Thyroid surgery and voice-related outcomes

BACKGROUND: Vocal dysfunction in patients with thyroid pathology has been poorly documented, and dysfunction after thyroid surgery is generally reported in terms of recurrent laryngeal nerve or external laryngeal nerve palsy. But voice dysfunction is more complex than simply nerve integrity. The present study reports the incidence of dysphonia in patients presenting for thyroid surgery, and relates postoperative changes in vocal function to recurrent and external laryngeal nerve function, and the surgical handling of the strap muscles. METHODS: Fifty patients were assessed by Visipitch before and after thyroidectomy. Following surgery the patients filled out a questionnaire. RESULTS: Overall 26 of 44 patients had no subjective postoperative voice change, while 10 reported subjective deterioration and eight reported subjective improvement in voicing. Postoperative objective assessment of these patients found that 17 were the same, eight refused to come for testing because they felt their voice had not changed, 13 were better and six were worse. Following surgery two patients (4.5%) had temporary recurrent laryngeal nerve palsies (2.5% of nerves at risk), and four patients (10%) suffered external laryngeal nerve palsies. Division of strap muscles was not detrimental to voicing. Six patients were lost to follow-up. Fifteen patients (34%) presented with vocal abnormalities, six (40%) of whom improved postoperatively. CONCLUSIONS: Patients may have voicing abnormalities before thyroid surgery is performed. Surgery may improve or worsen the voice irrespective of the pre-operative voice status.     

Intraoperative neuromonitoring of the recurrent laryngeal nerve - results and learning curve

Intraoperative neuromonitoring was introduced in thyroid surgery several years ago resulting in a facilitated identification of the recurrent laryngeal nerve and less recurrent laryngeal nerve injuries. Between 1999 and 2004 data of all patients (n=937) undergoing thyroid resection were recorded prospectively and analyzed yearly. The intraoperative identification of recurrent laryngeal nerve succeeded in 99.2% (1665 nerves at risk). The percentage of completely resecting surgical procedures raised from 17% to 56%. Minimal vocal cord dysfunction associated with hematoma and edema in most cases was diagnosed laryngosopically in 1.4-2.4%. Transient recurrent nerve palsies were seen in 2.3% without changes throughout the years.The permanent palsy rate of 0.8% in the first years decreased. No permanent palsies were diagnosed in the last 3 years. Routine introduction of intraoperative neuromonitoring in thyroid surgery is associated with a demonstrable learning curve lasting several years. Permanent palsy rate is decreased. The rate of minimal vocal cord movement disorders and transient recurrent laryngeal nerve palsies is not changed.     

Intraoperative neuro-monitoring of the recurrent laryngeal nerve. Experience of 1000 consecutive patients

Intraoperative neuro-monitoring was introduced in thyroid surgery several years ago resulting in a facilitated identification of the recurrent laryngeal nerve and less recurrent laryngeal nerve injuries. Between 1999 and 2005 data of all patients undergoing thyroid resection were recorded and analyzed yearly. The intraoperative identification of recurrent laryngeal nerve succeeded in 99.2% (1768 nerves at risk). The percentage of complete resecting surgical procedures raised from 17% to 84%. Minimal vocal cord dysfunction, associated with hematoma and edema in most cases, was diagnosed laryngoscopically in 2.9%. The permanent palsy rate of 0.8% in the first year decreased down to 0.32%. Routinely introduction of intraoperative neuro-monitoring in thyroid surgery is associated with a demonstrable decreased palsy rate. Anyway, the rate of minimal vocal cord movement disorders and transient recurrent laryngeal nerve palsies is not changed.     

