intra-operative-neural-monitoring-thyroid-surgery-porcine

Intra-Operative Neural Monitoring of Thyroid Surgery in a Porcine Model

Intraoperative injury to the recurrent laryngeal nerve (RLN) can cause vocal cord paralysis, which interferes with speech and can potentially interfere ...

investigation-electrophysiological-thermographic-safety-parameters

Investigation of the Electrophysiological and Thermographic Safety Parameters of Surgical Energy Devices During Thyroid and Parathyroid Surgery in a Porcine Model

In thyroid and parathyroid surgery, surgical energy devices (SEDs) provide more efficient hemostasis than conventional clamp-and-tie hemostasis in areas ...

Kaohsiung Medical University Hospital, Kaohsiung Medical University

Kaohsiung Medical University

The ferromagnetic (FM) device is a new surgical energy modality. This study investigated dynamic recurrent laryngeal nerve (RLN) electromyographic (EMG) data to define safety parameters for using FM devices in thyroidectomy.

Safety parameters of ferromagnetic device during thyroid surgery: Porcine model using continuous neuromonitoring.

The purpose of this study was to investigate and define safety parameters for using the Ligasure exact dissector (LED) for dissection close to the recurrent laryngeal nerve (RLN) during thyroidectomy.

Safety of Ligasure exact dissector in thyroidectomy with continuous neuromonitoring: a porcine model.

In remote thyroid surgery, a reliable intraoperative neuromonitoring (IONM) procedure is an important tool for reducing injury to recurrent laryngeal nerve (RLN). This study proposes an alternative or adjunct technique for performing full percutaneous (PC) IONM and confirms its feasibility in animal experiments.

Full percutaneous intraoperative neuromonitoring technique in remote thyroid surgery: Porcine model feasibility study.

The use of transcartilage (TC) intraoperative neuromonitoring (IONM) in a pediatric population has not been reported. This study evaluated the feasibility and the benefit of using TC-IONM for thyroid cancer surgery in a pediatric population. This retrospective single-center study enrolled 33 pediatric patients who had received an IONM-assisted thyroidectomy. Demographic characteristics, standardized IONM laryngeal examinations and stimulation information (L1-V1-R1-R2-V2-L2) were compared between endotracheal tube (ET) and TC methods. In the 15 cancer patients (30 nerves), TC-IONM provided significant higher electromyography (EMG) amplitude ( < 0.001), signal stability (lower V1/V2 signal correlation, r = 0.955 vs. r = 0.484,  = 0.004), signal quality (higher ratio of V1 or V2 amplitude <500 µV, 0.0% vs. 43.8%,  = 0.005) and lower R1-R2p change (7.1% vs. 37.5%,  = 0.049) compared to ET-IONM. In the 18 benign patients (28 nerves), TC-IONM provided significantly higher EMG amplitude ( < 0.001), signal stability (r = 0.945 vs. r = 0.746,  = 0.0324) and non-significant higher signal quality and R1-R2p change. This report is the first to discuss the use of TC-IONM in pediatric thyroid surgery. In contrast with ET-IONM, TC-IONM had superior amplitude, stability and quality of EMG signals, which greatly facilitates the meticulous recurrent laryngeal nerve dissection in pediatric thyroidectomies. The TC-IONM method can be considered a feasible, effective and preferable method of monitored thyroidectomy in pediatric thyroid cancer.

Laryngeal Neural Monitoring during Pediatric Thyroid Cancer Surgery-Is Transcartilage Recording a Preferable Method?

Intraoperative neuromonitoring can qualify and quantify RLN function during thyroid surgery. This study investigated how the severity and mechanism of RLN dysfunction during monitored thyroid surgery affected postoperative voice. This retrospective study analyzed 1021 patients that received standardized monitored thyroidectomy. Patients had post-dissection RLN(R2) signal <50%, 50-90% and >90% decrease from pre-dissection RLN(R1) signal were classified into Group A-no/mild, B-moderate, and C-severe RLN dysfunction, respectively. Demographic characteristics, RLN injury mechanisms(mechanical/thermal) and voice analysis parameters were recorded. More patients in the group with higher severity of RLN dysfunction had malignant pathology results (A/B/C = 35%/48%/55%,  = 0.017), received neck dissection (A/B/C = 17%/31%/55%,  < 0.001), had thermal injury ( = 0.006), and had asymmetric vocal fold motion in long-term postoperative periods (A/B/C = 0%/8%/62%,  < 0.001). In postoperative periods, Group C patients had significantly worse voice outcomes in several voice parameters in comparison to Group A/B. Thermal injury was associated with larger voice impairments compared to mechanical injury. This report is the first to discuss the severity and mechanism of RLN dysfunction and postoperative voice in patients who received monitored thyroidectomy. To optimize voice and swallowing outcomes after thyroidectomy, avoiding thermal injury is mandatory, and mechanical injury must be identified early to avoid a more severe dysfunction.

