Electrophysiologic facial nerve monitoring during parotidectomy

Facial nerve monitoring is an adjunctive method available to a surgeon during parotid surgery to assist with the functional preservation of the facial nerve. This review describes the goals, applications, technique, and benefits of electrophysiologic facial nerve monitoring during parotid surgery. A review and analysis of the relevant medical literature related to electrophysiologic facial nerve monitoring during parotid surgery are included. © 2009 Wiley Periodicals, Inc. Head Neck, 2010     

Prevalence and patterns of intraoperative nerve monitoring for thyroidectomy

OBJECTIVE: To estimate the patterns of use of intraoperative recurrent laryngeal nerve (RLN)-monitoring devices during thyroid surgery by otolaryngologists in the United States. METHODS: A questionnaire was mailed to 1685 randomly selected otolaryngologists, representing approximately half of all otolaryngologists currently practicing in the United States. Topics covered included training history and current practice setting, use and characteristics of use of RLN monitoring during thyroid surgery, as well as history of RLN injury and/or subsequent lawsuits. chi(2) test was used to examine associations between monitor usage and dependent variables, and odds ratios calculated by logistic regression were used to refine the magnitude of these associations. RESULTS: A total of 685 (40.7%) of questionnaires were returned, and 81 percent (555) of respondents reported performing thyroidectomy. Of those, only 28.6 percent (159) reported using intraoperative monitoring for all cases. Respondents were 3.14 times more likely to currently use intraoperative monitoring if they used it during their training. Surgeons currently using intraoperative RLN monitoring during thyroidectomy were 41 percent less likely to report a history of permanent RLN injury. Further information about surgeon background and rationale for decisions regarding RLN monitor usage are discussed. CONCLUSIONS: Presently, the majority of otolaryngologists in the United States do not report regular usage of RLN monitoring in their practices. Surgeon background and training, more so than surgical volume, significantly influenced the use of intraoperative RLN monitoring.     

Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy

BACKGROUND: Intraoperative nerve monitoring during thyroidectomy, parathyroidectomy, or related central neck procedures can elucidate actual or potential mechanisms of recurrent laryngeal nerve (RLN) injury, especially visually intact nerves, which were previously unknown to the endocrine surgeon. STUDY DESIGN: In this prospective evaluation study, 373 patients underwent 380 consecutive thyroidectomy- or parathyroidectomy-related operations using intraoperative nerve monitoring, with 666 RLNs at risk. The success of visual and functional identification of the RLN, persistent loss of RLN function to nerve stimulation, the mechanism and location of RLN injury, and anatomy of the RLN or technical difficulties that appeared potentially risky for RLN injury were recorded. RESULTS: RLN was identified visually or functionally in 98.2% of nerves at risk. Initial intraoperative injury to the RLN occurred in 25 nerves at risk (3.75%). It was significantly more likely to be a visually intact RLN (n = 22; 3.3%) than a transected RLN (n = 3; 0.45%), p < 0.001. Paralysis persisted in 2 RLNs (0.3%). Visual misidentification accounted for only 1 RLN injury; the most common cause of injury resulted from traction to the anterior motor branch of a bifurcated RLN near the ligament of Berry (n = 7; 28%), then paratracheal lymph node dissection (n = 6; 24%), incorporating ligature (n = 4; 16%), and adherent cancer (n = 4; 16%). Fifty nerves at risk (7.5%) were identified as particularly at risk for injury, most notably those with anatomic variants (n = 26; 52%) and large or vascular thyroid lobes (n = 19; 38%). CONCLUSIONS: RLN injury during thyroidectomy or parathyroidectomy occurs intraoperatively significantly more often to a visually intact RLN than to a transected nerve. The anterior motor branch of an RLN bifurcating near the ligament of Berry is particularly at risk of traction injury.     

