Skip to main content

IONM of the Recurrent Laryngeal Nerve

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

Abstract

Thyroid surgery can pose risk to both the right and the left recurrent laryngeal nerves (RLN) in a single surgical procedure. Unilateral vocal cord palsy (VCP) can lead to morbidity related to changes in voice, especially in professional voice users, as well as potential dysphagia and aspiration, while bilateral VCP may require tracheostomy. Visualization of the RLN during surgery has been considered the gold standard for preventing injury to the RLN; however, an intraoperatively visualized and structurally intact nerve does not necessarily represent a postoperatively functioning nerve. Neural monitoring has increasingly gained the attention of surgeons performing thyroid and parathyroid surgeries around the world. Current studies suggest that a majority of general and head and neck surgeons use neural monitoring in at least some of their thyroid surgical cases. This chapter presents a historical overview and usage patterns of intraoperative neural monitoring (IONM) of the RLN and discusses its impact on surgical practice, including intraoperative applications of IONM, medicolegal aspects and standards of IONM, normative data, as well as current advances in IONM such as continuous IONM.

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

Access this chapter

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

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

Similar content being viewed by others

References

  1. Lahey FH, Hoover WB. Injuries to the recurrent laryngeal nerve in thyroid operations: their management and avoidance. Ann Surg. 1938;108:545–62.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Karlan MS, Catz B, Dunkelman D, Uyeda RY, Gleischman S. A safe technique for thyroidectomy with complete nerve dissection and parathyroid preservation. Head Neck Surg. 1984;6:1014–9.

    Article  CAS  PubMed  Google Scholar 

  3. Jatzko GR, Lisborg PH, Muller MG, Wette VM. Recurrent nerve palsy after thyroid operations—principal nerve identification and a literature review. Surgery. 1994;115:139–44.

    CAS  PubMed  Google Scholar 

  4. Hermann M, Alk G, Roka R, Glaser K, Freissmuth M. Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon in more than 27,000 nerves at risk. Ann Surg. 2002;235:261–8.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Bliss RD, Gauger PG, Delbridge LW. Surgeon's approach to the thyroid gland: surgical anatomy and the importance of technique. World J Surg. 2000;24:891–7.

    Article  CAS  PubMed  Google Scholar 

  6. Gharib H, Papini E, Paschke R, et al. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules. Endocr Pract. 2010;16 Suppl 1:1–43.

    Article  PubMed  Google Scholar 

  7. Davies L, Randolph G. Evidence-based evaluation of the thyroid nodule. Otolaryngol Clin North Am. 2014;47:461–74.

    Article  PubMed  Google Scholar 

  8. Bergenfelz A, Jansson S, Kristoffersson A, et al. Complications to thyroid surgery: results as reported in a database from a multicenter audit comprising 3,660 patients. Langenbecks Arch Surg. 2008;393: 667–73.

    Article  CAS  PubMed  Google Scholar 

  9. Randolph GW. The importance of pre- and postoperative laryngeal examination for thyroid surgery. Thyroid. 2010;20:453–8.

    Article  PubMed  Google Scholar 

  10. 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 

  11. Thompson NW, Olsen WR, Hoffman GL. The continuing development of the technique of thyroidectomy. Surgery. 1973;73:913–27.

    CAS  PubMed  Google Scholar 

  12. Dralle H. Impact of modern technologies on quality of thyroid surgery. Langenbecks Arch Surg. 2006;391:1–3.

    Article  PubMed  Google Scholar 

  13. Dionigi G, Dionigi R. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation: to the editor. World J Surg. 2010;34:2794–5.

    Article  CAS  PubMed  Google Scholar 

  14. Sala F. Intraoperative neurophysiology is here to stay. Childs Nerv Syst. 2010;26:413–7.

    Article  PubMed  Google Scholar 

  15. Randolph GW, Dralle H, Abdullah H, et al. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope. 2011;121 Suppl 1:S1–16.

    Article  PubMed  Google Scholar 

  16. Dionigi G, Bacuzzi A, Barczynski M, et al. Implementation of systematic neuromonitoring training for thyroid surgery. Updates Surg. 2011;63:201–7.

    Article  CAS  PubMed  Google Scholar 

  17. Shedd DP, Durham C. Electrical identification of the recurrent laryngeal nerve. I. Response of the canine larynx to electrical stimulation of the recurrent laryngeal nerve. Ann Surg. 1966;163:47–50.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Riddell V. Thyroidectomy: prevention of bilateral recurrent nerve palsy. Results of identification of the nerve over 23 consecutive years (1946-69) with a description of an additional safety measure. Br J Surg. 1970;57:1–11.