The evaluation of the causes of subjective voice disturbances after thyroid surgery

BACKGROUND: Voice changes following thyroidectomy is a rare form of morbidity not infrequently encountered. Injury to the recurrent laryngeal nerve or external branch of the superior laryngeal nerve is the most well-known cause of post-thyroidectomy voice disturbances. However, voice dysfunction is a more complex entity. The aim of the current study was to assess the possible factors that influence voice changes after thyroidectomy. METHODS: Forty-eight consecutive patients who had undergone thyroidectomy were studied. The acoustic voice analysis (mean vocal fundamental frequency [Fo], mean percentage vocal jitter and shimmer, and noise-to-harmonic ratio) and videolaryngostroboscopic examination of these patients were performed preoperatively, on the second postoperative day, and 3 months after the operation. The presence of subjective voice changes was recorded prospectively based on a symptom scale. RESULTS: No major complications occurred perioperatively or in the postoperative period. Videolaryngostroboscopic examinations were normal in all patients before and after thyroidectomy. Eighteen (37.5%) patients complained of subjective voice changes in the early postoperative period and 7 (14.6%) of these were still uncomfortable after 3 months. Although the difference was significant by means of all acoustic voice parameters measured in the early postoperative period, Fo is the only parameter that continues to be significant after 3 months. CONCLUSIONS: Irrespective from recurrent laryngeal nerve and/or injuries to the external branch of the superior laryngeal nerve, voice may temporarily be affected by thyroidectomy. Most of the subjective complaints and acoustic voice parameters return to normal in a few months after surgery.     

Routine examination of the vocal cords before and after thyroid and parathyroid surgery

A prospective study of the value of routine examination of the vocal cords in 239 patients before and after thyroid or parathyroid surgery is presented. From the patient's history and voice the surgeon assessed before and after operation whether vocal cord examination was necessary or not. The surgeon's judgement was compared with the phoniatrician's report. All except one of the documented recurrent laryngeal nerve palsies were suspected by the surgeon. No additional important clinical information was gained by the laryngologist's examinations. Routine vocal cord examination in connection with thyroid and parathyroid surgery is probably not necessary.     

Recurrent laryngeal nerve paralysis in patients with papillary thyroid carcinomas: evaluation and management of resulting vocal dysfunction

BACKGROUND: Recurrent laryngeal nerve paralysis (RLNP) occurs in patients with thyroid malignancy. This study prospectively evaluated vocal function and management outcomes of patients with papillary thyroid carcinomas (PTCs) and RLNP. METHODS: Of 319 PTC patients, 256 underwent total thyroidectomy with or without neck dissection, 42 underwent lobectomy, and 21 underwent reoperation for recurrent cancers. All patients underwent laryngoscopy and vocal function measurements before and after surgery. Patients with RLNP and poor vocal function underwent voice surgery. RESULTS: Temporary and permanent RLNP rates were 2.8% and .9% at nerve-at-risk-based analysis, respectively. Of 28 patients with tumor invasion of RLN, 14 had preoperative RLNP, with 9 of 14 showing voice changes. RLNP was detected in 9 of 291 (3.1%) patients without documented nerve injury; 8 recovered. Nine of 15 patients with RLN section had poor vocal function, which improved in 8 patients after medialization of the unilateral vocal fold. CONCLUSIONS: Patients with PTC may have vocal dysfunction from cancer or surgery-related RLNP. Vocal evaluation and management may help improve their vocal function, thus enhancing their quality of life.     

