Successful intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve, a multidisciplinary approach: The Massachusetts Eye and Ear Infirmary monitoring collaborative protocol with experience in over 3000 cases

Macias, Alvaro A.; Eappen, Sunil; Malikin, Ilya; Goldfarb, Jeremy; Kujawa, Sharon G.; Konowitz, Paul M.; Kamani, Dipti; Randolph, Gregory W.

doi:10.1002/hed.24468

Cited by 24 publications

(23 citation statements)

References 52 publications

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“…Based on our experience in this series, and supported by the work of Chiang et al with thyroid cartilage needle electrodes, the ALE may reduce the frequency of confusing amplitude drops or frank LOS (false positive errors) that can be caused by malpositioning of ETT surface electrodes. 8,15 This could potentially provide more reliable IONM and reduce operative time by eliminating the additional time needed by the anesthetist to reposition the ET tube during surgery.…”

Section: Discussionmentioning

confidence: 99%

“…For ETT‐based electrodes to provide reliable IONM, the anesthesiologist must accurately place the ETT so that the surface electrodes are positioned at the level of the vocal folds during intubation. This position must remain stable during retraction of the thyroid and airway, as well as with alterations in both head/neck positioning and the anesthesia circuit during surgery . Multiple factors throughout the course of surgery may cause the tube to rotate or migrate from this optimal placement, thereby leading to a decrease or frank loss of EMG signal upon neural stimulation.…”

Section: Introductionmentioning

confidence: 99%

“…This position must remain stable during retraction of the thyroid and airway, as well as with alterations in both head/neck positioning and the anesthesia circuit during surgery. 8 Multiple factors throughout the course of surgery may cause the tube to rotate or migrate from this optimal placement, thereby leading to a decrease or frank loss of EMG signal upon neural stimulation. Several studies have reported that monitoring equipment-related issues, especially ETT displacement, lead to a false positive loss of signal (LOS), reported to occur in 3.8% to 23% of monitored surgeries.…”

Section: Introductionmentioning

confidence: 99%

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Anterior laryngeal electrodes for recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: New expanded options for neural monitoring

et al. 2018

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Objectives/Hypothesis Intraoperative neural monitoring is a useful adjunct for the laryngeal nerve function assessment during thyroid and parathyroid surgery. Typically, monitoring is performed by measurement of electromyographic responses recorded by endotracheal tube (ETT) surface electrodes. Tube position alterations during surgery can cause displacement of the electrodes relative to the vocal cords, leading to false positive loss of signal. Numerous reports have denoted monitoring equipment–related issues, especially endotracheal tube displacement, as the dominant source of false positive error. The false positive error may result in inappropriate decisions by the surgeon. This study tests the hypothesis that anterior laryngeal electrodes (ALEs) can help reduce this error. Placement of ALEs directly onto the thyroid cartilage represent an adjunctive and possible alternative method to standard ETT surface electrodes. Study Design Retrospective review. Methods Fifteen consecutive patients undergoing thyroid and parathyroid surgery with intraoperative neuromonitoring using both ETT electrodes and ALEs were studied. Data collected included site of neural stimulation, laterality, and electromyographic parameters. Results With vagal and recurrent laryngeal nerve stimulation, the ALEs recorded mean vocalis muscle waveform amplitude within 83% of that recorded with standard ETT electrodes. The latency measurements with the anterior laryngeal and endotracheal electrodes were similar, with both electrodes recording significantly longer latency for the left vagus nerve as compared to the right vagus nerve. With superior laryngeal nerve stimulation, the ALEs recorded a 800% greater mean amplitude than the ETT electrodes. The ALEs demonstrated similar sensitivity to stimulation at low current as ETT electrodes and provided stable intraoperative monitoring information. Conclusions Compared to ETT surface electrodes, the ALEs provide similar and stable electromyographic responses with equal sensitivity for recording evoked responses during neural monitoring in thyroid and parathyroid surgery. The ALEs offer significantly more robust monitoring of the external branch of the superior laryngeal nerve. Furthermore, ALEs are contained within the operative field, are totally surgeon controlled, and are unaffected by the potential vicissitudes of ETT position during surgery. Level of Evidence 4 Laryngoscope, 128:2910–2915, 2018

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Anterior laryngeal electrodes for recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: New expanded options for neural monitoring

et al. 2018

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“…Several studies have attempted to evaluate the efficacy of IONM in reducing RLN injury . The proponents of IONM argue that nerve monitoring can aid in revision surgery, as IONM has been shown by select authors to be useful in predicting postoperative nerve function .…”

Section: Introductionmentioning

confidence: 99%

“…Several studies have attempted to evaluate the efficacy of IONM in reducing RLN injury. [7][8][9][10][11][12] The proponents of IONM argue that nerve monitoring can aid in revision surgery, as IONM has been shown by select authors to be useful in predicting postoperative nerve function. 11,12 One of the biggest pitfalls of IONM remains that although a positive signal from the nerve monitoring apparatus is reassuring, the lack of nerve stimulation during surgery can represent anything from equipment malfunction to stimulation of a non-nerve structure or an injured RLN.…”

Section: Introductionmentioning

confidence: 99%

Intraoperative nerve monitoring during parathyroid surgery: The Fort Worth experience

et al. 2017

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Clarifying optimal outcome measures in intermittent and continuous laryngeal neuromonitoring

et al. 2021

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Background Intraoperative neuromonitoring (IONM) techniques have evolved over the past decade into intermittent IONM (I‐IONM) and continuous IONM (C‐IONM) modes of application. Despite many prior publications on both types of IONM, there remains uncertainty about what outcomes should be measured for each form of IONM. The primary objective of this paper is to define categories of benefit for I‐IONM/C‐IONM and to clarify and standardize their reporting outcomes. Methods Expert review consensus statement utilizing modified Delphi methodology. Results I‐IONM provides diagnosis, classification, and prevention of nerve injury through accurate and early nerve identification. C‐IONM provides real‐time information on nerve functional integrity and thus may prevent some types of nerve injury but cannot assist in nerve localization. Sudden mechanisms of nerve injury cannot be predicted or prevented by either technique. Conclusions I‐IONM and C‐IONM are complementary techniques. Future studies evaluating the utility of IONM should focus on outcomes that are appropriate to the type of IONM being utilized.

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Successful intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve, a multidisciplinary approach: The Massachusetts Eye and Ear Infirmary monitoring collaborative protocol with experience in over 3000 cases

Abstract: An IONM system entails an anesthesiologist who understands the challenges posed by this technique; muscle relaxation must be minimized/eliminated to optimize IONM. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1494, 2016.

Cited by 24 publications

References 52 publications

Anterior laryngeal electrodes for recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: New expanded options for neural monitoring

Anterior laryngeal electrodes for recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: New expanded options for neural monitoring

Intraoperative nerve monitoring during parathyroid surgery: The Fort Worth experience

Clarifying optimal outcome measures in intermittent and continuous laryngeal neuromonitoring

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