    Article  CAS  PubMed  Google Scholar 

  19. Gavilan J, Gavilan C. Recurrent laryngeal nerve. Identification during thyroid and parathyroid surgery. Arch Otolaryngol Head Neck Surg. 1986;112:1286–8.

    Article  CAS  PubMed  Google Scholar 

  20. Randolph G. Surgical anatomy of recurrent laryngeal nerve. In: Randolph GW, editor. Surgery of the thyroid and parathyroid glands. Philadelphia: Saunders; 2013.

    Google Scholar 

  21. Lamade W, Fogel W, Rieke K, Senninger N, Herfarth C. Intraoperative monitoring of the recurrent laryngeal nerve. A new method. Chirurg. 1996;67:451–4.

    CAS  PubMed  Google Scholar 

  22. Dionigi G, Lombardi D, Lombardi CP, et al. 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 

  23. Wu CW, Lu IC, Randolph GW, et al. Investigation of optimal intensity and safety of electrical nerve stimulation during intraoperative neuromonitoring of the recurrent laryngeal nerve: a prospective porcine model. Head Neck. 2010;32:1295–301.

    Article  PubMed  Google Scholar 

  24. Chan WF, Lo CY. Pitfalls of intraoperative neuromonitoring for predicting postoperative recurrent laryngeal nerve function during thyroidectomy. World J Surg. 2006;30:806–12.

    Article  PubMed  Google Scholar 

  25. 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 

  26. Chiang FY, Lee KW, Chen HC, et al. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation. World J Surg. 2010;34:223–9.

    Article  PubMed  Google Scholar 

  27. Lamade W, Meyding-Lamade U, Buchhold C, et al. First continuous nerve monitoring in thyroid gland surgery. Chirurg. 2000;71:551–7.

    Article  CAS  PubMed  Google Scholar 

  28. Consensus: protocolli gestionali in chirurgia tiroidea. http://www.clubdelleuec.it/protocolli.htm.

  29. 2.6.1. Darstellung des Nervus laryngeus recurrens. http://www.dgch.de.

  30. Musholt TJ, Clerici T, Dralle H, et al. German Association of Endocrine Surgeons practice guidelines for the surgical treatment of benign thyroid disease. Langenbecks Arch Surg. 2011;396:639–49.

    Article  PubMed  Google Scholar 

  31. National Institute for Health and Care Excellence (NICE). Intraoperative nerve monitoring during thyroid surgery. 2008. https://www.nice.org.uk/guidance/ipg255.

  32. Chandrasekhar SS, Randolph GW, Seidman MD, et al. Clinical practice guideline: improving voice outcomes after thyroid surgery. Otolaryngol Head Neck Surg. 2013;148:S1–37.

    Article  PubMed  Google Scholar 

  33. International Neural Monitoring Study Group (INMSG). http://www.inmsg.org.

  34. Barczynski M, Randolph GW, Cernea CR, et al. External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: International Neural Monitoring Study Group standards guideline statement. Laryngoscope. 2013;123 Suppl 4:S1–14.

    Article  PubMed  Google Scholar 

  35. First World Congress of Neural Monitoring in Thyroid and Parathyroid Surgery. 2015; Krakow, Poland. Jagiellonian University. http://ionmworldcongress.com/.

  36. Horne SK, Gal TJ, Brennan JA. Prevalence and patterns of intraoperative nerve monitoring for thyroidectomy. Otolaryngol Head Neck Surg. 2007;136:952–6.

    Article  PubMed  Google Scholar 

  37. Sturgeon C, Sturgeon T, Angelos P. Neuromonitoring in thyroid surgery: attitudes, usage patterns, and predictors of use among endocrine surgeons. World J Surg. 2009;33:417–25.

    Article  PubMed  Google Scholar 

  38. Ho Y, Carr MM, Goldenberg D. Trends in intraoperative neural monitoring for thyroid and parathyroid surgery amongst otolaryngologists and general surgeons. Eur Arch Otorhinolaryngol. 2013;270: 2525–30.

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  40. Mihai R, Chadwick D. Intraoperative nerve monitoring is used by a small (but slowly increasing) minority of members of British Association Of Endocrine And Thyroid Surgeons (BAETS). Paper presented at the 33rd BAETS Annual Scientific Meeting, Rome, Italy. October 2013.