Neurorrhaphy of the recurrent laryngeal nerve

BACKGROUND: It has been controversial to anastomose the severed recurrent laryngeal nerve after transection because when severed recurrent nerves are directly anastomosed, the vocal cords do not regain normal movements and are fixed in the median. The objective of this study was to learn whether direct neurorrhaphy is necessary if the recurrent laryngeal nerve is severed during thyroid or parathyroid surgery. STUDY DESIGN: From 1998 to 2001, 12 patients who had a complete recurrent laryngeal nerve injury during thyroid or parathyroid surgery were enrolled into this study. Eight had primary repair of the nerve; four did not have repair because of cancer invasion. Patients were followed with laryngoscopic or laryngovideostroboscopic examination at 3 months and 6 months postoperatively. Subjective ratings of aspiration and voice quality were based on patient reports. Perceptual voice quality was rated according to grade, roughness, breathiness, asthenia, and strain (GRBAS) scales. If a patient's voice quality, aspiration, and GRBAS scales did not improve at 6 months postoperatively, medialization laryngoplasty was considered. RESULTS: Eight patients with immediate repair showed improved voice quality, aspiration, GRBAS scales, and maximum phonation time at 6 months after surgery. A significant decrease of glottal gap was also noted in patients with neurorrhaphy but not in four patients without neurorrhaphy. Medialization laryngoplasty was performed in all four patients without neurorrhaphy in the followup period. Immobilization of the vocal cord was noted in all of them, but only one in the neurorrhaphy group had an atrophy of the cord; all four patients without neurorrhaphy had atrophy. CONCLUSIONS: Neurorrhaphy of the recurrent laryngeal nerve is a simple and effective procedure to improve voice quality, aspiration, GRBAS scales, glottal gap, and maximum phonation time by preventing atrophy of the vocal cord.     

甲状腺手术时喉返神经损伤的神经修复治疗

目的探讨甲状腺手术喉返神经损伤神经修复治疗。方法对病程 2年以内甲状腺手术喉返神经损伤声带麻痹 4 2例患者行单侧损伤神经减压 8例、颈袢喉返神经吻合 2 1例、喉返神经端端吻合 6例 ,双侧损伤膈神经移植联合术 7例 (一侧膈神经移植 ,另一侧行神经减压 2例、神经肌蒂植入术 5例 )。手术前后喉镜、嗓音声学参数、肌电图检查等评价手术效果。结果单侧损伤神经减压组病程 4个月内 5例恢复了正常的声带运动功能 ,4个月以内 1例、4个月以上 2例及颈袢吻合组、喉返神经端端吻合组则未恢复声带运动 ,但上述 3种术式均能使喉内收肌获有效的再神经支配 ,发音时声门闭合良好 ,嗓音恢复正常。双侧损伤膈神经移植术侧恢复明显吸气性声带外展功能 6例 ;其中2例对侧神经减压恢复了正常的声带运动功能 ,4例对侧肌蒂埋植术仅 2例轻微外展 ,获肌电图检查的证实 ,这些患者均顺利拔管。 1例双侧均无外展。结论甲状腺手术喉返神经损伤以神经减压效果最佳 ;颈袢吻合也能有效地恢复喉的发音功能 ;膈神经移植术治疗双侧损伤较肌蒂植入术效果更满意 ;喉神经修复术式选择应根据病程、神经损伤程度、类型而定。     

喉返神经未损伤甲状腺术后语音障碍的因素探讨

甲状腺切除术是对甲状腺疾病特别是甲状腺恶性肿瘤的有效治疗的手段之一,由于术中喉返神经损伤而引起声带麻痹影响患者术后语音障碍已经被共识.但是,在临床工作中,许多患者在没有明显喉返神经损伤的情况下术后语音发生改变.随着现代电子声学检测技术的发展,对术中没有喉返神经损伤患者术后语音质量有了定量研究,从而探讨、发现喉返神经未损伤甲状腺术后语音障碍的因素.     

Use of the laryngeal mask airway in thyroid and parathyroid surgery as an aid to the identification and preservation of the recurrent laryngeal nerves.

A prospective study was carried out in patients undergoing thyroid and parathyroid surgery using a laryngeal mask airway (LMA) and electrical nerve stimulation to identify the recurrent laryngeal nerves. A total of 150 consecutive patients undergoing thyroid and parathyroid surgery by a single surgeon were assessed for suitability of anaesthesia via the LMA. Peroperatively, a fibre-optic laryngoscope was passed through the LMA to enable the anaesthetist to visualise the vocal cords while adduction of the cords was elicited by applying a nerve stimulator in the operative field. In all, 144 patients were selected for anaesthesia via the LMA. Fibre-optic laryngoscopy and nerve stimulation were performed in 64 patients (42.7%). The trachea was deviated in 51 (34.0%) and narrowed in 33 (22.0%). The recurrent laryngeal nerves were identified in all patients. There were no cases of vocal cord dysfunction resulting from surgery. The LMA can be safely used for thyroid and parathyroid surgery even in the presence of a deviated or narrowed trachea. It can assist in identification and preservation of the recurrent laryngeal nerve and is, therefore, of benefit to both patient and surgeon.     