The influence of sample site on intraoperative PTH monitoring during parathyroidectomy

BACKGROUND: Intraoperative parathyroid hormone (IOPTH) monitoring is common during parathyroidectomy. We hypothesized that sample site (peripheral vs central vein) may impact IOPTH interpretation. METHODS: Two hundred and one patients underwent curative parathyroidectomy for single-gland disease. IOPTH was drawn peripherally (PV) in 114 patients and centrally (CV, jugular vein) in 87 patients. Decrease from baseline IOPTH and the presence of a normal value at 10 and 15 minutes were determined. The slope of IOPTH decay was calculated. These data were compared between sample sites. RESULTS: Median baseline IOPTH was 268 pg/mL (CV) and 191 pg/mL (PV, P = .003). The mean IOPTH decay slopes were -0.75 (PV) and -0.76 (CV, P = NS), and the mean percent IOPTH decrease at 10 minutes was 79% PV and 80% CV (P = NS). At 10 minutes, a > or =50% drop from baseline was seen in 94% (CV) versus 97% (PV) of patients ( P = NS), resulting in a median IOPTH of 40 pg/mL (CV) versus 34 pg/mL (PV, P = .09). By 15 minutes, the central IOPTH had decreased by > or =50% of baseline in 98% of patients ( P = NS when compared to the 10-minute PV site). CONCLUSIONS: IOPTH kinetics are largely the same for PV and CV sample sites, but baseline values are higher with central sampling. Consequently, CV IOPTH levels are generally higher at 10 minutes, but this discrepancy resolves by 15 minutes. The surgeon utilizing CV samples may need to extend the sampling period.     

Immediate and medium-term results of intraoperative parathyroid hormone monitoring during video-assisted parathyroidectomy

HYPOTHESIS: Using an intraoperative parathyroid hormone (IOPTH) assay during video-assisted parathyroidectomy by lateral approach is useful in patients with sporadic primary hyperparathyroidism, and the medium-term results of surgery are excellent. DESIGN: Retrospective study of patients with sporadic primary hyperparathyroidism following video-assisted parathyroidectomy by lateral approach with IOPTH measurement. PATIENTS: Of 394 patients with sporadic primary hyperparathyroidism, 200 (67%) were eligible for video-assisted parathyroidectomy by lateral approach: patients in whom a single enlarged gland was clearly localized by ultrasonography, sestamibi scintigraphy, or both. MAIN OUTCOME MEASURES: An IOPTH assay was used in 198 patients. Intraoperative parathyroid hormone was measured at induction, skin incision, ablation, and 5 and 15 minutes after ablation. RESULTS: The immediate results of the IOPTH assay were true positive in 187 cases (94.4%), true negative in 8 cases (4%), false negative in 2 cases (1%), and false positive in 1 case (0.5%). The overall accuracy of the IOPTH assay was 98.5%. All patients were normocalcemic postoperatively. The median follow-up was 20.5 months in 150 reviewed: 149 patients (99.4%) were normocalcemic, 17 patients (11.3%) had an elevated PTH level with normocalcemia, and 1 patient (0.6%) had recurrent primary hyperparathyroidism. CONCLUSIONS: In our experience, IOPTH monitoring during video-assisted parathyroidectomy by lateral approach is useful in detecting multiple gland disease not suspected by preoperative localization studies. Overall, IOPTH monitoring predicts medium-term normocalcemia with a success rate of 98.5% in patients with sporadic primary hyperparathyroidism.     

Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring

Background

Reoperative parathyroidectomy (R-PTX) in primary hyperparathyroidism (1HPT) has increased failure rates and morbidity. This study evaluated R-PTX during the era of minimal-access PTX with intraoperative parathyroid hormone (IOPTH) monitoring.

Methods

Two thousand sixty-five patients with 1HPT who underwent PTX were assessed for R-PTX. Preoperative studies, operative findings, and outcomes were evaluated.

Results

Two hundred twenty-eight patients underwent 236 R-PTX procedures. Imaging performed included sestamibi (89%), ultrasound (US; 56%), computed axial tomography/magnetic resonance imaging (5%), and selective venous sampling (1%). Sestamibi was more sensitive than US (84% vs 68%). Curative surgery was performed in 89% of patients. IOPTH was 99% sensitive. There was no relationship between cure and the following parameters: preoperative calcium or PTH levels, persistent or recurrent disease, or use of IOPTH. Solitary gland disease and a single previous operation were associated with increased likelihood of cure (P = .06). Hypoparathyroidism was decreased using IOPTH monitoring (2% vs 9%). One patient had recurrent laryngeal nerve palsy.