    Google Scholar 

  41. Hopkins C, Khemani S, Terry RM, Golding-Wood D. How we do it: nerve monitoring in ENT surgery: current UK practice. Clin Otolaryngol. 2005;30: 195–8.

    Article  CAS  PubMed  Google Scholar 

  42. Godballe C. Registry of surgical results: organization and outcomes. In: 34th Annual meeting of the European Thyroid Association. ETA, Lisbon, 2009.

    Google Scholar 

  43. Personal communication by Carnaille B. General and Endocrine Surgery, Centre Hospitalier Universitaire Lille, France during the 6th Meeting of the International Neural Monitoring Study Group—INMSG, 2013.

    Google Scholar 

  44. Personal communication by Duran Poveda MC. Department of Endocrine Surgery, University Hospital of Fuenlabrada Health Sciences School, King Juan Carlos University, Madrid, Spain during the 6th Meeting of the International Neural Monitoring Study Group—INMSG, 2013.

    Google Scholar 

  45. Personal communication by Barczyński M. Third Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland, during the Polish Club of Endocrine Surgery in 2014.

    Google Scholar 

  46. Personal communication by Chiang FY. The Department of Otolaryngology—Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, during the 7th Meeting of the INMSG, 2014.

    Google Scholar 

  47. Barczynski M, Konturek A, Cichon S. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg. 2009;96:240–6.

    Article  CAS  PubMed  Google Scholar 

  48. Dralle H, Sekulla C, Lorenz K, Brauckhoff M, Machens A. Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg. 2008;32:1358–66.

    Article  CAS  PubMed  Google Scholar 

  49. Dionigi G, Barczynski M, Chiang FY, et al. Why monitor the recurrent laryngeal nerve in thyroid surgery? J Endocrinol Invest. 2010;33:819–22.

    Article  CAS  PubMed  Google Scholar 

  50. Dionigi G, Bacuzzi A, Boni L, Rausei S, Rovera F, Dionigi R. Visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy: what about the costs? World J Surg. 2012;36: 748–54.

    Article  PubMed  Google Scholar 

  51. Kern KA. Medicolegal analysis of errors in diagnosis and treatment of surgical endocrine disease. Surgery. 1993;114:1167–73. discussion 1173–4.

    CAS  PubMed  Google Scholar 

  52. Shaw GY, Pierce E. Malpractice litigation involving iatrogenic surgical vocal fold paralysis: a closed-claims review with recommendations for prevention and management. Ann Otol Rhinol Laryngol. 2009;118:6–12.

    Article  PubMed  Google Scholar 

  53. Rosenthal MS, Angelos P, Cooper DS, et al. Clinical and professional ethics guidelines for the practice of thyroidology. Thyroid. 2013;23:1203–10.

    Article  PubMed  Google Scholar 

  54. Lydiatt DD. Medical malpractice and the thyroid gland. Head Neck. 2003;25:429–31.

    Article  PubMed  Google Scholar 

  55. Dralle H, Lorenz K, Machens A. Verdicts on malpractice claims after thyroid surgery: emerging trends and future directions. Head Neck. 2012;34:1591–6.

    Article  PubMed  Google Scholar 

  56. Angelos P. Ethical and medicolegal issues in neuromonitoring during thyroid and parathyroid surgery: a review of the recent literature. Curr Opin Oncol. 2012;24:16–21.

    Article  PubMed  Google Scholar 

  57. Angelos P. Recurrent laryngeal nerve monitoring: state of the art, ethical and legal issues. Surg Clin North Am. 2009;89:1157–69.

    Article  PubMed  Google Scholar 

  58. Rulli F, Ambrogi V, Dionigi G, et al. Meta-analysis of recurrent laryngeal nerve injury in thyroid surgery with or without intraoperative nerve monitoring. Acta Otorhinolaryngol Ital. 2014;34:223–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  59. Mangano A, Wu CW, Lianos GD, et al. Evidence-based analysis on the clinical impact of intraoperative neuromonitoring in thyroid surgery: state of the art and future perspectives. Surg Technol Int. 2014;25:91–6.

    PubMed  Google Scholar 

  60. Cernea CR, Brandao LG, Brandao J. Neuromonitoring in thyroid surgery. Curr Opin Otolaryngol Head Neck Surg. 2012;20:125–9.

