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European Annals of Otorhinolaryngology, Head and Neck Diseases
Volume 135, n° 1S
pages 7-10 (février 2018)
Doi : 10.1016/j.anorl.2017.11.010
International Consensus (ICON) - IFOS Paris 2017 - ENT World Congress

International consensus (ICON) on comprehensive management of the laryngeal nerves risks during thyroid surgery

S. Périé a, , J. Santini b, H.Y. Kim c, H. Dralle d, G.W. Randolph e
a Service Oto-rhino-laryngologie et Chirurgie Cervico-faciale, Hôpital Tenon, Faculté Médecine Sorbonne Université, AP–HP, 4, rue de la Chine, 75020 Paris, France 
b Chirurgie de la face et du cou, IUFC-CHU de Nice, 31, avenue Valombrose, 06100 Nice, France 
c Korea university hospital, Korea university college of medicine, department of surgery, division of breast and endocrine surgery, Seoul. Korea 
d University hospital Essen, section of endocrine surgery, department of general, visceral and transplantation surgery, FEBS Head, Essen, Germany 
e Harvard Medical School, Massachusetts general hospital, Massachusetts Eye and Ear Infirmary, thyroid/parathyroid endocrine surgical divisions, USA 

Corresponding author.

The laryngeal monitoring of the inferior and superior laryngeal nerves, and the vagus nerve, has advanced for last years, in practice of thyroid and parathyroid surgery. Different methods are used, using direct or indirect laryngeal stimulation and also intermittent or continuous nerve registration. At present time, various recommendations of it in the world use are reported, and availability of the tool used remains a limit in some countries. The aim of this Icon during Ifos 2017 was to share knowledge about laryngeal intraoperative nerve monitoring (LIONM) procedures and to evaluate current practices used to improve the quality of thyroid and parathyroid surgery. Benefits of LIONM were discussed with three experts (Pr G. Randolph from Boston, Pr Henning Dralle from Halle in Germany, Pr Hoon Yub KIM from Seoul). All of them have been actively involved in the development and use of laryngeal nerve monitoring during thyroid and parathyroid surgery.

The full text of this article is available in PDF format.

Keywords : Laryngeal intraoperative nerve monitoring (LIONM), Recurrent or inferior laryngeal nerve, Vagus nerve, Laryngeal paralysis, Thyroid surgery, Parathyroid surgery


The laryngeal intraoperative laryngeal nerve monitoring (LIONM) has advanced for last years, in the practice of thyroid and parathyroid surgery, improving the outcome of patients undergoing neck surgery [1]. The recurrent laryngeal nerve (RLN), which is located near the thyroid gland, supplies the main motor function to the larynx. Damage to this nerve during surgery can result in a patient losing the ability to speak, to breath and to swallow.

The first condition well-demonstrated of laryngeal nerve preservation is its visualization [2, 3, 4, 5, 6]. This is also required for LIONM. Pre- and postoperative laryngoscopy also remains a condition to evaluate preservation of laryngeal nerves [7]. It is very important to ascertain if there is or not laryngeal paralysis and term of paresis following surgery should be excluded in this postoperative evaluation.

To monitor the nerve during surgery can help to avoid damage to the nerve, both the inferior and superior laryngeal nerves, to prevent nerve injury during surgical manipulation, and also to provide a prognosis for postoperative nerve function. However, one study assessed nerve monitoring impact with significantly lower rates of temporary RLN paralysis with LIONM [8], in contrast to others who reported no difference in transient or permanent paralysis of the recurrent laryngeal nerve (RLN) [9, 10, 11, 12]. The limit to demonstrate efficacy of LIONM is related to the low incidence of RLN paralysis [4]. IONM decreased the incidence of transient RLN paralysis in repeated thyroid surgery [13, 14, 15]. Recently, Bergenfelz et al. [16] reported from a large Scandinavia database, a significant reduction in permanent RLN paralysis with LIONM utilization, but only 33% of postoperative laryngoscopy was performed.

Various LIONM methods have been used, direct electromyography by needle or hook wires placed in cricothyroid or thyroarytenoid muscles to test either the superior or the inferior laryngeal nerves, or the use of adhesive surface electrodes or the electrode itself embedded in the endotracheal tube (ETT) to monitor muscles by stimulation of superior or inferior laryngeal nerves [13], or the vagus nerve. The use of ETT is gaining popularity due to ease of setup for all surgeons, especially for non-otolaryngologists. Furthermore, intermittent (I-LIONM) or continuous nerve registration (C-LIONM) [17, 18, 19, 20], with automatic periodic stimulation (APS) electrode on the vagus nerve [21, 22], may be recorded, also during endoscopic and robotic surgery [23, 24]. The system Inomed (Neurosign® 100/400/800; Inomed GmbH, Feningen, Germany) or NIM (NIM2, NIM3; Medtronic Xomed, Jacksonville, Floride, USA) are the most commonly used.

