takami H, Volpi E, Woodson G. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope. 2011;121:S1–16.

    Article  PubMed  Google Scholar 

  2. Dralle H, Sekulla C, Lorenz K, Brauckhoff M, Machens A. Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg. 2008;32:1438–66.

    Article  Google Scholar 

  3. Dralle H, Lorenz K. Intraoperative neuromonitoring of thyroid gland operations: surgical standards and aspects of expert assessment. Chirurg. 2010;81:612–9.

    Article  CAS  PubMed  Google Scholar 

  4. Dralle H, Lorenz K, Schabram P, Musholt TJ, Dotzenrath C, Goretzki PE, Kußmann J, Nies C, Scheuba C, Simon D, Steinmüller T, Trupka A. Intraoperative neuromonitoring in thyroid surgery. Recommendations of the German association of endocrine surgeons (CAEK). Chirurg. 2013;84: 1049–56.

    Article  CAS  PubMed  Google Scholar 

  5. Schneider R, Sekulla C, Machens A, Lorenz K, Nguyen Thanh P, Dralle H. Postoperative vocal fold palsy in patients undergoing in thyroid surgery with continuous and intermittent nerve monitoring. Br J Surg. 2015;102(11):1380–7.

    Article  CAS  PubMed  Google Scholar 

  6. Lorenz K, Dralle H. Intraoperatives Neuromonitoring in der Schilddrüsenchirurgie. In: Dralle H, editor. Endokrine Chirurgie. Evidenz und Erfahrung. Stuttgart: Schattauer; 2014. p. 88–111.

    Google Scholar 

  7. Schneider R, Randolph GW, Sekulla C, Phelan E, Nguyen Thanh P, Bucher M, Machens A, Dralle H, Lorenz K. Continuous intraoperative vagus nerve stimulation for identification of imminent recurrent laryngeal nerve injury. Head Neck. 2013;35:1591–8.

    Article  PubMed  Google Scholar 

  8. Lorenz K, Abuazab M, Sekulla C, Schneider R, Nguyen Thanh P, Dralle H. Results of intraoperative neuromonitoring in thyroid surgery and preoperative vocal cord paralysis. World J Surg. 2014;38:582–91.

    Article  PubMed  Google Scholar 

  9. Fontenot TE, Randolph GW, Setton TE, Alsaleh N, Kandil E. Does intraoperative nerve monitoring reliably aid in staging of total thyroidectomies? Laryngoscope. 2015;125(9):2232–5. doi:10.1002/lary.25133.

    Article  PubMed  Google Scholar 

  10. Lorenz K, Sekulla C, Schelle J, Schmeiss B, Brauckhoff M, Dralle H, German Neuromonitoring Study Group. What are normal quantitative parameters of intraoperative neuromonitoring (IONM) in thyroid surgery? Langenbecks Arch Surg. 2010;395: 901–9.

    Article  PubMed  Google Scholar 

  11. Randolph GW, Kamani D. The importance of preoperative laryngoscopy in patients undergoing thyroidectomy: voice, vocal cord function, and the preoperative detection of invasive thyroid malignancy. Surgery. 2006;139:357–62.

    Article  PubMed  Google Scholar 

  12. Chiang FY, Lu IC, Tsai CJ, Hsiao PJ, Hsu CC, Wu CW. Does extensive dissection of recurrent laryngeal nerve during thyroid operation increase the risk of nerve injury? Evidence from the application of intraoperative neuromonitoring. Am J Otolaryngol. 2011;32:499–503.

    Article  PubMed  Google Scholar 

  13. Périé S, Aïit-Mansour A, Devos M, Sonji G, Buajat B, St Guily JL. Value of recurrent laryngeal nerve monitoring in the operative strategy during total thyroidectomy and parathyroidectomy. Eur Ann Otorhinolaryngol Head Neck Dis. 2013;130:131–6.