    Article  PubMed  Google Scholar 

  61. Cernea CR, Brandao LG, Hojaij FC, et al. How to minimize complications in thyroid surgery? Auris Nasus Larynx. 2010;37:1–5.

    Article  PubMed  Google Scholar 

  62. Zheng S, Xu Z, Wei Y, Zeng M, He J. Effect of intraoperative neuromonitoring on recurrent laryngeal nerve palsy rates after thyroid surgery—a meta-analysis. J Formos Med Assoc. 2013;112:463–72.

    Article  PubMed  Google Scholar 

  63. 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 

  64. Jeannon JP, Orabi AA, Bruch GA, Abdalsalam HA, Simo R. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. Int J Clin Pract. 2009;63:624–9.

    Article  PubMed  Google Scholar 

  65. Dionigi G, Chiang FY, Dralle H, et al. Safety of neural monitoring in thyroid surgery. Int J Surg. 2013;11 Suppl 1:S120–6.

    Article  PubMed  Google Scholar 

  66. Chiang FY, Wang LF, Huang YF, Lee KW, Kuo WR. Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve. Surgery. 2005;137:342–7.

    Article  PubMed  Google Scholar 

  67. Kunath M, Hussock J, Marusch F, Horschig P, Gastinger I. Identifying the recurrent laryngeal nerve by intraoperative neuromonitoring. Zentralbl Chir. 1999;124:641–5.

    CAS  PubMed  Google Scholar 

  68. Lamade W, Renz K, Willeke F, Klar E, Herfarth C. Effect of training on the incidence of nerve damage in thyroid surgery. Br J Surg. 1999;86:388–91.

    Article  CAS  PubMed  Google Scholar 

  69. Thomusch O, Machens A, Sekulla C, et al. Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany. World J Surg. 2000;24:1335–41.

    Article  CAS  PubMed  Google Scholar 

  70. Barczynski M, Konturek A, Pragacz K, Papier A, Stopa M, Nowak W. Intraoperative nerve monitoring can reduce prevalence of recurrent laryngeal nerve injury in thyroid reoperations: results of a retrospective cohort study. World J Surg. 2014;38:599–606.

    Article  PubMed  Google Scholar 

  71. Snyder SK, Lairmore TC, Hendricks JC, Roberts JW. Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy. J Am Coll Surg. 2008;206:123–30.

    Article  PubMed  Google Scholar 

  72. Alesina PF, Hinrichs J, Meier B, Cho EY, Bolli M, Walz MK. Intraoperative neuromonitoring for surgical training in thyroid surgery: its routine use allows a safe operation instead of lack of experienced mentoring. World J Surg. 2014;38:592–8.

    Article  CAS  PubMed  Google Scholar 

  73. Sari S, Erbil Y, Sumer A, et al. Evaluation of recurrent laryngeal nerve monitoring in thyroid surgery. Int J Surg. 2010;8:474–8.

    Article  PubMed  Google Scholar 

  74. Dionigi G, Boni L, Rovera F, Bacuzzi A, Dionigi R. Neuromonitoring and video-assisted thyroidectomy: a prospective, randomized case-control evaluation. Surg Endosc. 2009;23:996–1003.

    Article  PubMed  Google Scholar 

  75. Barczyński M, Konturek A, Stopa M, et al. Randomized controlled trial of visualization versus neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy. World J Surg 2012;36(6):1340–7.

    Google Scholar 

  76. Lifante JC, McGill J, Murry T, Aviv JE, Inabnet 3rd WB. A prospective, randomized trial of nerve monitoring of the external branch of the superior laryngeal nerve during thyroidectomy under local/regional anesthesia and IV sedation. Surgery. 2009;146:1167–73.

    Article  PubMed  Google Scholar 

  77. Khaled AO, Irfan M, Baharudin A, Shahid H. Comparing the morbidity of external laryngeal nerve injury in thyroid surgery with and without identifying the nerve using intraoperative neuromonitoring. Med J Malaysia. 2012;67:289–92.

    CAS  PubMed  Google Scholar 

  78. Sanabria A, Ramirez A, Kowalski LP, et al. Neuromonitoring in thyroidectomy: a meta-analysis of effectiveness from randomized controlled trials. Eur Arch Otorhinolaryngol. 2013;270:2175–89.

    Article  PubMed  Google Scholar 

  79. Dionigi G, Van Slycke S, Boni L, Rausei S, Mangano A. Limits of neuromonitoring in thyroid surgery. Ann Surg. 2013;258:e1–2.

