Thyroid Surgery Guided by Intraoperative Neuromonitoring

  • Henning Dralle
  • Gregory W. Randolph
  • Kerstin Lorenz
  • Andreas Machens


From its humble beginnings 150 years ago, thyroid surgery not only endeavored to resect thyroid disease but at the same time strove to preserve those structures adjacent to the thyroid gland that are of utmost importance physiologically and for maintenance of quality of life: recurrent laryngeal nerves (RLN) and parathyroid glands. Postoperative RLN palsy and postoperative hypoparathyroidism, more than recurrence of thyroid disease, were to become key performance indicators of the quality of thyroid surgery.

For decades, the chief controversy in thyroid surgery in general and for RLN management in particular revolved around preservation of the nerve through visual identification. This is not surprising given the nerve’s unique vulnerability and anatomic course which closely approximates the line of resection during thyroidectomy.


Recurrent Laryngeal Nerve Vagus Nerve Stimulation Thyroid Surgery Recurrent Laryngeal Nerve Palsy Vocal Cord Function 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Abadin SS, Kaplan EL, Angelos P (2010) Malpractice litigation after thyroid surgery: the role of recurrent laryngeal nerve ­injuries, 1989–2009. Surgery 148:718–723PubMedCrossRefGoogle Scholar
  2. 2.
    Barczynski M, Konturek A, Cichon S (2009) Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg 96:240–246PubMedCrossRefGoogle Scholar
  3. 3.
    Brauckhoff M, Walls G, Brauckhoff K, Nguyen Thanh P, Thomusch O, Dralle H (2002) Identification of the non-recurrent inferior laryngeal nerve using intraoperative neurostimulation. Langenbecks Arch Surg 386:482–487PubMedCrossRefGoogle Scholar
  4. 4.
    Brauckhoff M, Nguyen Thanh P, Dralle H (2004) Nervus laryngeus inferior non recurrens and lusorial artery. Thyroid 14:79–81PubMedCrossRefGoogle Scholar
  5. 5.
    Brauckhoff M, Machens A, Sekulla C, Lorenz K, Dralle H (2011) Latencies shorter than 3.5 ms after vagus nerve stimulation signify a non-recurrent inferior laryngeal nerve prior to dissection. Ann Surg 253:1172–1177PubMedCrossRefGoogle Scholar
  6. 6.
    British Thyroid Association-BTA. Guideline for the management of thyroid cancer in adults. Available at:
  7. 7.
    Casella C, Pata G, Nascimbeni R, Mittempergher F, Salerni B (2009) Does extralaryngeal branching have an impact on the rate of postoperative transient or permanent recurrent laryngeal nerve palsy? World J Surg 33:261–265PubMedCrossRefGoogle Scholar
  8. 8.
    Chiang FY, Lu IC, Kuo WR, Lee KW, Chang NC, Wu CW (2008) The mechanism of recurrent laryngeal nerve injury during thyroid surgery – the application of intraoperative neuromonitoring. Surgery 143:743–749PubMedCrossRefGoogle Scholar
  9. 9.
    Dralle H, Sekulla C, Haerting J, Timmermann W, Neumann HJ, Kruse E, Grond S, Mühlig HP, Richter C, Voß J, Thomusch O, Lippert H, Gastinger I (2004) Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 136:1310–1322PubMedCrossRefGoogle Scholar
  10. 10.
    Dralle H, Kruse E, Hamelmann WH, Grond S, Neumann HJ, Sekulla C, Richter C, Thomusch O, Mühlig HP, Voss J, Timmermann W (2004) Nicht jeder stimmlippenstillstand nach schilddrüsenoperation ist eine chirurgisch bedingte rekurrensparese. Chirurg 75:810–822PubMedGoogle Scholar
  11. 11.
    Dralle H, Sekulla C, Lorenz K, Brauckhoff M, Machens A (2008) Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg 32:1358–1366PubMedCrossRefGoogle Scholar
  12. 12.
    Dralle H, Machens A (2010) European endocrine surgery in the 150-year history of Langenbeck’s archives of surgery. Langenbecks Arch Surg 395:S43–S55CrossRefGoogle Scholar