    Article  PubMed  Google Scholar 

  14. Friedrich C, Ulmer C, Rieber F, Kern E, Kohler A, Schymik K, Thon KP, Lamadé W. Safety analysis of vagal nerve stimulation for continuous nerve monitoring during thyroid surgery. Laryngoscope. 2012;122: 1979–87.

    Article  PubMed  Google Scholar 

  15. Caragacianu D, Kamani D, Randolph GW. Intraoperative monitoring: normative range associated with normal postoperative glottic function. Laryngoscope. 2013;123:3026–31.

    Article  PubMed  Google Scholar 

  16. Phelan E, Schneider R, Lorenz K, Dralle H, Kamani D, Potenza A, Sritharan N, Shin J, Randolph G W. Continuous vagal IONM prevents recurrent laryngeal nerve paralysis by revealing initial EMG changes of impending neuropraxic injury: a prospective, multicenter study. Laryngoscope. 2014;124:1498–505.

    Article  PubMed  Google Scholar 

  17. Pavier Y, Saroul N, Pereira B, Tauveron I, Gilain L, Mom T. Acute prediction of laryngeal outcome during thyroid surgery by electromyographic laryngeal monitoring. Head Neck. 2015;37(6):835–9. doi:10.1002/hed.23676.

    Article  PubMed  Google Scholar 

  18. Sritharan N, Chase M, Kamani D, Randolph M, Randolph GW. The vagus nerve, recurrent laryngeal nerve, and external branch of the superior laryngeal nerve have unique latencies allowing for intraoperative documentation of intact neural function during thyroid surgery. Laryngoscope. 2015;125:E84–9.

    Article  PubMed  Google Scholar 

  19. Schneider R, Sekulla C, Triponez F, Dionigi G, Vamvakidis K, Brauckhoff M, Barczysnki M, Musholt TJ, Almquist M, Innaro N, Chiang FY, Jimenez-Garcia A, Kraimps JL, Miyauchi A, Randolph GW, Wojtczak B, Donatini G, Lombardi D, Müller U, Pezzullo L, Ratia T, Van Slycke S, Nguyen Thanh P, Lorenz K, Machens A, Dralle H. Prognostic impact of intraoperative loss of nerve signal upon postoperative vocal fold mobility after thyroidectomy: an international neuromonitoring study group prospective evaluation study (POLT). 2015. doi: 10.1002/lary.25807

    Google Scholar 

  20. Sitges-Serra A, Fontané J, Dueñas JP, Duque CS, Lorente L, Trillo L, Sancho JJ. Prospective study on loss of signal on the first side during neuromonitoring of the recurrent laryngeal nerve in total thyroidectomy. Br J Surg. 2013;100:662–6.

    Article  CAS  PubMed  Google Scholar 

  21. Wang LF, Lee KW, Kuo WR, Wu CW, Lu SP, Chiang FY. The efficacy of intraoperative corticosteroids in recurrent laryngeal nerve palsy after thyroid surgery. World J Surg. 2006;30:299–303.

    Article  PubMed  Google Scholar 

  22. Hydman J, Björck G, Persson JK, Zedenius J, Mattsson P. Diagnosis and prognosis of iatrogenic injury of the recurrent laryngeal nerve. Ann Otol Rhinol Laryngol. 2009;118:506–11.

    Article  PubMed  Google Scholar 

  23. Sridharan SS, Rosen CA, Smith LJ, Young VN, Munin MC. Timing of nimodipine therapy for the treatment of vocal fold paralysis. Laryngoscope. 2015;125:186–90.

    Article  CAS  PubMed  Google Scholar 

  24. Schietroma M, Cecilia EM, Carlei F, Sista F, De Santis G, Lancione L, Amicucci G. Dexamethasone for the prevention of recurrent laryngeal nerve palsy and other complications after thyroid surgery: a randomized double-blind placebo-controlled trial. Otolaryngol Head Neck Surg. 2013;139:471–8.