    Article  PubMed  Google Scholar 

  80. Timmerman WHW. Thyroid surgery: neuromonitoring of the RLN during thyroid surgery. Dtsch Arztebl Int. 2004;101.

    Google Scholar 

  81. Ulmer C, Friedrich C, Kohler A, et al. Impact of continuous intraoperative neuromonitoring on autonomic nervous system during thyroid surgery. Head Neck. 2011;33:976–84.

    Article  PubMed  Google Scholar 

  82. Yarbrough DE, Thompson GB, Kasperbauer JL, Harper CM, Grant CS. Intraoperative electromyographic monitoring of the recurrent laryngeal nerve in reoperative thyroid and parathyroid surgery. Surgery. 2004;136:1107–15.

    Article  PubMed  Google Scholar 

  83. Dralle H, Sekulla C, Haerting J, et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery. 2004;136:1310–22.

    Article  PubMed  Google Scholar 

  84. Frattini F, Mangano A, Boni L, Rausei S, Biondi A, Dionigi G. Intraoperative neuromonitoring for thyroid malignancy surgery: technical notes and results from a retrospective series. Updates Surg. 2010;62:183–7.

    Article  PubMed  Google Scholar 

  85. Chan WF, Lang BH, Lo CY. The role of intraoperative neuromonitoring of recurrent laryngeal nerve during thyroidectomy: a comparative study on 1000 nerves at risk. Surgery. 2006;140:866–72. discussion 872–3.

    Article  PubMed  Google Scholar 

  86. Shindo M, Chheda NN. Incidence of vocal cord paralysis with and without recurrent laryngeal nerve monitoring during thyroidectomy. Arch Otolaryngol Head Neck Surg. 2007;133:481–5.

    Article  PubMed  Google Scholar 

  87. Robertson ML, Steward DL, Gluckman JL, Welge J. Continuous laryngeal nerve integrity monitoring during thyroidectomy: does it reduce risk of injury? Otolaryngol Head Neck Surg. 2004;131:596–600.

    Article  PubMed  Google Scholar 

  88. Rice DH, Cone-Wesson B. Intraoperative recurrent laryngeal nerve monitoring. Otolaryngol Head Neck Surg. 1991;105:372–5.

    CAS  PubMed  Google Scholar 

  89. Steurer M, Passler C, Denk DM, Schneider B, Niederle B, Bigenzahn W. Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope. 2002;112:124–33.

    Article  PubMed  Google Scholar 

  90. Chiang FY, Lu IC, Kuo WR, Lee KW, Chang NC, Wu CW. The mechanism of recurrent laryngeal nerve injury during thyroid surgery—the application of intraoperative neuromonitoring. Surgery. 2008;143:743–9.

    Article  PubMed  Google Scholar 

  91. Dionigi G, Alesina PF, Barczynski M, et al. Recurrent laryngeal nerve injury in video-assisted thyroidectomy: lessons learned from neuromonitoring. Surg Endosc. 2012;26:2601–8.

    Article  CAS  PubMed  Google Scholar 

  92. Lo CY, Kwok KF, Yuen PW. A prospective evaluation of recurrent laryngeal nerve paralysis during thyroidectomy. Arch Surg. 2000;135:204–7.

    Article  CAS  PubMed  Google Scholar 

  93. Caldarelli DD, Holinger LD. Complications and sequelae of thyroid surgery. Otolaryngol Clin North Am. 1980;13:85–97.

    CAS  PubMed  Google Scholar 

  94. Patow CA, Norton JA, Brennan MF. Vocal cord paralysis and reoperative parathyroidectomy. A prospective study. Ann Surg. 1986;203:282–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  95. Dionigi G. Energy based devices and recurrent laryngeal nerve injury: the need for safer instruments. Langenbecks Arch Surg. 2009;394:579–80. author reply 581–6.

    Article  PubMed  Google Scholar 

  96. Agarwal BB, Agarwal S. Recurrent laryngeal nerve, phonation and voice preservation—energy devices in thyroid surgery—a note of caution. Langenbecks Arch Surg. 2009;394:911–2. author reply 913–4.

    Article  PubMed  Google Scholar 

  97. Chiang FY, Lu IC, Chen HC, et al. Intraoperative neuromonitoring for early localization and identification of recurrent laryngeal nerve during thyroid surgery. Kaohsiung J Med Sci. 2010;26:633–9.

