International neuromonitoring study group guidelines 2018: Part II: Optimal recurrent laryngeal nerve management for invasive thyroid cancer—incorporation of surgical, laryngeal, and neural electrophysiologic data

Abstract

The purpose of this publication was to inform surgeons as to the modern state‐of‐the‐art evidence‐based guidelines for management of the recurrent laryngeal nerve invaded by malignancy through blending the domains of 1) surgical intraoperative information, 2) preoperative glottic function, and 3) intraoperative real‐time electrophysiologic information. These guidelines generated by the International Neural Monitoring Study Group (INMSG) are envisioned to assist the clinical decision‐making process involved in recurrent laryngeal nerve management during thyroid surgery by incorporating the important information domains of not only gross surgical findings but also intraoperative recurrent laryngeal nerve functional status and preoperative laryngoscopy findings. These guidelines are presented mainly through algorithmic workflow diagrams for convenience and the ease of application. These guidelines are published in conjunction with the INMSG Guidelines Part I: Staging Bilateral Thyroid Surgery With Monitoring Loss of Signal. Level of Evidence: 5 Laryngoscope, 128:S18–S27, 2018

Increased prevalence of neural monitoring during thyroidectomy: Global surgical survey

“…Despite the possibly more ubiquitous use demonstrated in our North American cohort, our data suggests a general similarity in these attitudes between North American and non‐North American surgeons. This information, when taken in context with recent consensus guideline, also indicates that several learning opportunities exist with regard to the utility of vagal stimulation, overall safety of neural stimulation (that continued neural stimulation does not lead to loss of signal), and incorporation of loss of signal into the surgical strategy of a planned total thyroidectomy …”

“…The ATA Surgical Affairs Committee Consensus Statement on Outpatient Thyroid Surgery and the ATA Statement on Optimal Surgical Management of Goiter notes neural monitoring has a role in confirming intact neural function at the end of surgery, especially if the loss of signal is bilateral . Recently, the INMSG has published two new guidelines regarding neural monitoring . The first guideline recommends strong consideration toward staging planned contralateral lobe surgery in the setting of ipsilateral loss of electromyography (EMG) signal.…”

“…26,27 Recently, the INMSG has published two new guidelines regarding neural monitoring. 28,29 The first guideline recommends strong consideration toward staging planned contralateral lobe surgery in the setting of ipsilateral loss of electromyography (EMG) signal. The second document discusses comprehensive management of RLN using preoperative laryngeal exam and intraoperative IONM EMG data when RLN is grossly invaded by tumor to allow personalized surgical RLN management.…”

Trans–thyroid cartilage recording for neural monitoring of the recurrent laryngeal nerve in thyroid surgery

“…Endotracheal tube–based nerve monitoring has become widely accepted as a standard for intraoperative neural monitoring during thyroid surgery . It is not, however, used without several limitations.…”

“…Endotracheal tube-based nerve monitoring has become widely accepted as a standard for intraoperative neural monitoring during thyroid surgery. [1][2][3][4] It is not, however, used without several limitations. First, proper electromyography (EMG) tube placement and fixation is a complicated and time-consuming procedure.…”