How the Severity and Mechanism of Recurrent Laryngeal Nerve Dysfunction during Monitored Thyroidectomy Impact on Postoperative Voice.

A recurrent laryngeal nerve (RLN) injury resulting in vocal fold paralysis and dysphonia remains a major source of morbidity after thyroid and parathyroid surgeries. Intraoperative neural monitoring (IONM) is increasingly accepted as an adjunct to the standard practice of visual RLN identification. Endotracheal tube (ET) surface recording electrode systems are now widely used for IONM; however, the major limitation of the clinical use of ET-based surface electrodes is the need to maintain constant contact between the electrodes and vocal folds during surgery to obtain a high-quality recording. An ET that is malpositioned during intubation or displaced during surgical manipulation can cause a false decrease or loss of electromyography (EMG) signal. Since it may be difficult to distinguish from an EMG change caused by a true RLN injury, a false loss or decrease in EMG signal may contribute to inappropriate surgical decision making. Therefore, researchers have investigated alternative electrode systems that circumvent common causes of poor accuracy in ET-based neuromonitoring. Recent experimental and clinical studies have confirmed the hypothesis that needle or adhesive surface recording electrodes attached to the thyroid cartilage (transcartilage and percutaneous recording) or attached to the overlying neck skin (transcutaneous recording) can provide functionality similar to that of ET-based electrodes, and these recording methods enable access to the EMG response of the vocalis muscle that originates from the inner surface of the thyroid cartilage. Studies also indicate that, during surgical manipulation of the trachea, transcartilage, percutaneous, and transcutaneous anterior laryngeal (AL) recording electrodes could be more stable than ET-based surface electrodes and could be equally accurate in depicting RLN stress during IONM. These findings show that these AL electrodes have potential applications in future designs of recording electrodes and support the use of IONM as a high-quality quantitative tool in thyroid and parathyroid surgery. This article reviews the major recent developments of newly emerging transcartilage, percutaneous, and transcutaneous AL recording techniques used in IONM and evaluates their contribution to improved voice outcomes in modern thyroid surgery.

New Developments in Anterior Laryngeal Recording Technique During Neuromonitored Thyroid and Parathyroid Surgery.

High-pitched voice impairment (HPVI) is not uncommon in patients without recurrent laryngeal nerve (RLN) or external branch of superior laryngeal nerve (EBSLN) injury after thyroidectomy. This study evaluated the correlation between subjective and objective HPVI in patients after thyroid surgery.

Correlation Between Objective and Subjective High-Pitched Voice Impairment in Patients After Thyroid Surgery.

Technological advances in thyroid surgery have rapidly increased in recent decades. Specifically, recently developed energy-based devices (EBDs) enable simultaneous dissection and sealing tissue. EBDs have many advantages in thyroid surgery, such as reduced blood loss, lower rate of post-operative hypocalcemia, and shorter operation time. However, the rate of recurrent laryngeal nerve (RLN) injury during EBD use has shown statistically inconsistent. EBDs generate high temperature that can cause iatrogenic thermal injury to the RLN by direct or indirect thermal spread. This article reviews relevant medical literatures of conventional electrocauteries and different mechanisms of current EBDs, and compares two safety parameters: safe distance and cooling time. In general, conventional electrocautery generates higher temperature and wider thermal spread range, but when applying EBDs near the RLN adequate activation distance and cooling time are still required to avoid inadvertent thermal injury. To improve voice outcomes in the quality-of-life era, surgeons should observe safety parameters and follow the standard procedures when using EBDs near the RLN in thyroid surgery.