    Article  PubMed  Google Scholar 

  98. 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 

  99. Jonas J. Reliability of intraoperative recurrent laryngeal nerve monitoring in thyroid surgery. Zentralbl Chir. 2002;127:404–8.

    Article  CAS  PubMed  Google Scholar 

  100. Neumann HJ. Intraoperative neurophysiological monitoring (IONM) of the recurrent laryngeal nerve and microdissection. Surgical techniques for decreasing the risk of recurrent laryngeal nerve paralysis. Laryngorhinootologie. 2000;79:290–6.

    Article  CAS  PubMed  Google Scholar 

  101. 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.

    Google Scholar 

  102. Chiang FY, Lu IC, Chen HC, et al. Anatomical variations of recurrent laryngeal nerve during thyroid surgery: how to identify and handle the variations with intraoperative neuromonitoring. Kaohsiung J Med Sci. 2010;26:575–83.

    Article  PubMed  Google Scholar 

  103. Barczynski M, Konturek A, Stopa M, Hubalewska-Dydejczyk A, Richter P, Nowak W. Clinical value of intraoperative neuromonitoring of the recurrent laryngeal nerves in improving outcomes of surgery for well-differentiated thyroid cancer. Pol Przegl Chir. 2011;83:196–203.

    PubMed  Google Scholar 

  104. Serpell JW, Yeung MJ, Grodski S. The motor fibers of the recurrent laryngeal nerve are located in the anterior extralaryngeal branch. Ann Surg. 2009;249:648–52.

    Article  PubMed  Google Scholar 

  105. Yalcin B. Anatomic configurations of the recurrent laryngeal nerve and inferior thyroid artery. Surgery. 2006;139:181–7.

    Article  PubMed  Google Scholar 

  106. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009; 19:1167–1214.

    Google Scholar 

  107. Bilimoria KY, Bentrem DJ, Ko CY, et al. Extent of surgery affects survival for papillary thyroid cancer. Ann Surg. 2007;246:375–81. discussion 381–4.

    Article  PubMed  PubMed Central  Google Scholar 

  108. Rios A, Rodriguez JM, Galindo PJ, Montoya MJ, Canteras M, Parrilla P. Surgical treatment of multinodular goiter in young patients. Endocrine. 2005;27:245–52.

    Article  CAS  PubMed  Google Scholar 

  109. Friguglietti CU, Lin CS, Kulcsar MA. Total thyroidectomy for benign thyroid disease. Laryngoscope. 2003;113:1820–6.

    Article  PubMed  Google Scholar 

  110. Sancho JJ, Pascual-Damieta M, Pereira JA, Carrera MJ, Fontane J, Sitges-Serra A. Risk factors for transient vocal cord palsy after thyroidectomy. Br J Surg. 2008;95:961–7.

    Article  CAS  PubMed  Google Scholar 

  111. Lekacos NL, Tzardis PJ, Sfikakis PG, Patoulis SD, Restos SD. Course of the recurrent laryngeal nerve relative to the inferior thyroid artery and the suspensory ligament of Berry. Int Surg. 1992;77: 287–8.

    CAS  PubMed  Google Scholar 

  112. Berlin D. The recurrent laryngeal nerve in total ablation of the normal thyroid gland. Surg Gynecol Obstet. 1935;19.

    Google Scholar 

  113. Armstrong WG, Hinton JW. Multiple divisions of the recurrent laryngeal nerve. An anatomic study. AMA Arch Surg. 1951;62:532–9.

    Article  CAS  PubMed  Google Scholar 

  114. Wafae N, Vieira MC, Vorobieff A. The recurrent laryngeal nerve in relation to the inferior constrictor muscle of the pharynx. Laryngoscope. 1991;101:1091–3.

    Article  CAS  PubMed  Google Scholar 

  115. Lorenz RR, Esclamado RM, Teker AM, et al. Ansa cervicalis-to-recurrent laryngeal nerve anastomosis for unilateral vocal fold paralysis: experience of a single institution. Ann Otol Rhinol Laryngol. 2008;117:40–5.

    Article  PubMed  Google Scholar 

  116. Chou F-F, Su C-Y, Jeng S-F, Hsu K-L, Lu K-Y. Neurorrhaphy of the recurrent laryngeal nerve. J Am Coll Surg. 2003;197:52–7.