Conclusions

R-PTX can be performed effectively with minimal complications. IOPTH is an accurate predictor of cure and may decrease the frequency of permanent hypoparathyroidism.     

Direct intraoperative continuous monitoring of intraocular pressure.

We present a system of intraoperative continuous monitoring of intraocular pressure (IOP) consisting of a sterilizable pressure sensor attached to a digital monitor and an analogic recording instrument. Used in conjunction with an anterior-chamber maintainer, IOP may be accurately maintained at a specific and desired level.     

Outcomes analysis of intraoperative adjuncts during minimally invasive parathyroidectomy for primary hyperparathyroidism

BackgroundThe aim of this study was to determine whether minimally invasive radioguided parathyroidectomy (MIRP) and intraoperative parathyroid hormone–guided parathyroidectomy (ioPTH) have equivalent intermediate-term outcomes in primary hyperparathyroidism (PHPT).MethodsA retrospective study of 244 patients who underwent parathyroidectomy for PHPT in a 25-month time period was conducted. Patients who either underwent MIRP- or ioPTH-guided parathyroidectomies were included. The primary outcome was persistent disease. Conversion to bilateral exploration, complications, and multigland disease (MGD) were secondary outcomes.ResultsThere was 1 MIRP patient and no ioPTH patients who had persistent disease. The ioPTH group had more conversions to a bilateral exploration (bilateral neck exploration [BNE]) (3.7% vs 13%, P = .024). In the MIRP group, no patients were found to have MGD. In the ioPTH group, 7 patients with double adenomas and 6 patients with MGD were found (0 vs 13, P = .0028).ConclusionsioPTH facilitates successful minimally invasive parathyroidectomy (MIP) when compared with MIRP and provides cure rates similar to BNE.     

Validity and limits of intraoperative parathyroid hormone monitoring during minimally invasive parathyroidectomy: a 10-year experience

Background  

The availability of intraoperative intact parathyroid hormone monitoring allows the success of minimally invasive parathyroidectomy to be ensured during the operation. However, false-negative results leading to unnecessary explorations and difficulties in interpreting the data raise concern about the effectiveness of the method.     

Influence of concurrent chronic kidney disease on intraoperative parathyroid hormone monitoring during parathyroidectomy for primary hyperparathyroidism

Background

The influence of chronic kidney disease on intraoperative parathyroid hormone monitoring during parathyroidectomy for primary hyperparathyroidism has not been well-established. We hypothesize that chronic kidney disease influences intraoperative parathyroid hormone degradation kinetics during parathyroidectomy.

Use of monitoring intraoperative parathyroid hormone during parathyroidectomy in patients on waiting list for renal transplantation

This report describes the use of intraoperative parathyroid hormone (ioPTH) assay during parathyroidectomy for patients with secondary hyperparathyroidism on the waiting list for renal transplantation. The levels of ioPTH were determined among waiting list patients undergoing subtotal parathyroidectomy and tertiary hyperparathyroidism patients undergoing procedures. The levels of ioPTH were significantly reduced at 10 minutes by 59.7,3% among with secondary hyperparathyroidism and 68.9% among tertiary hyperparathyroidism. A 15 minutes it was 85% in secondary hyperparathyroidism and 89.7% in tertiary hyperparathyroidism. A decrement of 50% in basal values at 10 minutes and 85% decrement or more at 15 minutes was predictive for the success of abnormal parathyroid gland removal. The application of this technique during subtotal parathyroidectomy results was useful to predict a correct excision of abnormal parathyroid glands among patients with secondary hyperparathyroidism on the waiting list and for tertiary hyperparathyroidism patients.     

显露喉返神经在非神经监测与神经监测下单侧甲状腺手术中的临床分析

目的 探讨显露喉返神经在非神经监测与神经监测下单侧甲状腺手术中的临床效果分析.方法 回顾性分析南方医科大学顺德医院2019年1月至2020年11月66例单侧甲状腺手术患者临床资料,根据是否应用喉返神经监测技术分为非神经监测组和神经监测组,每组各33例.非神经监测组钝性分离直接显露喉返神经,神经监测组在神经监测提示下逐步...