Ann Surg Treat Res.  2015 Nov;89(5):233-239. 10.4174/astr.2015.89.5.233.

Intraoperative neuromonitoring of the external branch of the superior laryngeal nerve during robotic thyroid surgery: a preliminary prospective study

• Kim SJ
• Lee KE
• Oh BM
• Oh EM
• Bae DS
• Choi JY
• Myong JP
• Youn YK

• KMID: 2095528
• DOI: http://doi.org/10.4174/astr.2015.89.5.233

Abstract

PURPOSE
The aim of this study was to evaluate the feasibility of monitoring external branch of the superior laryngeal nerve (EBSLN) during robotic thyroid surgery.
METHODS
A total of 10 patients undergoing bilateral axillo-breast approach (BABA) robotic thyroid surgery were enrolled. The nerve integrity monitor (NIM Response 2.0 System) was used for EBSLN monitoring. We performed voice assessments preoperatively and at 1 and 3 months postoperatively using Voice Handicap Index-10 (VHI-10), maximal phonation time (MPT), phonation efficient index (PEI), and laryngeal electromyography (EMG).
RESULTS
A total of 19 EBSLNs were at risk and 14 EBSLNs (73.7%) were identified using neuromonitoring. VHI-10 showed a change of voice over time (0.1 vs. 3.6 vs. 1.3); however, this was not statistically significant. VHI-10 scores normalized at 3 months postoperatively compared to the preoperative scores. MPT (a) (16.0 vs. 15.6 vs. 15.4), and MPT (e) (20.1 vs. 15.4 vs. 18.5) showed no significant differences preoperatively compared to the values obtained 1 and 3 months postoperatively. There was a significant change of PEI over time (4.8 vs. 1.1 vs. 4.6) (P = 0.036); however, the values normalized at 3 months postoperatively. Laryngeal EMG results showed 4 cases (21.2%) of neuropathy of EBSLNs at 1 month postoperatively, and electrodiagnostic studies revealed nearly complete recovery of the function of EBSLNs in 4 patients at 3 months postoperatively
CONCLUSION
It is suggested that neuromonitoring of EBSLNs during BABA robotic thyroid surgery is feasible and might be helpful to preserve voice quality.

Keyword

Robotic surgical procedures; Thyroidectomy; Laryngeal nerves; Intraoperative neurophysiological monitoring

MeSH Terms

Electromyography
Humans
Intraoperative Neurophysiological Monitoring
Laryngeal Nerves*
Phonation
Prospective Studies*
Thyroid Gland*
Thyroidectomy
Voice
Voice Quality

Figure

• 

  Fig. 1 (A) Comparison of the Voice Handicap Index-10 (VHI-10) preoperatively (preop) and at 1 and 3 months postoperatively. The VHI-10 showed a change of voice over time (0.1 vs. 3.6 vs. 1.3); however, this was not statistically significant (P = 0.056). VHI-10 normalized at 3 months postoperatively compared with VHI-10 preoperatively. Squares indicate mean and bars indicate minimum to maximum range. (B) Comparison of maximal phonation time (MPT) (a) preoperatively and at 1 and 3 months postoperatively. MPT (a) showed no significant change over time (16.0 vs. 15.6 vs. 15.4) (P = 0.889). Squares indicate mean and bars indicate minimum to maximum range. (C) Comparison of MPT (e) preoperatively and at 1 and 3 months postoperatively. MPT (e) showed no significant change over time (20.1 vs. 15.4 vs. 18.5) (P = 0.174). Squares indicate mean and bars indicate minimum to maximum range. (D) Comparison of phonation efficient index (PEI) preoperatively and at 1 and 3 months postoperatively. A significant change of PEI over time was observed (4.8 vs. 1.1 vs. 4.6) (P = 0.036); however, PEI normalized at 3 months postoperatively. Squares indicate mean and bars indicate minimum to maximum range. a,bsymbol of post hoc analysis.

Reference

1. Thomusch O, Machens A, Sekulla C, Ukkat J, Lippert H, Gastinger I, et al. Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany. World J Surg. 2000; 24:1335–1341.

2. Friedman M, LoSavio P, Ibrahim H. Superior laryngeal nerve identification and preservation in thyroidectomy. Arch Otolaryngol Head Neck Surg. 2002; 128:296–303.

3. Teitelbaum BJ, Wenig BL. Superior laryngeal nerve injury from thyroid surgery. Head Neck. 1995; 17:36–40.

4. Cernea CR, Nishio S, Hojaij FC. Identification of the external branch of the superior laryngeal nerve (EBSLN) in large goiters. Am J Otolaryngol. 1995; 16:307–311.

5. Kierner AC, Aigner M, Burian M. The external branch of the superior laryngeal nerve: its topographical anatomy as related to surgery of the neck. Arch Otolaryngol Head Neck Surg. 1998; 124:301–303.

6. Soylu L, Ozbas S, Uslu HY, Kocak S. The evaluation of the causes of subjective voice disturbances after thyroid surgery. Am J Surg. 2007; 194:317–322.

7. Bellantone R, Boscherini M, Lombardi CP, Bossola M, Rubino F, De Crea C, et al. Is the identification of the external branch of the superior laryngeal nerve mandatory in thyroid operation? Results of a prospective randomized study. Surgery. 2001; 130:1055–1059.