    Article  Google Scholar 

  25. Sadowski SM, Soardo P, Leuchter I, Robert JH, Triponez F. Systematic use of recurrent laryngeal nerve neuromonitoring changes the operative strategy in planned bilateral thyroidectomy. Thyroid. 2013;23: 329–33.

    Article  PubMed  Google Scholar 

  26. Pisanu A, Porceddu G, Podda M, Cois A, Uccheddu A. Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy. J Surg Res. 2014;188:152–61.

    Article  PubMed  Google Scholar 

  27. Wu CW, Wang MH, Chen CC, Chen HC, Chen HY, Yu JY, Chang PY, Lu IC, Lin YC, Chiang FY. Loss of signal in recurrent nerve neuromonitoring: causes and management. Gland Surg. 2015;4:19–26.

    PubMed  PubMed Central  Google Scholar 

  28. Chandrasekhar SS, Randolph GW, Seidman MD, Rosenfeld RM, Angelos P, Barkmeier-Kraemer J, Benninger MS, Blumin JH, Dennis G, Hanks J, Haymart MR, Kloos RT, Seals B, Schreibstein JM, Thomas MA, Waddington C, Warren B, Robertson PJ. Clinical practice guideline: improving voice outcomes after thyroid surgery. Otolaryngol Head Neck Surg. 2013;148:S1–37.

    Article  PubMed  Google Scholar 

  29. Dralle H, Sekulla C, Lorenz K, Nguyen Thanh P, Schneider R, Machens A. Loss of nerve monitoring signal during bilateral thyroid surgery. Br J Surg. 2012;99:1089–95.

    Article  CAS  PubMed  Google Scholar 

  30. Goretzki PE, Schwarz K, Brinkmann J, Wirowski D, Lammers BJ. The impact of intraoperative neuromonitoring (IONM) on surgical strategy in bilateral thyroid diseases: is it worth the effort? World J Surg. 2010;34:1274–84.

    Article  PubMed  Google Scholar 

  31. Dionigi G, Boni L, Rovera F, Rausei S, Castelnuovo P, Dionigi R. Postoperative laryngoscopy in thyroid surgery: proper timing to detect recurrent laryngeal nerve injury. Langenbecks Arch Surg. 2010;395: 327–31.

    Article  PubMed  Google Scholar 

  32. Chen D, Chen S, Wang W, Zhang C, Zheng H. Spontaneous regeneration of recurrent laryngeal nerve following long-term vocal fold paralysis in humans. Laryngoscope. 2011;121:1035–9.

    Article  PubMed  Google Scholar 

  33. Dionigi G, Lombardi D, Lombardi CP, Carcoforo P, Boniardi M, Innaro N, Chiofalo MG, Cavicchi O, Biondi A, Basile F, Zaccaroni A, Mangano A, Leotta A, Lavazza M, Calo PG, Nicolosi A, Castelnuovo P, Nicaolai P, Pezzulo L, De Toma G, Bellantone R, Sacco R. Intraoperative neuromonitoring in thyroid surgery: a point prevalence survey on utilization, management, and documentation in Italy. Updates Surg. 2014;66:269–76.

    Article  PubMed  Google Scholar 

  34. Hamelmann WH, Meyer T, Timm S, Timmermann W. A critical estimation of intraoperative neuromonitoring (IONM) in thyroid surgery. Zentralbl Chir. 2002;127:409–13.

    Article  CAS  PubMed  Google Scholar 

  35. Thomusch O, Sekulla C, Machens A, Neumann HJ, Timmermann W, Dralle H. Validity of intra-operative neuromonitoring signals in thyroid surgery. Langenbecks Arch Surg. 2004;389:499–503.

    Article  PubMed  Google Scholar 

  36. Beldi G, Kinsbergen T, Schlumpf R. Evaluation of intraoperative recurrent nerve monitoring in thyroid surgery. World J Surg. 2004;28:589–91.

