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Drawbacks of neural monitoring troubleshooting algorithms in transoral endoscopic thyroidectomy

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Abstract

Introduction

The application of intraoperative neural monitoring (IONM) trouble-shooting algorithms procedures in transoral endoscopic thyroidectomy vestibular approach (TOETVA) was investigated.

Methods

Loss of signal (LOS) is defined as a loss of the primary electromyographic (EMG) normal biphasic waveform with reduced amplitude response to less than 100μV with a stimulation level intensity of 1–2mA. A systematic review of the IONM system at LOS was covered methodically: (i) correct endotracheal tube verification, (ii) stimulation of the recurrent laryngeal nerve (RLN) at entry point, (iii) ipsilateral or contralateral vagal nerve (VN) stimulation, and (iv) laryngeal twitch (LT).

Results

The function of 223 nerves at risk (NAR) was recorded with IONM. Twenty-seven (12%) NAR experienced a suspected LOS. LT could not be appreciated. In 15/27 (55%) cases, the application of the IONM trouble-shooting algorithm revealed upward displacement of the EMG tube (all orotracheal intubations). In 9 (4%) NAR, VN stimulation was not accomplished. In detail, there were n.5 left and n. 4 right VNs. Two VNs were ipsilateral, and 7 VNs contralateral. For EMG tube displacement, because the oral/nasal area is included in the aseptic field, it is less possible to re-check by the laryngoscope or fiberscope.

Conclusions

A limit for applying the IONM trouble-shooting algorithm to TOETVA is determined by (a) inability to appreciate the LT, (b) difficulty in stimulating the ipsilateral and contralateral VN, and (c) remodeling EMG endotracheal tube position. A modified IONM trouble-shooting algorithm for TOETVA is proposed.

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Authors and Affiliations

  1. Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, 126 Xiantai Blvd, Changchun City, Jilin Province, China

    Daqi Zhang, Tie Wang, Yishen Zhao & Hui Sun

  2. Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan

    Che-Wei Wu

  3. College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

    Che-Wei Wu

  4. Department of Surgery, Korea University College of Medicine, Seoul, Korea

    Hoon Yub Kim

  5. Division of Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy

    Antonella Pino & Gianlorenzo Dionigi

Authors
  1. Daqi Zhang
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  2. Che-Wei Wu
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  3. Tie Wang
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  4. Yishen Zhao
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  5. Hoon Yub Kim
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  6. Antonella Pino
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  7. Gianlorenzo Dionigi
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  8. Hui Sun
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Contributions

All authors equally contributed to conception, design, manuscript writing, and final approval of manuscript.

Corresponding authors

Correspondence to Antonella Pino or Hui Sun.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee.

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Patients signed an informed consent before surgery for dataset use.

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The authors declare no competing interests.

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Zhang, D., Wu, CW., Wang, T. et al. Drawbacks of neural monitoring troubleshooting algorithms in transoral endoscopic thyroidectomy. Langenbecks Arch Surg 406, 2433–2440 (2021). https://doi.org/10.1007/s00423-021-02217-6

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  • DOI: https://doi.org/10.1007/s00423-021-02217-6

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