Original Research Article| Volume 223, ISSUE 5, P918-922, May 2022

Nerve monitoring decreases recurrent laryngeal nerve injury risk for neoplasm-related thyroidectomy

Published:October 13, 2021DOI:


      • Retrospective review of prospectively collected ACS-NSQIP Thyroidectomy database.
      • Of 6942 patients undergoing thyroidectomy, 4269 used intraoperative neuromonitoring.
      • Similar rate of overall nerve injury in intraoperative nerve monitor use and without.
      • Nerve monitoring was associated with decreased odds of severe nerve injury.



      Conflicting reports exist regarding the benefit of intraoperative neuromonitoring (INM) for patients undergoing thyroidectomy. We hypothesized that in a national sample, the risk of mild and severe RLNi is decreased for patients undergoing neoplasm-related disease (NRD) thyroidectomy with INM compared to patients without INM.


      The database was queried for patients that underwent total thyroidectomy for NRD with and without INM. A multivariable logistic regression model was used to determine the associated odds of RLNi.


      From 6942 patients, 4269 (61.5%) had INM during thyroidectomy. Patients with INM had a similar rate of overall RLNi compared to patients without INM (5.7% vs. 6.6%, p = 0.118). After adjusting for covariates, INM was associated with decreased odds of severe-RLNi (OR 0.23, p = 0.036) but not mild-RLNi (p = 0.16).


      INM is associated with a nearly 80% decreased associated odds of severe RLNi during thyroidectomy for NRD. Future prospective confirmation is needed, and if confirmed, patients undergoing thyroidectomy for NRD should have INM to reduce the risk of RLNi and its associated morbidity.


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        • Sun G.
        • DeMonner S.
        • Davis M.M.
        Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996-2006.
        Thyroid. 2013; 23: 727-733
      1. Cancer stat facts: thyroid cancer. National Cancer Institute. Accessed 11.26.2019.

      2. Wirth L, Shah M. Are thyroid cancer incidence and mortality rates truly increasing in the United States? The ASCO post. Accessed 12.15.2019.