    Article  PubMed  Google Scholar 

  117. Miyauchi A, Ito Y, Miya A, et al. Lateral mobilization of the recurrent laryngeal nerve to facilitate tracheal surgery in patients with thyroid cancer invading the trachea near Berry’s ligament. World J Surg. 2007;31:2081–4.

    Article  PubMed  Google Scholar 

  118. Miyauchi A, Inoue H, Tomoda C, et al. Improvement in phonation after reconstruction of the recurrent laryngeal nerve in patients with thyroid cancer invading the nerve. Surgery. 2009;146:1056–62.

    Article  PubMed  Google Scholar 

  119. Chi SY, Lammers B, Boehner H, Pohl P, Goretzki PE. Is it meaningful to preserve a palsied recurrent laryngeal nerve? Thyroid. 2008;18:363–6.

    Article  PubMed  Google Scholar 

  120. Dionigi G, Frattini F. Staged thyroidectomy: time to consider intraoperative neuromonitoring as standard of care. Thyroid. 2013;23:906–8.

    Article  PubMed  Google Scholar 

  121. Fontenot TE, Randolph GW, Setton TE, Alsaleh N, Kandil E. Does intraoperative nerve monitoring reliably aid in staging of total thyroidectomies? Laryngoscope. 2015;125:2232–5.

    Article  PubMed  Google Scholar 

  122. Pemberton JJ. Exophthalmic goiter: Indications for the stage-operation. Arch Surg. 1929;18:735–44.

    Article  Google Scholar 

  123. 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 

  124. 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 

  125. Erdem E, Gulcelik MA, Kuru B, Alagol H. Comparison of completion thyroidectomy and primary surgery for differentiated thyroid carcinoma. Eur J Surg Oncol. 2003;29:747–9.

    Article  CAS  PubMed  Google Scholar 

  126. 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 

  127. Chu KS, Wu SH, Lu IC, et al. Feasibility of intraoperative neuromonitoring during thyroid surgery after administration of nondepolarizing neuromuscular blocking agents. World J Surg. 2009;33:1408–13.

    Article  PubMed  Google Scholar 

  128. Eltzschig HK, Posner M, Moore Jr FD. The use of readily available equipment in a simple method for intraoperative monitoring of recurrent laryngeal nerve function during thyroid surgery: initial experience with more than 300 cases. Arch Surg. 2002;137:452–6. discussion 456–7.

    Article  PubMed  Google Scholar 

  129. Lu IC, Chu KS, Tsai CJ, et al. Optimal depth of NIM EMG endotracheal tube for intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroidectomy. World J Surg. 2008;32:1935–9.

    Article  PubMed  Google Scholar 

  130. Randolph GW, Kobler JB, Wilkins J. Recurrent laryngeal nerve identification and assessment during thyroid surgery: laryngeal palpation. World J Surg. 2004;28:755–60.

    Article  PubMed  Google Scholar 

  131. Dionigi G, Bacuzzi A, Boni L, Rovera F, Dionigi R. What is the learning curve for intraoperative neuromonitoring in thyroid surgery? Int J Surg. 2008;6 Suppl 1:S7–12.

    Article  PubMed  Google Scholar 

  132. Duclos A, Lifante JC, Ducarroz S, Soardo P, Colin C, Peix JL. Influence of intraoperative neuromonitoring on surgeons’ technique during thyroidectomy. World J Surg. 2011;35:773–8.

    Article  PubMed  Google Scholar 

  133. Jonas J, Bahr R. Intraoperative neuromonitoring of the recurrent laryngeal nerve—results and learning curve. Zentralbl Chir. 2006;131:443–8.

    Article  CAS  PubMed  Google Scholar 

  134. Dionigi G, Chiang FY, Rausei S, et al. Surgical anatomy and neurophysiology of the vagus nerve (VN) for standardised intraoperative neuromonitoring (IONM) of the inferior laryngeal nerve (ILN) during thyroidectomy. Langenbecks Arch Surg. 2010;395: 893–9.

    Article  PubMed  Google Scholar 

  135. 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. 2014.

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Gianlorenzo Dionigi M.D., F.A.C.S., Ph.D. .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Dionigi, G., Dralle, H., Liddy, W., Kamani, D., Kyriazidis, N., Randolph, G.W. (2016). IONM of the Recurrent Laryngeal Nerve. In: Randolph, G. (eds) The Recurrent and Superior Laryngeal Nerves. Springer, Cham. https://doi.org/10.1007/978-3-319-27727-1_14

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-27727-1_14

  • 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