One of the great benefits of LIONM utilization is to perform a staged thyroidectomy when a loss of monitoring signal (LOS) is intraoperatively detected on the first side during planned bilateral thyroidectomy, to avoid risk of contralateral RLN injury and bilateral RLN palsy [25, 26, 27, 28, 29]. LOS is defined as decrease of the nerve amplitude unless 100μV from a baseline amplitude of more than 500μV after supra-threshold vagus stimulation at 1 to 2mA Loss of neuromonitoring signal is subdivided into segmental, focal type 1 injury, and global LOS type 2 [26, 30, 31, 32]. Type 1 reflected more severe nerve damage than global nerve injury. It is interesting to notice that injury on the first laryngeal nerve detected may dramatically increase from 9 [33] to 17% [34] the risk of contralateral laryngeal nerve damage [29].

In addition to intraoperative information in determining surgical strategy in patients undergoing bilateral (para)thyroidectomy, LIONM may also be determinant to predict prognosis of nerve injury.

At present time, recommendations of LIONM is reported, but its current use remains various around the world, partly due to availability of the tool. Recent guidelines from the American Academy of Otolaryngology Head and Neck Surgery recommend IONM use in thyroid surgery to improve voice outcomes [35]. The German Association of Endocrine Surgeons practice guidelines and the International Neural Monitoring Study Group guidelines both support using IONM in all thyroid surgeries [26, 36], while the American Head and Neck Society endorses its utilization in thyroid cancer cases, especially in patients with preoperative RLN palsy [37]. In France, the Rapport of the French ORL, expressed that its use is especially recommended in bilateral dissection of RLN, in preoperative RLN paralysis, and in cases of previous thyroid surgery [38, 39].

All of experts have been actively involved to LIONM guidelines, during (para)thyroid surgery; we have proposed to share opinions in its use to discuss both current procedures and applications in view of the literature [40]. Six selected questions have been previously addressed to experts (Hoon Yub Kim, HYK; Gregory W. Randolph, GR; Henning Dralle, HD) and exposed.

This reported ICON does not include grade of recommendations, since these are different and precised from different group of experts [13, 26, 38, 39], and this work is an experts’ point of view and not a recommendation.

Selected questions

Which system of LIONM do you use during thyroid/parathyroid surgery (electrodes on endotracheal tube, translaryngeal electrodes)?
Which nerves are systematically recorded by laryngeal LIONM during thyroid/parathyroid surgery? Is there specific method for LIONM during robotic thyroid surgery?
Is continuous LIONM (C-LIONM) indicated in selected cases?
How do you confirm loss of signal during LIONM and consequences on surgery?
In cases of laryngeal IONM not available, do you modify the dissection of the RLN?
Usefulness of LIONM for prognosis of laryngeal nerve paralysis?

Which system of LIONM do you use during thyroid/parathyroid surgery (electrodes on endotracheal tube, translaryngeal electrodes)?

HY: I use the EMG electrodes on the endotracheal tubes for LIONM in all my thyroid and parathyroid operations. Mores specifically, the system more used for LIOM in my experience is the NIM 3.0 system from the Medtronic, along with the classic NIM Contact Tube, because the NIM Trivantage tube is not imported to Korea yet.

GR: I think currently virtually all utilizing neural monitoring routinely use electrodes on the endotracheal tube. There are experimental trends laryngeal electrode options but I would say these have not penetrated into the typical neural monitoring surgical venue to any significant extent.

HD: We started with routine use of I-IONM in 1997 by using translaryngeal stich electrodes to the vocal muscles. Since 2002, we are using tube electrodes only as well for I-IONM as since 2011 for continuous vagus stimulation (C-IONM).

Which nerves are systematically recorded by laryngeal IONM during thyroid/parathyroid surgery? Is there specific method for LIONM during robotic thyroid surgery?

HYK: I always monitor the vagus and the RLN in all types of thyroid and parathyroid operations, including the robotics. In addition, I always try to monitor the external branch of the superior laryngeal nerve as well, however, in some cases, it is difficult to monitor the EMG response of external branch of the superior laryngeal nerve by the system because the sensitive Trivantage tube is not available in the market in Korea.

I have done hundreds of BABA robotic thyroidectomies, and recently more than a hundred of transoral robotic thyroidectomies with I-IONM. You may grasp and use the needle nerve stimulator incorporated into the trocar insertion site by the robotic needle driver. However, I’ve found that it is more easy and convenient to use the robotic monopolar cauterization hook as the nerve stimulator, which can be easily transformed by simply connecting the NIM system to the hook with simple electric conducting wires.

GR: most typically the vagus, RLN and external branch of the superior laryngeal nerve are monitored-or can be monitored. I would say most commonly data is routinely obtained on the RLN, next most common is vagus and probably least common external branch of the superior laryngeal nerve in terms of what is currently performed.