External vocal fold medialization in patients with recurrent nerve paralysis following cardiothoracic surgery.

OBJECTIVES: Recurrent laryngeal nerve injury is a possible complication following cardiothoracic surgery. Due to insufficient glottal closure, dysphonia and dysphagia with aspiration may occur. The purpose of the study was to outline the effect of vocal fold medialization thyroplasty on voice, swallowing and breathing impairments. METHODS: Between 1999 and 2001, medialization thyroplasty using the titanium implant (TVFMI) according to Friedrich was performed in 14 patients with postoperative left-sided recurrent nerve paralysis (five female and nine male patients, mean age 64 years) by an external approach. Previous surgical procedures comprised six lobectomies (combined with resection and replacement of the subclavian artery in one case), two pneumonectomies, one resection of a schwannoma in the aortopulmonary window, two replacements of the descending aorta, one aortocoronary bypass procedure (with LIMA), and two esophageal resections using Akiyama technique, respectively. Before and after thyroplasty, the patients underwent an otolaryngological/phoniatric examination including videostroboscopy, voice sound analysis, voice range profile measurement, pulmonary function testing, and in selected cases videofluoroscopy of swallowing. RESULTS: Following thyroplasty, all patients reported on subjective improvement of voice, swallowing and breathing functions. Videostroboscopy revealed an improved glottal closure (six complete, six with posterior gap). All voice related parameters (e.g. roughness, breathiness, hoarseness, maximum sound pressure levels of the singing and shouting voices) were significantly improved. CONCLUSIONS: Due to potential risk of recurrent nerve alteration in left-sided intrathoracic procedures, a preoperative and postoperative laryngoscopic examination is recommended. The external medialization of the vocal folds can be regarded as an excellent method for improvement of voice, swallowing and breathing, in particular, when the quality of life is impaired due to persistent recurrent nerve paralysis.     

Therapeutic management of postoperatively diagnosed bilateral recurrent laryngeal nerve paralysis

Bilateral vocal cord paralysis is a rare but potentially dangerous postoperative complication in thyroid gland surgery. There is a controversial discussion about therapeutic management of postoperative bilateral vocal cord paralysis. METHODS: We analysed the frequency of bilateral nerve palsy in 985 operations. The disease of thyroid gland, the operative procedure, the exposure of laryngeal nerve, the mobility of vocal cord detected by an otolaryngologist, clinical symptoms and therapy of patients with bilateral paralysis were analysed. All patients were examined immediately postoperatively and 5 days, 14 days, 6 and 12 months after resection. RESULTS: The overall transient bilateral palsy rate was 0.7%, the permanent 0.3%. The palsy rate depended on the disease of thyroid gland. After resection of simple goitre we found a 0.2% transient injury rate (0.1% permanent), after operation of thyroid cancer 2.0% transient (1.0% permanent) and in cases of recurrent goitre 5.9% transient (1.9% permanent) palsies. The immediate postoperative symptoms are also very different. There are patients suffering from stridor and dyspnoea, patients with dysphonia without dyspnoea and those without any symptoms. These different clinical symptoms are due to the different grade of laryngeal nerve damage and the resulting position of vocal cords. The bilateral paralysis was completely temporary in 4 cases. 12 months later 4 patients suffered from dysphonia. Only in 3 patients with thyroid cancer and a preoperative unilateral vocal cord paralysis tracheostomy was necessary after operation. The vocal cord mobility did not recover in these 3 cases after 12 months and the patients are not decannulated. DISCUSSION: Bilateral paralysis is only relevant in thyroid cancer and recurrent goitre. The symptoms varies and no patient should leave the hospital without examination of the vocal cords by an otolaryngologist. Because vocal cord paralysis is temporary in most cases an emergency tracheostomy is seldom indicated.     

