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Routine Intraoperative Recurrent Laryngeal Nerve Monitoring During Thyroidectomy
*Rachelle N Damle, *Kate Dinh, Anne C. Larkin, Robert Quinlan, Giles Whalen
University of Massachusetts, Worcester, MA

Objective: To evaluate the efficacy of routine intraoperative neuromonitoring (IONM) in preventing recurrent laryngeal nerve (RLN) injury during thyroidectomy.
Design: Retrospective chart review.
Setting: Academic institution.
Patients: Consecutive patients undergoing thyroidectomy at a single institution by experienced endocrine surgeons between 2006 and 2009 following adoption of routine IONM.
Interventions: Intraoperative IONM.
Main Outcome Measures: RLN injury.
Results: Between 2006 and 2008, 296 subjects underwent thyroid lobectomy or total thyroidectomy by an experienced endocrine surgeon. One patient was excluded because of preoperative documentation of RLN injury. IONM was used in 253 (88%) cases during adoption of this technology (with 403 nerves at risk of injury). Loss of RLN signal following surgical dissection occurred in 13 cases, prompting a change in surgical plan in one case. Three patients with RLN signal loss had transient post-operative voice changes. Post-operative laryngoscopy was performed in eight patients with persistent hoarseness, documenting vocal cord paralysis in one patient who had clear intraoperative anatomic evidence of RLN injury. In no case did loss of RLN signal after dissection lead to persistent voice change without anatomical evidence of injury detected by the surgeon. IONM had a one-time cost for reusable equipment of $29,536, and an average disposable cost of $420 to $437 per case.
Conclusions: In our early experience, routine IONM did not appear to increase protection of the RLN over visual identification. Loss of IONM signal did not reliably predict post-operative voice changes. Furthermore, IONM added equipment cost of around $450 per case.
N(%)
Female194(77%)
Mean age (years)49--
Procedure
Total thyroidectomy152(60%)
Right lobectomy43(17%)
Left lobectomy39(16%)
Completion thyroidectomy19(7%)
Reoperation25(10%)
Signal lost after dissection13(5%)
Signal loss prompted change in surgical plan1(0.3%)
Post-operative voice change14(5%)
Immediately14(5%)
2 weeks14(5%)
6 weeks3(1%)
2 years1(0.3%)
Laryngoscopy performed8(3%)
Normal7(1%)
Cord paralysis1(0.3%)
Visual identification of RLN injury1(0.3%)
Malfunction of IONM system17(7%)
Fixed Cost
Main unit$29,536
Variable Cost
Endotracheal tube$230-247
Stimulator probe$103
Electrodes$87


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IMPORTANT DATES
Abstract Submission Deadline:
May 5, 2014

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August 13, 2014

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August 11, 2014
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