Staged Completion Thyroidectomy Following Lost Recurrent Laryngeal Nerve Signal During Index Thyroid Operation
*Jacob S. Bodde MS, Anna Kobzeva-Herzog MD, *Akshay Ravandur , *Andrea Merrill MD, Frederick T. Drake , David McAneny MD
Department of Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston Medical Center, Boston, MA
Background: Intraoperative nerve monitoring (IONM) is commonly used by surgeons during thyroid and parathyroid operations to identify the recurrent laryngeal nerve (RLN) and guide decision-making. At our institution, a strategy was adopted to convert planned total thyroidectomies to thyroid lobectomies if RLN signal was lost during removal of the first lobe, aiming to prevent bilateral vocal cord injuries. We sought to evaluate the impact of this approach, especially whether RLN injuries developed during the staged contralateral operation. Study Design: Single-institution retrospective review (October 2011-December 2023). Included patients intended for total thyroidectomy who underwent thyroid lobectomy and staged completion thyroidectomy after RLN signal loss on IONM during the index operation. Functional RLN injury was assumed if IONM signal disappeared, especially if the RLN or vagus nerve responded to earlier stimulation. Completion thyroidectomy was delayed until laryngoscopy confirmed paresis resolution. Primary outcomes were vocal cord function recovery and development of RLN injuries during completion thyroidectomy. Secondary outcomes included other post-operative complications. Results: Among the 13 identified patients, the average age was 44.4 (± 11.5) years, 31% were male, and the right side was affected during the index operation in 69% of cases. Primary indications for surgery included Graves’ disease (38.5%), thyroid cancer (38.5%), and multinodular goiter (23%). Eight specimens (61.5%) had histologic features of inflammation. Mean length of hospital stay for index operations was 0.92 days, versus 0.54 days for completion thyroidectomy. An average of 156.4 (± 85.4) days elapsed between initial operation and completion thyroidectomy. Excluding two outliers with delays due to social circumstances, an average of 126.5 (± 37.9) days elapsed between operations. During the completion thyroidectomies, all RLNs responded properly to stimulation and no patient manifested subsequent hoarseness. A single patient developed a seroma after both operations, neither episode required intervention. No other complications developed, including hypoparathyroidism or hematoma formation. During the study interval, the surgeons’ collective incidence of transient nerve pareses was 3.5% (76 pareses among 2,152 nerves at risk during thyroid operations). Conclusion: In this series, staged thyroid operations, following loss of RLN signal during the index operation, were not associated with adverse consequences or significant delays. RLN function was not compromised during any completion thyroidectomy, and no significant complications occurred. When an intra-operative RLN stimulation signal is lost during a planned total thyroidectomy, a safe tactic to avoid bilateral pareses is to limit the operation to an ipsilateral lobectomy and delay completion thyroidectomy until the RLN paresis resolves. In doing so, a four-month delay between operations can be expected.
Table 1: Overview of Patients with Recurrent Laryngeal Nerve Injury after Staged Thyroidectomy
| Characteristics/Variables | Total (N=13) |
| Age (at index operation), mean ± SD | 44.4 ± 11.5 |
| Male sex, n (%) | 4 (30.7%) |
| Surgeon, n (%) | |
| Surgeon 1 | 9 (69.2%) |
| Surgeon 2 | 3 (23.1%) |
| Surgeon 3 | 1 (7.7%) |
| Primary indication for operation, n (%) | |
| Cancer | 5 (38.5%) |
| Graves’ disease | 5 (38.5%) |
| Symptomatic multinodular goiter | 3 (23%) |
| Index operation, n (%) | |
| Left lobectomy | 4 (30.8%) |
| Right lobectomy | 9 (69.2%) |
| Number of days between index operation and nerve recovery (confirmed by laryngoscopy), mean ± SD | 84.8 ± 40.0 |
| Number of days between nerve recovery and completion thyroidectomy, mean ± SD | 71.5 ± 71.7 |
| Number of days between index operation and completion thyroidectomy, mean ± SD | 156.4 ± 85.4 |
| Complication rate, n (%) | |
| Complications from index operation (other than RLN paresis) | 1 seroma (7.7%) |
| Complications from completion thyroidectomy | 1 seroma (7.7%) |
| Length of hospital stay, mean ± SD | |
| Index operation | 0.92 ± 0.28 |
| Completion thyroidectomy | 0.54 ± 0.52 |
| Weight of thyroid gland (aggregate of index and completion operations, in grams), mean ± SD | 71.7 ± 74.1 |
| Number of specimens with thyroiditis by histology, n (%) | 8 (61.5%) |
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