      3. Thyroidectomy: the surgeon volume effect. Physician’s Weekly. Accessed 12.15.2019.

        • Burge M.
        • Zeise T.M.
        • Johnsen M.
        • Conway M.
        • Qualls C.
        Risk of complication following thyroidectomy.
        J Gen Intern Med. 1998; 13: 24-31
        • Shaw G.Y.
        • Pierce E.
        Malpractice litigation involving iatrogenic surgical vocal fold paralysis: a close-claims review with recommendations for prevention and management.
        Ann Otol Rhinol Laryngol. 2009; 118: 6-12
        • Landerholm K.
        • Wasner A.
        • Jarhult J.
        Incidence and risk factors for injuries to the recurrent laryngeal nerve during neck surgery in the moderate-volume setting.
        Langenbeck's Arch Surg. 2014; 399: 509-515
        • Zakaria H.
        • Awad N.
        • Kreedes A.
        • et al.
        Recurrent laryngeal nerve injury in thyroid surgery.
        Oman Med J. 2011; 26: 34-38
        • Jeannon J.P.
        • Orabi A.A.
        • Bruch G.A.
        • Abdalsalam H.A.
        • Simo R.
        Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review.
        Int J Clin Pract. 2009; 63: 624-629
        • Steurer M.
        • Passler C.
        • Denk D.M.
        • Schneider B.
        • Niederle B.
        • Bigenzahn W.
        Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk.
        Laryngoscope. 2002; 112: 124-133
        • Joliat G.R.
        • Guarnero V.
        • Demartines N.
        • Schweizer V.
        • Matter M.
        Recurrent laryngeal nerve injury after thyroid and parathyroid surgery: incidence and postoperative evolution assessment.
        Medicine (Baltim). 2017; 96e6674
        • Schneider M.
        • Dahm V.
        • Passler C.
        • et al.
        Complete and incomplete recurrent laryngeal nerve injury after thyroid and parathyroid surgery: characterizing paralysis and paresis.
        Surgery. 2019; 166: 369-374
        • Lahey F.H.
        Routine dissection and demonstration of recurrent laryngeal nerves in subtotal thyroidectomy.
        Surg Gynecol Obstet. 1938; 66: 775-777
        • Shedd D.
        • Burget G.
        Identification of the recurrent laryngeal nerve.
        Arch Surg. 1966; 92: 861-864
        • Chan W.F.
        • Lo C.Y.
        Pitfalls of intraoperative neuromonitoring for predicting postoperative recurrent laryngeal nerve function during thyroidectomy.
        World J Surg. 2006; 30: 806-812
        • Thomusch O.
        • Sekulla C.
        • Walls G.
        • Machens A.
        • Dralle H.
        Intraoperative neuromonitoring for surgery for benign goiter.
        Am J Surg. 2002; 183: 673-678
        • Cirocchi R.
        • Arezzo A.
        • D'Andrea V.
        • et al.
        Intraoperative neuromonitoring versus visual nerve identification for prevention of recurrent laryngeal nerve injury in adults undergoing thyroid surgery.
        Cochrane Database Syst Rev. 2019; 1: CD012483
        • Jatzko G.R.
        • Lisborg P.H.
        • Muller M.G.
        • Wette V.M.
        Recurrent nerve palsy after thyroid operations – principal nerve identification and a literature review.
        Surgery. 1994; : 115139-115144
        • Gremillion G.
        • Fatakia A.
        • Dornelles A.
        • Amedee R.G.
        Intraoperative recurrent laryngeal nerve monitoring in thyroid surgery: is it worth the cost?.
        Oshsner J. 2012; 12: 363-366
        • Chung T.
        • Rosenthal E.
        • Porterfield J.
        • Carroll W.
        • Richman J.
        • Hawn M.
        Examining national outcomes after thyroidectomy with nerve monitoring.
        J Am Coll Surg. 2014; 219: 765-770
        • Sanapala A.
        • Nagaraju M.
        • Rao L.
        • Koteswar Nalluri
        Management of bilateral recurrent laryngeal nerve paresis after thyroidectomy.
        Anesth Essays Res. 2015; 9: 251-253
        • Dralle H.
        • Sekulla C.
        • Haerting J.
        • et al.
        Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery.
        Surgery. 2004; 136: 1310-1322
        • Barczyriski M.
        • Konturek A.
        • Cichori S.
        Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy.
        Br J Surg. 2009; 96: 240-246
        • Pisanu A.
        • Porceddu G.
        • Podda M.
        • Cois A.
        • Uccheddu A.
        Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy.
        J Surg Res. 2014; 188: 152-161
        • Beldi G.
        • Kinsbergen T.
        • Schlumpf R.
        Evaluation of intraoperative recurrent nerve monitoring in thyroid surgery.
        World J Surg. 2004; 28: 589-591
        • Shindo M.
        • Chheda N.N.
        Incidence of vocal cord paralysis with and without recurrent laryngeal nerve monitoring during thyroidectomy.
        Arch Otolaryngol Head Neck Surg. 2007; 133: 481-485
        • Higgins T.
        • Gupta R.
        • Ketcham A.
        • Sataloff R.
        • Wadsworth J.T.
        • Sinacori J.
        Recurrent laryngeal nerve monitoring versus identification alone on post-thyroidectomy true vocal fold palsy: a meta-analysis.
        Laryngology. 2011; 121: 1009-1017
        • Sarkis L.M.
        • Zaidi N.
        • Norlen O.
        • Delbridge L.W.
        • Sywak M.S.
        • Sidhu S.B.
        Bilateral recurrent laryngeal nerve injury in a specialized thyroid surgery unit: would routine intraoperative neuromonitoring alter outcomes?.
        ANZ J Surg. 2017; 87: 364-367
        • Bai B.
        • Chen W.
        Protective effects of intraoperative nerve monitoring (IONM) for recurrent laryngeal nerve injury in thyroidectomy: meta-analysis.
        Sci Rep. 2018; 8: 7761
        • Angeletti F.
        • Musholt P.B.
        • Musholt T.J.
        Continuous intraoperative neuromonitoring in thyroid surgery.
        Surg Technol Int. 2015; 27: 79-85