HD: I have some experience with transaxillary endoscopic thyroidectomy but not with robotic, neither transaxillary nor transoral. During open thyroidectomy, we are using routinely C-IONM by APS electrode. I-IONM is used only in the case of parathyroidectomy (first surgery) for primary hyperprathyroidism. With I-IONM and C-IONM RLN and vagus nerve, EMG's are routinely recorded before and after resection (V1; R1; V2; R2). External branch of the superior laryngeal nerve is recorded only when successful EMG is obtained.

Is continuous LIONM indicated in selected cases?

HY: I use C-IONM in all my open conventional cases, because I believe it has the great role to make it possible to avoid the traction injury of RLN. However, frankly speaking, I do not use C-IONM in all my series of transoral robotic thyroidectomies, because it really takes extra time and effort for me to put the automatic periodic stimulating (APS) around the vagus nerve in the robotic operations. But it is fortunate and glad to find out that I had not experienced any traction injury case in my recent >130 consecutive transoral robotic thyroidectomy series, which may be reported to be the advantage of the cephalo-caudal procedure.

GR: continuous monitoring is still, I am afraid, in its infancy, but has great application for the potential prevention of traction injury.

HD: in my departments C-IONM is used in all cases. We do not favour selective C-IONM, because we have learned and published with the International Nerve Monitoring Study Group (INMSG) that instead of direct nerve injuries with LOS Type 1, indirect nerve injuries (e.g. tension) with LOS Type 2 are occurring much more frequently. However, LOS 2 can best be prevented by C-IONM.

How do you confirm loss of signal during LIONM and consequences on surgery?

HYK: as in the International Intraoperative Monitoring Study Group's guideline published in Laryngoscope [26], I confirm the LOS by the loss of signal or amplitude decrease to less than 100μV on adequate stimulation to 2–3mA. In the planned bilateral surgery, I usually stop the surgery when LOS occurred at the initial side, unless it is the definite permanent irreversible injury caused by the obvious reason such as the segmental RLN resection caused by the extensive cancer invasion.

GR: there are many references and guidelines in the literature that help to define what loss of signal is and how that should be integrated in the decision for proceeding with bilateral surgery.

HD: LOS is confirmed by loss of signal, or amplitude decrease to less than 100μV on stimulation with 1 to 2mA. LOS has no consequences when only one side is operated, or it happens at the second side in bilateral surgery. In patients with planned bilateral surgery, we stop surgery when LOS occurred at first side. Exceptions from that rule are made only individually.

In cases of laryngeal IONM not available, do you modify the dissection of the RLN?

HYK: no, I will not. If IONM is not available, I will try my best to clearly visualize the nerve and to dissect gently around the nerve with minimization of the traction.

GR: I do not have personal experience with cases where monitoring is not available and feel monitoring should be available for all cases of thyroidectomy.

HD: since 1997, I do not do neck surgeries without IONM. In case IONM does not work at first side in planned bilateral surgery, we would use our second nerve monitoring device, and when that also does not work, I would prefer stop surgery at the end of first side.

Usefulness of LIONM for prognosis of laryngeal nerve paralysis?

HYK: I definitely agree with Dr Randolph's and Dr Dralle's opinions. More than 7 series suggest that the negative predictive value of LIONM is reaching over 95%.

GR: perhaps the most well worked-out application of neural monitoring is in its prognostic role. Multiple series in the literature suggests negative predictive value of over 95%.

HD: when LOS has been confirmed after checking the troubleshooting algorithm, and the nerve amplitude fails to recover at least 50% of initial baseline the risk of postoperative vocal cord palsy is about 90% by using C-IONM, and about 70% by using I-IONM. Signal recovery less than 50% of baseline amplitude indicated postoperative vocal cord palsy in all patients with LOS type 1, and two thirds of patients with LOS type 2 injuries.

Conclusion, experts’ recommendations

Although there is no consensus that IONM decreases laryngeal nerve injury when compared to traditional nerve visualization alone, LIONM has many advantages, as most of injured nerves appear visually intact [12, 14, 23, 40]. The major role is to prevent bilateral RLN injury by allowing surgeons to stage the surgery when the signal is lost on the first side, thus avoiding bilateral RLN paralysis. It may be integrated in the decision for proceeding bilateral surgery and to discuss the extent of surgery, such recurrent laryngeal nerve neck dissection on the contralateral side in cases of thyroid cancer. The second advantage is that IONM give prognostic of postoperative nerve function, a positive signal during surgery, traducting preservation of laryngeal function in the long term follow up. Its use is especially recommended in higher risk of laryngeal nerves injury, such anatomical variation and abnormal courses of the nerves (non-recurrent RLN, arteria lusoria, large goiters), bilateral thyroidectomy, thyroid cancer patients, and patients with prior anterior cervical neck surgery. C-IONM is a more recent modality of LIONM that can prevent potential nerve injury by detecting immediate signal changes, and detect very proximal injuries. However, the availability of the LIONM may limit its current use.

Disclosure of interest

The authors declare that they have no competing interest.


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