Voice changes and thyroid surgery: is pre-operative indirect laryngoscopy necessary?

BACKGROUND: Indirect laryngoscopy (IDL) is often performed prior to thyroid surgery to detect pre-existing vocal cord pathology. METHODS: A retrospective chart review of 201 patients undergoing thyroid surgery at the Prince of Wales Hospital was undertaken in order to study the patterns of pre-operative and postoperative voice changes and IDL findings. RESULTS: A total of 9% of patients had pre-operative voice symptoms, and 22% of this group had abnormalities detected on pre-operative IDL. Of 160 documented IDL, 4% revealed vocal cord pathology in asymptomatic patients, including an asymptomatic recurrent laryngeal nerve palsy. CONCLUSIONS: Indirect laryngoscopy remains a useful but flawed pre-operative screening tool for patients with voice symptoms, but the literature suggests that more advanced phoniatric tests will provide superior diagnostic sensitivity. The role of routine pre-operative laryngoscopy for asymptomatic patients is of debatable value.     

Neuromonitoring of the recurrent laryngeal nerve--a critical analysis of patients with postoperative nerve palsy

The transligamental intraoperative neuromonitoring of the recurrent nerve is established in many surgical clinics as an useful and reliable technique. It is especially suitable to identify the recurrent nerve and to monitor its function during thyroid operation. We have analysed 14 early postoperative recurrent nerve palsies between June 1997 and December 2000 (1,23 % related to nerves at risk). As a result of complete follow up we found 4 permanent nerve palsies (0,35 % related to nerves at risk). In 11 out of 14 cases the neuromonitoring revealed a dysfunction of the recurrent nerve. The following long distance microsurgical preparation showed no interruption of the continuity of the nerve. Knowing the fact of unilateral negative monitoring signal we adapted our operative strategy. Therefore we did not observe bilateral nerve palsies. In 3 patients we found a positive nerve signal but nevertheless these patients showed postoperative unilateral recurrent palsies. The possible reasons are discussed.We are convinced that the neuromonitoring of the recurrent laryngeal nerve is an important progress in thyroid surgery.     

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??Analysis of superior thyroid pole through the cervical strap muscles approach??A clinical analysis of 55 patients WANG Chao, ZHANG Song-tao, ZHAI Yi-fei, et al. Department of Thyroid??Head and Neck Surgery, Tumor Hospital Affiliated to Zhengzhou University; Henan Cancer Hospital??Zhengzhou 450000, China
Corresponding author: QIN Jian-wu, E-mail??qinjianwu62@163.com
Abstract Objective To investigate the feasibility and advantages of treatment of the superior thyroid pediclevia the cervical strap muscles approach. Methods The clinical data of 55 patients undergoing thyroidectomy in Henan Cancer Hospital fromApril 2016 toOctober 2016 were reviewedretrospectively. External branch of the superior laryngeal nerve ??EBSLN?? should be exposed viacervical strap muscles approach. Finally?? 55 patients with 86 lobectomies were identified. Results The identification rate of EBSLN was 96.5% ??83/86??. All the patients had no voice impairment due to EBSLN injury.No permanent hypoparathyroidism occurred in all patients.Conclusion Via the natural space between the anterior cervical muscles?? the superior thyroid pedicle can be exposed completely??which will greatly improve the safety of surgery.     