Improving Voice Outcomes After Thyroid Surgery - Review of Safety Parameters for Using Energy-Based Devices Near the Recurrent Laryngeal Nerve.

In patients with recurrent laryngeal nerve (RLN) injury after thyroid surgery, unrecovered vocal fold motion (VFM) and subjective voice impairment cause extreme distress. For surgeons, treating these poor outcomes is extremely challenging. To enable early treatment of VFM impairment, this study evaluated prognostic indicators of non-transection RLN injury and VFM impairment after thyroid surgery and evaluated correlations between intraoperative neuromonitoring (IONM) findings and perioperative voice parameters.

Prognostic Indicators of Non-Transection Nerve Injury and Vocal Fold Motion Impairment After Thyroid Surgery - Correlation Between Intraoperative Neuromonitoring Findings and Perioperative Voice Parameters.

Quantum molecular resonance (QMR) devices have been applied as energy-based devices in many head and neck surgeries; however, research on their use in thyroid surgery is lacking. This study aimed to investigate the safety parameters of QMR devices during thyroidectomy when dissection was adjacent to the recurrent laryngeal nerve (RLN).

Safety Parameters of Quantum Molecular Resonance Devices During Thyroid Surgery: Porcine Model Using Continuous Neuromonitoring.

Inducing and reversing neuromuscular block is essential to a positive outcome of thyroid surgery, with intraoperative neuromonitoring (IONM) being used to decrease recurrent and superior laryngeal nerve injuries and improve vocal outcome. Neostigmine is a non-specific broad-spectrum and inexpensive reversal agent for neuromuscular blocking agents (NMBAs). The aim of this porcine study was to explore the effect of neostigmine on electromyography (EMG) signal recovery profile following the commonly used NMBAs, cisatracurium and rocuronium.

A comparison between cisatracurium and rocuronium-induced neuromuscular block on laryngeal electromyography recovery after neostigmine reversal in a porcine model.

ArticleTotal : 2	Year
Publication title Cited by 19	2019
Publication title Cited by 1	2022

Article	Year
Safety parameters of ferromagnetic device during thyroid surgery: Porcine model using continuous neuromonitoring. Head & neck\| PubMed ID: 32567742	2020
Safety of Ligasure exact dissector in thyroidectomy with continuous neuromonitoring: a porcine model. Gland surgery\| PubMed ID: 32775260	2020
Full percutaneous intraoperative neuromonitoring technique in remote thyroid surgery: Porcine model feasibility study. Head & neck\| PubMed ID: 33026701	2021
Laryngeal Neural Monitoring during Pediatric Thyroid Cancer Surgery-Is Transcartilage Recording a Preferable Method? Cancers\| PubMed ID: 34439205	2021
How the Severity and Mechanism of Recurrent Laryngeal Nerve Dysfunction during Monitored Thyroidectomy Impact on Postoperative Voice. Cancers\| PubMed ID: 34771543	2021
New Developments in Anterior Laryngeal Recording Technique During Neuromonitored Thyroid and Parathyroid Surgery. Frontiers in endocrinology\| PubMed ID: 34777256	2021
Correlation Between Objective and Subjective High-Pitched Voice Impairment in Patients After Thyroid Surgery. Frontiers in endocrinology\| PubMed ID: 34867830	2021
Improving Voice Outcomes After Thyroid Surgery - Review of Safety Parameters for Using Energy-Based Devices Near the Recurrent Laryngeal Nerve. Frontiers in endocrinology\| PubMed ID: 34899616	2021
Prognostic Indicators of Non-Transection Nerve Injury and Vocal Fold Motion Impairment After Thyroid Surgery - Correlation Between Intraoperative Neuromonitoring Findings and Perioperative V... Frontiers in endocrinology\| PubMed ID: 34917026	2021
Safety Parameters of Quantum Molecular Resonance Devices During Thyroid Surgery: Porcine Model Using Continuous Neuromonitoring. Frontiers in endocrinology\| PubMed ID: 35813650	2022
A comparison between cisatracurium and rocuronium-induced neuromuscular block on laryngeal electromyography recovery after neostigmine reversal in a porcine model. Frontiers in endocrinology\| PubMed ID: 36004347	2022

Hsin-Yi Tseng

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