Recurrent Laryngeal Nerve Monitoring: State of the Art, Ethical and Legal Issues
Section snippets
Options for RLN monitoring
Although RLN monitoring has garnered significantly more interest in recent years, there were attempts in prior decades to use technology to minimize the risk of injury to the RLN. As early as the 1960s, some clinicians were exploring the use of electrical stimulation of the RLN as a means of identification and preservation.11, 12 However, only in recent years has the technology become sufficiently user-friendly and commercially available that widespread use of RLN monitoring during thyroid
Effectiveness of RLN monitoring
A review of the relevant medical literature on RLN monitoring in the last 10 years shows many articles that explore aspects of RLN monitoring in different settings. Some of the earlier studies were small series designed to show that RLN monitoring was feasible. In 1999, Timon and Rafferty31 showed in 21 consecutive patients that a nerve monitor could be helpful in RLN localization. Also in 1999, Horn and Rotzscher30 reported on a series of 96 patients with 167 nerves at risk, in which the
How to use the RLN monitor for intraoperative decision making
It is essential for any surgeon contemplating use of the RLN monitor to fully understand how to use the technology to optimize patient care. Many authors have pointed out that there are technology-related issues that can make the use of the RLN monitor problematic. Specifically, when one begins an operation, one does not know that the system is connected correctly or that the electrode is in the correct location in the vocal cords (if the endotracheal surface electrode is being used). It is for
Contemporary use of RLN monitoring
One of the central questions that a practicing surgeon often faces is whether what he or she is doing in the operating room is similar to or different from what other surgeons are doing. A major source of discussion when surgeons who perform significant volumes of thyroid and parathyroid surgery meet relates to neuromonitoring. All surgeons who do these operations know the risks of RLN injury, and most can remember patients who have been affected by a nerve injury either transiently or
Potential legal issues in RLN monitoring
Kern10 examined jury verdict reports in malpractice cases involving endocrine surgery between 1985 and 1991 and found that surgical injuries, mostly recurrent nerve injuries, accounted for the greatest number of cases and the highest cost of litigation. Therefore, some attention must be given to the legal issues surrounding RLN monitoring. Among respondents to the AAES survey described earlier, 10% of the users of neuromonitoring and 12% of the nonusers had been named in a lawsuit due to RLN
Potential ethical issues in RLN monitoring
The biggest ethical issues that arise with respect to neuromonitoring in thyroid surgery surround informed consent and advertising by surgeons or medical facilities. Based on the data in the literature, neuromonitoring does not result in lower rates of RLN injury. Despite this, there are many surgeons who will be tempted to tell patients that using the RLN monitor will make the operation safer. Because patients present to surgeons seeking accurate medical information, surgeons have a
Summary
Does the analysis of the literature along with the legal and ethical issues discussed earlier suggest that RLN neuromonitoring should not be used? The answer is unquestionably “No.” Quite the contrary—although there is no increase in documented safety of RLN monitoring during thyroid surgery, there may be other reasons why a surgeon might choose to use monitoring. Some of these issues have been suggested in the questionnaire study by Horne and colleagues.60 Some surgeons believe that RLN
References (61)
Injury to recurrent laryngeal nerves during thyroidectomy—a comparison between the results of identification and non-identification in 1022 nerves exposed to risk
Lancet
(1956)- et al.
Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery
Surgery
(2004) - et al.
Spasmodic dysphonia and vocal fold paralysis: outcomes of voice problems on work-related functioning
J Voice
(1998) - et al.
First experiences in intraoperative neurostimulation of the recurrent laryngeal nerve during thyroid surgery of children and adolescents
J Pediatr Surg
(2002) - et al.
Intraoperative electromyographic monitoring of the recurrent laryngeal nerve in reoperative thyroid and parathyroid surgery
Surgery
(2004) - et al.
Prospective analysis of the efficacy of continuous intraoperative nerve monitoring during thyroidectomy, parathyroidectomy, and parotidectomy
Otolaryngol Head Neck Surg
(2001) - et al.
The mechanism of recurrent laryngeal nerve injury during thyroid surgery–the application of intraoperative neuromonitoring
Surgery
(2008) - et al.
Influence of muscle relaxation on neuromonitoring of the recurrent laryngeal nerve during thyroid surgery
Br J Anaesth
(2005) - et al.
Real-time monitoring of the recurrent laryngeal nerve: an observational clinical trial
Surgery
(2008) Recurrent laryngeal nerve electrophysiologic monitoring in thyroid surgery: the standard of care?
J Voice
(2005)
Prevalence and patterns of intraoperative nerve monitoring for thyroidectomy
Otolaryngol Head Neck Surg
Routine dissection and demonstration of the recurrent laryngeal nerve in subtotal thyroidectomy
Surg Gynecol Obstet
Laryngeal recurrent nerve injury in surgery for benign thyroid diseases—effect of nerve dissection and impact of individual surgeon in more than 27,000 nerves at risk
Ann Surg
Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany
World J Surg
Recurrent laryngeal nerve injury following thyroid operations
Surg Gynecol Obstet
Recurrent laryngeal nerve palsy after thyroid gland surgery
Br J Surg
Effect of voice disorders on the quality of life
J Med Speech Lang Pathol
Medicolegal analysis of errors in diagnosis and treatment of surgical endocrine disease
Surgery
Electrical stimulation of the human recurrent laryngeal nerve during thyroid operation
Acta Otolaryngol Suppl
Electrical identification of the recurrent laryngeal nerve. I. Response of the canine larynx to electrical stimulation of the recurrent laryngeal nerve
Ann Surg
A simple method for identifying and testing the recurrent laryngeal nerve
Surg Gynecol Obstet
Recurrent laryngeal nerve identification and assessment during thyroid surgery: laryngeal palpation
World J Surg
Sensitivity and specificity of intraoperative recurrent laryngeal nerve stimulation test for predicting vocal cord palsy after thyroid surgery
World J Surg
Nerve stimulation in thyroid surgery: is it really useful?
ANZ J Surg
Thyroidectomy: prevention of bilateral recurrent nerve palsy. Results of identification of the nerve over 23 consecutive years (1946–69) with a description of an additional safety measure
Br J Surg
The use of readily available equipment in a simple method for intraoperative monitoring of recurrent laryngeal nerve function during thyroid surgery: initial experience with more than 300 cases
Arch Surg
Intraoperative electrophysiologic monitoring of laryngeal muscle during thyroid surgery
Laryngoscope
Intraoperative recurrent laryngeal nerve monitoring
Otolaryngol Head Neck Surg
Comparison of various methods of electromyographic monitoring of the recurrent laryngeal nerve in thyroid surgery
Ann Otol Rhinol Laryngol
Laryngorhinootologie
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