  13. 13.
    Dralle H, Lorenz K (2010) Intraoperatives neuromonitoring bei schilddrüsenoperationen. Chirurg 81:612–619PubMedCrossRefGoogle Scholar
  14. 14.
    Dralle H, Schabram P (2010) Intraoperative neuromonitoring in a case of completion thyroidectomy with postoperative unilateral recurrent laryngeal nerve palsy: essential – desirable – dispensable? Zentralbl Chir 135:194–196Google Scholar
  15. 15.
    Henry JF, Audiffret J, Denizot A, Plan M (1988) The nonrecurrent inferior laryngeal nerve: review of 33 cases, including two on the left side. Surgery 104:977–984PubMedGoogle Scholar
  16. 16.
    Hermann M, Alk G, Roka R, Glaser G, Freismuth M (2002) Laryngeal recurrent nerve injury in surgery for benign thyroid diseases. Ann Surg 235:261–268PubMedCrossRefGoogle Scholar
  17. 17.
    Hydman J, Remahl S, Björck G, Svensson M, Mattsson P (2007) Nimodipine improves reinnervation and neuromuscular function after injury to the recurrent laryngeal nerve in the rat. Ann Otol Rhinol Laryngol 116:623–630PubMedGoogle Scholar
  18. 18.
    Iacobone M, Viel G, Zanella S, Bottussi M, Frego M, Favia G (2008) The usefulness of preoperative ultrasonographic identification of nonrecurrent inferior laryngeal nerve in neck surgery. Langenbecks Arch Surg 393:633–634PubMedCrossRefGoogle Scholar
  19. 19.
    Jatzko GR, Lisborg PH, Müller MG, Wette VM (1994) Recurrent nerve palsy after thyroid operations – principal nerve identification and a literature review. Surgery 115:139–144PubMedGoogle Scholar
  20. 20.
    Kern KA (1999) Medicolegal analysis of errors in diagnosis and treatment of surgical endocrine disease. Chirurg 70:1131–1138CrossRefGoogle Scholar
  21. 21.
    Koester M, Zorowka P, Wolf S (2003) Neuromonitoring in thyroid surgery: the view of the laryngologist. Eur Surg 35:246–249CrossRefGoogle Scholar
  22. 22.
    Lahey FH (1938) Routine dissection and demonstration of the recurrent laryngeal nerve in subtotal thyroidectomy. Surg Gynecol Obstet 66:775–777Google Scholar
  23. 23.
    Lorenz K, Sekulla C, Schelle J, Schmeiss B, Brauckhoff M, Dralle H (2010) What are normal quantitative parameters of intraoperative neuromonitoring (IONM) in thyroid surgery? Langenbecks Arch Surg 395:901–909PubMedCrossRefGoogle Scholar
  24. 24.
    Lu IC, Chu KS, Tsai CJ (2008) Optimal depth of NIM EMG endotracheal tube for intraoperative neuromonitoring of the RLN during thyroidectomy. World J Surg 32:1935–1939PubMedCrossRefGoogle Scholar
  25. 25.
    Marusch F, Hussock J, Haring G, Hachenberg T, Gastinger I (2005) Influence of muscle relaxation on neuromonitoring of the recurrent laryngeal nerve during thyroid surgery. Br J Anaesth 5:596–600CrossRefGoogle Scholar
  26. 26.
    Moley JF, Lairmore TC, Doherty GM, Brunt LM, DeBenedetti MK (1999) Preservation of the recurrent laryngeal nerves in thyroid and parathyroid reoperations. Surgery 125:673–679CrossRefGoogle Scholar
  27. 27.
    Musholt TJ, Musholt PB, Garm J, Napiontek U, Keilmann A (2006) Changes in the speaking and singing voice after thyroid or parathyroid surgery. Surgery 140:988–989CrossRefGoogle Scholar
  28. 28.
    Randolph GW (2003) Surgical anatomy of the recurrent laryngeal nerve. In: Randolph GW (ed) Surgery of the thyroid and parathyroid glands. W. B. Saunders, Philadelphia, pp 300–342Google Scholar
  29. 29.
    Randolph GW, Kobler JB, Wilkins J (2004) Recurrent laryngeal nerve identification and assessment during thyroid surgery: laryngeal palpation. World J Surg 28:755–760PubMedCrossRefGoogle Scholar