8. Lore JM Jr, Kokocharov SI, Kaufman S, Richmond A, Sundquist N. Thirty-eightyear evaluation of a surgical technique to protect the external branch of the superior laryngeal nerve during thyroidectomy. Ann Otol Rhinol Laryngol. 1998; 107:1015–1022.

9. Miccoli P, Elisei R, Materazzi G, Capezzone M, Galleri D, Pacini F, et al. Minimally invasive video-assisted thyroidectomy for papillary carcinoma: a prospective study of its completeness. Surgery. 2002; 132:1070–1073.

10. Lombardi CP, Raffaelli M, Princi P, De Crea C, Bellantone R. Minimally invasive video-assisted functional lateral neck dissection for metastatic papillary thyroid carcinoma. Am J Surg. 2007; 193:114–118.

11. Lee J, Nah KY, Kim RM, Ahn YH, Soh EY, Chung WY. Differences in postoperative outcomes, function, and cosmesis: open versus robotic thyroidectomy. Surg Endosc. 2010; 24:3186–3194.

12. Lee KE, Rao J, Youn YK. Endoscopic thyroidectomy with the da Vinci robot system using the bilateral axillary breast approach (BABA) technique: our initial experience. Surg Laparosc Endosc Percutan Tech. 2009; 19:e71–e75.

13. Inabnet WB, Murry T, Dhiman S, Aviv J, Lifante JC. Neuromonitoring of the external branch of the superior laryngeal nerve during minimally invasive thyroid surgery under local anesthesia: a prospective study of 10 patients. Laryngoscope. 2009; 119:597–601.

14. Deary IJ, Webb A, Mackenzie K, Wilson JA, Carding PN. Short, self-report voice symptom scales: psychometric characteristics of the voice handicap index-10 and the vocal performance questionnaire. Otolaryngol Head Neck Surg. 2004; 131:232–235.

15. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and validation of the voice handicap index-10. Laryngoscope. 2004; 114:1549–1556.

16. Miyauchi A, Matsusaka K, Kihara M, Matsuzuka F, Hirai K, Yokozawa T, et al. The role of ansa-to-recurrent-laryngeal nerve anastomosis in operations for thyroid cancer. Eur J Surg. 1998; 164:927–933.

17. Miyauchi A, Inoue H, Tomoda C, Fukushima M, Kihara M, Higashiyama T, et al. Improvement in phonation after reconstruction of the recurrent laryngeal nerve in patients with thyroid cancer invading the nerve. Surgery. 2009; 146:1056–1062.

18. Hurtado-Lopez LM, Pacheco-Alvarez MI, Montes-Castillo Mde L, Zaldivar-Ramirez FR. Importance of the intraoperative identification of the external branch of the superior laryngeal nerve during thyroidectomy: electromyographic evaluation. Thyroid. 2005; 15:449–454.

19. Dackiw AP, Rotstein LE, Clark OH. Computer-assisted evoked electromyography with stimulating surgical instruments for recurrent/external laryngeal nerve identification and preservation in thyroid and parathyroid operation. Surgery. 2002; 132:1100–1106.

20. Munin MC, Murry T, Rosen CA. Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin North Am. 2000; 33:759–770.

21. Koufman JA, Postma GN, Whang CS, Rees CJ, Amin MR, Belafsky PC, et al. Diagnostic laryngeal electromyography: The Wake Forest experience 1995-1999. Otolaryngol Head Neck Surg. 2001; 124:603–606.

22. Simpson CB, Fleming DJ. Medical and vocal history in the evaluation of dysphonia. Otolaryngol Clin North Am. 2000; 33:719–730.

23. Heman-Ackah YD, Mandel S, Manon-Espaillat R, Abaza MM, Sataloff RT. Laryngeal electromyography. Otolaryngol Clin North Am. 2007; 40:1003–1023.

24. Dumitru D, Zwarts MJ. Focal cranial neuropathies. In : Dumitru D, Zwarts MJ, editors. Electrodiagnostic medicine. 2nd ed. Philadelphia: Hanley & Belfus;2002. p. 653–712.

25. Cernea CR, Ferraz AR, Furlani J, Monteiro S, Nishio S, Hojaij FC, et al. Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Am J Surg. 1992; 164:634–639.

26. Lifante JC, McGill J, Murry T, Aviv JE, Inabnet WB 3rd. A prospective, randomized trial of nerve monitoring of the external branch of the superior laryngeal nerve during thyroidectomy under local/regional anesthesia and IV sedation. Surgery. 2009; 146:1167–1173.

27. Jonas J, Bahr R. Neuromonitoring of the external branch of the superior laryngeal nerve during thyroid surgery. Am J Surg. 2000; 179:234–236.

28. Lee KE, Koo do H, Kim SJ, Lee J, Park KS, Oh SK, et al. Outcomes of 109 patients with papillary thyroid carcinoma who underwent robotic total thyroidectomy with central node dissection via the bilateral axillo-breast approach. Surgery. 2010; 148:1207–1213.

29. Rubin JS, Lieberman J, Harris TM. Laryngeal manipulation. Otolaryngol Clin North Am. 2000; 33:1017–1034.

30. Gulec SA, O'Leary JP. Fable on the superior laryngeal nerve. Am Surg. 1999; 65:490–492.