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Ultrasound visualization of the vagus nerve for intraoperative neuromonitoring in thyroid surgery

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Abstract

Objective

Localization of the vagus nerve is required during intraoperative neuromonitoring (IONM) for thyroid surgery in order to electromyographically verify the functional integrity of inferior laryngeal nerve and aim to reduce the risk of postoperative vocal fold paralysis. Classically, the vagus nerve courses within the carotid sheath between the common carotid artery and internal jugular vein, but anatomic variations have been described. Our aim was to compare preoperative ultrasound (US) and intraoperative localization of vagus nerve and to document anatomic variations.

Patients and methods

Retrospective study of patients undergoing thyroidectomy. The vagus nerve was identified 2 cm below the inferior border of the cricoid cartilage, on US performed 6 weeks prior to surgery; then, vagus nerve was identified surgically.

Results

For 82 patients, on preoperative US, the right vagus nerve was in between, superficial, or deep to the vessels in 94%, 2.4%, and 3.6%, and on the left in 72%, 24.4%, and 3.6%. Intraoperatively, the right vagus was in between, superficial, or deep in 90%, 4%, and 6%, and on the left in 67%, 27%, and 6%. US correlated with surgery on the right in 79/82 (96%) and on the left in 78/82 (95%).

Conclusions

To our knowledge, this is the first study directly comparing US and intraoperative findings. The US and surgical findings were identical in 95% on the left and 96% on the right The vagus nerve was superficial in 27% of cases on the left and 4% on the right. Identifying this anatomic variation preoperatively may facilitate IONM.

Key Points

• Localization of the vagus nerve is necessary during thyroid surgery when using neuromonitoring for electromyographic testing of the inferior laryngeal nerve to reduce the risk of postoperative vocal fold paralysis.

• The vagus nerve in the neck can be routinely visualized using ultrasound, and is generally in between the common carotid artery and the internal jugular vein. Its location on ultrasound corresponds very closely to that observed in vivo during surgery (95%).

• At the level of the thyroid lobe, there is an anatomic variant with the vagus nerve superficial to the common carotid artery which is seen more often on the left than on the right.

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Abbreviations

CC:

Common carotid artery

IJ:

Internal jugular vein

IONM:

Intraoperative neuromonitoring

mA:

Milliampere

SD:

Standard deviation

US:

Ultrasound

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Funding

The authors state that this work has not received any funding.

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Authors and Affiliations

  1. Department of Surgery, Anesthesia and Interventional Medicine, Gustave Roussy Cancer Campus and University Paris-Saclay, Villejuif, Cedex, France

    Dana M. Hartl, Joanne Guerlain & Ingrid Breuskin

  2. Department of Radiology, Gustave Roussy Cancer Campus and University Paris-Saclay, Villejuif, Cedex, France

    Sophie Bidault, Elizabeth Girard & Marie Terroir

  3. Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy Cancer Campus and University Paris-Saclay, Villejuif, Cedex, France

    Livia Lamartina & Sophie Leboulleux

Authors
  1. Dana M. Hartl
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  2. Sophie Bidault
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  3. Elizabeth Girard
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  4. Joanne Guerlain
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  5. Ingrid Breuskin
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  6. Livia Lamartina
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  7. Marie Terroir
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  8. Sophie Leboulleux
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Corresponding author

Correspondence to Dana M. Hartl.

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Guarantor

The scientific guarantor of this publication is Dr. Dana Hartl.

Conflict of interest

The authors of this manuscript declare relationships with the following companies: Dr. Hartl has received consulting fees from Medtronic®.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

None of the study subjects or cohorts has been previously reported.

This study was presented as an e-poster at the Francophone Congress of Radiology (“Journées Francophones de Radiologie”), Paris, France, October 11–14, 2019.

Methodology

• retrospective

• observational

• performed in only one center

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Hartl, D.M., Bidault, S., Girard, E. et al. Ultrasound visualization of the vagus nerve for intraoperative neuromonitoring in thyroid surgery. Eur Radiol 31, 4063–4070 (2021). https://doi.org/10.1007/s00330-020-07472-7

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  • DOI: https://doi.org/10.1007/s00330-020-07472-7

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