  30. 30.
    Randolph GW, Kamani D (2006) The importance of preoperative laryngoscopy in patients undergoing thyroidectomy: voice, vocal cord function, and the preoperative detection of invasive thyroid malignancy. Surgery 139:357–362PubMedCrossRefGoogle Scholar
  31. 31.
    Randolph GW (2010) The importance of pre- and postoperative laryngeal examination for thyroid surgery. Thyroid 20:453–458PubMedCrossRefGoogle Scholar
  32. 32.
    Randolph GW, Dralle H (2011) Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope 121:1–16CrossRefGoogle Scholar
  33. 33.
    Riddell VH (1956) Injury to recurrent laryngeal nerves during thyroidectomy – a comparison between the results of identification and non-identification in 1022 nerves exposed to risk. Lancet 29:638–641CrossRefGoogle Scholar
  34. 34.
    Sancho JJ, Pascual-Damieta M, Pereira JA, Carrera MJ, Fontane J, Sitges-Serra A (2008) Risk factors for transient vocal cord palsy after thyroidectomy. Br J Surg 95:961–967PubMedCrossRefGoogle Scholar
  35. 35.
    Schneider R, Przybyl J, Pliquett U, Hermann M, Wehner M, Pietsch UC, König F, Hauss J, Jonas S, Leinung S (2010) A new vagal anchor electrode for real-time monitoring of the recurrent laryngeal nerve. Am J Surg 199:507–514PubMedCrossRefGoogle Scholar
  36. 36.
    Schulte KM, Roher HD (1999) Medico-legal aspects of thyroid surgery. Chirurg 70:1131–1138PubMedCrossRefGoogle Scholar
  37. 37.
    Serpell JW, Yeung MJ, Grodski S (2009) The motor fibers of the recurrent laryngeal nerve are located in the anterior extralaryngeal branch. Ann Surg 249:648–652PubMedCrossRefGoogle Scholar
  38. 38.
    Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R (1998) The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 228:320–330PubMedCrossRefGoogle Scholar
  39. 39.
    Steurer M, Passler C, Denk DM (2002) Advantages of recurrent laryngeal nerve identification in thyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope 112:124–133PubMedCrossRefGoogle Scholar
  40. 40.
    Stojadinovic A, Shaha AR, Orlikoff RF, Nissan A, Kornak MF, Singh B, Boyle JO, Shah JP, Brennan MF, Kraus DH (2002) Prospective functional voice assessment in patients undergoing thyroid surgery. Ann Surg 236:823–832PubMedCrossRefGoogle Scholar
  41. 41.
    Thomusch O, Sekulla C, Machens A, Neumann HJ, Timmermann W, Dralle H (2004) Validity of intra-operative neuromonitoring signals in thyroid surgery. Langenbecks Arch Surg 389:499–503PubMedCrossRefGoogle Scholar
  42. 42.
    Ulmer C, Koch KP, Seimer A, Molnar V, Meyding-Lamade U, Thon KP, Lamade W (2008) Real-time monitoring of the recurrent laryngeal nerve: an observational clinical trial. Surgery 143:359–365PubMedCrossRefGoogle Scholar
  43. 43.
    Wang LF, Lee KW, Kuo WR, Wu CW, Lu SP, Chiang FY (2006) The efficacy of intraoperative corticosteroids in recurrent laryngeal nerve palsy after thyroid surgery. World J Surg 30:299–303PubMedCrossRefGoogle Scholar
  44. 44.
    Worni M, Schudel HH, Seifert E, Inglin R, Hagemann M, Vorburger SA, Candinas D (2008) Randomized controlled trial on single dose steroid before thyroidectomy for benign disease to improve postoperative nausea, pain, and vocal function. Ann Surg 248:1060–1066PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Henning Dralle
    • 1
  • Gregory W. Randolph
    • 2
  • Kerstin Lorenz
    • 1
  • Andreas Machens
    • 1
  1. 1.Department of General, Visceral and Vascular Surgery, Medical FacultyUniversity of Halle-WittenbergHalle/SaaleGermany
  2. 2.Surgical DivisionMassachusetts General Hospital, Harvard Medical SchoolBostonUSA

Personalised recommendations