    Article  PubMed  Google Scholar 

  37. Hermann M, Hellebart C, Freissmuth M. Neuromonitoring in thyroid surgery: prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury. Ann Surg. 2004;240:9–17.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Chan WF, Lang BH, Lo CY. The role of intraoperative nerve monitoring of recurrent laryngeal nerve during thyroidectomy: a comparative study on 1000 nerves at risk. Surgery. 2006;140:866–72.

    Article  PubMed  Google Scholar 

  39. Tomoda C, Hirokawa Y, Uruno T, Takamura Y, Ito Y, Miya A, Kobayashi K, Matsuzuka F, Kuma K, Miyauchi A. Sensitivity and specificity of intraoperative recurrent laryngeal nerve stimulation test for predicting vocal cord palsy after thyroid surgery. World J Surg. 2006;30:1230–3.

    Article  PubMed  Google Scholar 

  40. Barczyński M, Konturek A, Cichoń S. Randomized clinical trial of visualization versus nerve monitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg. 2009;96:240–6.

    Article  PubMed  Google Scholar 

  41. Melin M, Schwarz K, Pearson MD, Lammers BJ, Goretzki PE. Postoperative vocal cord dysfunction despite normal intraoperative neuromonitoring: an unexpected complication with the risk of bilateral palsy. World J Surg. 2014;38:2597–602.

    Article  PubMed  Google Scholar 

  42. Calò PG, Pisano G, Medas F, Pittau MR, Gordini L, Demontis R, Nicolisi A. Identification alone versus intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroid surgery: experience of 2034 consecutive patients. J Otolaryngol Head Neck Surg. 2014;43:16–23.

    Article  PubMed  PubMed Central  Google Scholar 

  43. De Falco M, Santangelo G, Del Giudice S, Gallucci F, Parmeggiani U. Double probe intraoperative neuromonitoring with a standardized method in thyroid surgery. Int J Surg. 2014;12:S140–4.

    Article  PubMed  Google Scholar 

  44. Schneider R, Lorenz K, Sekulla C, Machens A, Nguyen-Thanh P, Dralle H. Surgical strategy during intended total thyroidectomy after loss of the EMG signal on the first side of resection. Chirurg. 2015;86: 154–63.

    Article  CAS  PubMed  Google Scholar 

  45. Dralle H, Randolph GW, Lorenz K, Machens A. Thyroid surgery guided by intraoperative neuromonitoring. In: Oertli D, Udelsman R, editors. Surgery of the thyroid and parathyroid glands. Berlin: Springer; 2012. p. 187–95.

    Chapter  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of General, Visceral, and Vascular Surgery, Medical Faculty, Martin Luther University of Halle-Wittenberg, Halle (Saale), Saxony-Anhalt, Germany

    Kerstin Lorenz M.D., Rick Schneider M.D., Andreas Machens M.D., Carsten Sekulla Ph.D. & Henning Dralle M.D.

  2. The Claire and John Bertucci Endowed Chair in Thyroid Surgery Oncology, Harvard Medical School, Boston, MA, USA

    Gregory W. Randolph M.D.

  3. Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology—Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA

    Gregory W. Randolph M.D.

  4. Department of Surgery, Endocrine Surgery Service, Massachusetts General Hospital, Boston, MA, USA

    Gregory W. Randolph M.D.

Authors
  1. Kerstin Lorenz M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rick Schneider M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andreas Machens M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Carsten Sekulla Ph.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Gregory W. Randolph M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Henning Dralle M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kerstin Lorenz M.D. .

Editor information

Editors and Affiliations

  1. The Claire and John Bertucci Endowed Cha, Harvard Medical School, Boston, Massachusetts, USA

    Gregory W. Randolph

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Lorenz, K., Schneider, R., Machens, A., Sekulla, C., Randolph, G.W., Dralle, H. (2016). Loss of Signal in IONM and Staged Thyroid Surgery. In: Randolph, G. (eds) The Recurrent and Superior Laryngeal Nerves. Springer, Cham. https://doi.org/10.1007/978-3-319-27727-1_18

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-27727-1_18

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-27725-7

  • Online ISBN: 978-3-319-27727-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation