Trends in intraoperative neural monitoring for thyroid and parathyroid surgery amongst otolaryngologists and general surgeons

Abstract

The role of intraoperative neural monitoring (IONM) in thyroid and parathyroid surgery remains a controversial subject for surgeons regardless of surgical training and background. This study aims to compare usage patterns and motivations behind IONM among otolaryngologist-head and neck surgeons (OTO-HNS) and general surgeons (GS) performing thyroid and parathyroid surgery. The study is a multi-institution survey of 103 otolaryngology and affiliated 103 GS programs in the US. 206 surveys were sent to OTO-HNS and GS academic program directors with a response rate of 44.7 %. Of those who performed thyroid surgery, 80.6 % of OTO-HNS and 48.0 % of GS surgeons reported using IONM. 44.3 % of OTO-HNS and 30.8 % of GS respondents used IONM in all thyroid cases. For thyroid surgery, as surgical volume increased, surgeons were more likely to use IONM more frequently. Fourteen percent (14 %) of the OTO-HNS and 41.7 % of the GS respondents used IONM primarily to locate the RLN. Forty percent (40 %) of the OTO-HNS and 8.3 % of the GS used IONM for medicolegal reasons. The majority of OTO-HNS programs use IONM for thyroid and parathyroid surgery, whereas less than half of GS programs regularly use IONM for these surgeries. Thyroid surgeons, with larger thyroid surgery volume, regardless of discipline, tend to use IONM more. The motivations for using IONM differ significantly between OTO-HNS and general surgeons in that more GS use it for locating the RLN, and more OTO-HNS use it for continuous monitoring of the nerve during resection and for medicolegal purposes.

Identification alone versus intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroid surgery: experience of 2034 consecutive patients

“…Many studies reported a high negative predictive value of 92-100% but a low and highly variable positive predictive value of 10-90% [2,32]. Recurrent laryngeal nerve monitoring is being used with increasing frequency in the United States during thyroidectomy, partly driven by the medico-legal system [10,22,33-35] while German surgeons use the method routinely even much more often than the Americans [1]; the rates of the use of neuromonitoring have recently become almost equivalent between general surgery- and otolaryngology-trained surgeons [14,22,36]. However, the use of recurrent laryngeal nerve monitoring is associated with increased time of setup and increased cost of equipment by about 5-7% [1,33].…”

The Utility of Recurrent Laryngeal Nerve Monitoring During Open Pharyngeal Diverticula Procedures

“…In fact, the RLN enters the larynx at precisely the origin of KJD: through the Killian-Jamieson triangle. 12,13 The use of a nerve monitor does not replace a surgeon's knowledge of head and neck anatomy, and during routine open ZD operations, the surgeon must be able to recognize the RLN if encountered. This is because the origin of ZD, Killian's dehiscence is located posteriorly, while the RLN enters the larynx laterally.…”

Opportunities and challenges of intermittent and continuous intraoperative neural monitoring in thyroid surgery

“…To remedy this deficiency, active efforts are being made to launch a series of training courses emphasizing the need to use intermittent IONM and continuous IONM (CIONM) in a standard fashion (1).…”

“…There are no corresponding data for CIONM, which may have been used in 2015 on almost 10% of all thyroid operations in Germany based on personal information (unpublished data). In the United States, the rationale for using IONM is split along professional lines: general surgeons prefer IONM to locate the RLN, whereas otolaryngologists use IONM more often for monitoring the RLN during thyroid resection and for documentation purposes to guard against malpractice claims (1).…”