Bilateral recurrent laryngeal nerve injury in a specialized thyroid surgery unit: would routine intraoperative neuromonitoring alter outcomes?

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Recurrent laryngeal nerve (RLN) dysfunction is the most common complication following thyroidectomy second only to hypoparathyroidism1 with its impairment being a frequent concern of litigation for treating thyroid surgeons. The reported incidence of permanent unilateral recurrent laryngeal palsy ranges from 0.3% to 3%2 of cases depending on the extent of surgery, surgical technique, surgical experience and type of disease. There is a void in the literature however, assessing the incidence of bilateral RLN palsy following total thyroidectomy, a life‐threatening complication with bilateral paralysis of the posterior cricoarytenoid muscles leading to airway compromise. This is largely attributed not only to the rarity of this serious complication, but also to the fact that such a complication would more likely be encountered in complicated cases following previous iatrogenic injury to the contralateral side or invasion by cancer, and hence would be referred to a high‐volume tertiary care centre. Previous reports in the literature indicate permanent bilateral cord paralysis rates of up to 0.6%.4 In recent times, intraoperative nerve monitoring (IONM) has been employed as an adjunct to assist with the identification of the RLN and to predict function post dissection. Multiple studies have failed to demonstrate any statistically significant reduction in the incidence of RLN palsy where IONM has been used for primary cases. While that may be due to the very low incidence of RLN palsy in high‐volume centres and lack of standardization in equipment use,6 recent studies have reported that the introduction of IONM is associated with an increase in nerve palsy rates in partial thyroidectomy cases.8 There is more evidence supporting the routine use of IONM in reoperative surgery, total thyroidectomy with neck dissection and malignant cases, where a trend for reduced RLN palsy rates has been observed.6 In the present study, we sought to determine the incidence of bilateral RLN palsy in a high‐volume tertiary care centre and determine whether the routine use of IONM would have made a difference to the outcome.
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