Prospective functional voice assessment in patients undergoing thyroid surgery

OBJECTIVE: To analyze voice function before and after thyroidectomy for patients with normal preoperative voice using a standardized multidimensional voice assessment protocol. SUMMARY BACKGROUND DATA: The natural history of post-thyroidectomy voice disturbances for patients with preserved laryngeal nerve function has not been systematically studied and characterized with the intent of using the data for postoperative voice rehabilitation. METHODS: During a prospective single-arm study, patients with normal voice underwent functional voice testing using a standardized voice grading scale and a battery of acoustic, aerodynamic, glottographic, and videostroboscopic tests before, 1 week after, and 3 months after thyroidectomy. Differences in observed sample means were evaluated using analysis of covariance or t test; categorical data was analyzed using the Fisher exact or chi-square test. RESULTS: Fifty-four patients were enrolled; 50 and 46 were evaluable at 1 week and 3 months, respectively. No patient developed recurrent laryngeal nerve injury; one had superior laryngeal nerve injury. Fifteen (30%) patients reported early subjective voice change and seven (14%) reported late (3-month) subjective voice change. Forty-two (84%) patients had significant objective change in at least one voice parameter. Six (12%) had significant alterations in more than three voice measures, of which four (67%) were symptomatic, whereas 25% with three or fewer objective changes had symptoms. Patients with persistent voice change at 3 months had an increased likelihood of multiple (more than three) early objective changes (43% vs. 7%). Early maximum phonational frequency range and vocal jitter changes from baseline were significantly associated with voice symptoms at 3 months. CONCLUSIONS: Early vocal symptoms are common following thyroidectomy and persist in 14% of patients. Multiple (more than three) objective voice changes correlate with early and late postoperative symptoms. Alterations in maximum phonational frequency range and vocal jitter predict late perceived vocal changes. Factors other than laryngeal nerve injury appear to alter post-thyroidectomy voice. The variability of patient symptoms underscores the importance of understanding the physiology of dysphonia.     

Assessment of recurrent laryngeal nerve function during thyroid surgery

Introduction

There is disparity in the reported incidence of temporary and permanent recurrent laryngeal nerve (RLN) palsy following thyroidectomy. Much of the disparity is due to the method of assessing vocal cord function. We sought to identify the incidence and natural history of temporary and permanent vocal cord palsy following thyroid surgery. The authors wanted to establish whether intraoperative nerve monitoring and stimulation aids in prognosis when managing vocal cord palsy.

Methods

Prospective data on consecutive thyroid operations were collected. Intraoperative nerve monitoring and stimulation, using an endotracheal tube mounted device, was performed in all cases. Endoscopic examination of the larynx was performed on the first postoperative day and at three weeks.

Results

Data on 102 patients and 123 nerves were collated. Temporary and permanent RLN palsy rates were 6.1% and 1.7%. Most RLN palsies were identified on the first postoperative day with all recognised at the three-week review. No preoperative clinical risk factors were identified. Although dysphonia at the three-week follow-up visit was the only significant predictor of vocal cord palsy, only two-thirds of patients with cord palsies were dysphonic. Intraoperative nerve monitoring and stimulation did not predict outcome in terms of vocal cord function.

Conclusions

Temporary nerve palsy rates were consistent with other series where direct laryngoscopy is used to assess laryngeal function. Direct laryngoscopy is the only reliable measure of cord function, with intraoperative monitoring being neither a reliable predictor of cord function nor a predictor of eventual laryngeal function. The fact that all temporary palsies recovered within four months has implications for staged procedures.     

不同手术入路显露甲状腺喉上神经对比研究

目的 探讨处理甲状腺上极时选择不同手术入路显露喉上神经疗效。方法 回顾性分析2016年1月至2018年12月间蚌埠医学院第一附属医院肿瘤外科收治的须行腺叶切除的87例病人的临床资料,经术前超声评估肿瘤位于甲状腺上极或甲状腺腺体肥大,根据手术入路分为环甲肌入路（Cricothyroid approach）42例和胸骨舌骨肌-胸骨甲状肌间隙入路（带状肌间入路,viacervical strap muscles approach）45例,比较术中喉上神经显露情况及术后喉上神经功能及甲状腺旁腺的相关并发症。结果 与环甲肌入路组喉上神经找出率（ 83.3%）相比,经胸骨甲状肌-胸骨舌骨肌入路组喉上神经找出率高（95.6%）（P＜0.05）,环甲肌入路组喉上神经寻找所用时间（5.75±0.24） min,经胸骨甲状肌-胸骨舌骨肌入路组较短（3.83±0.37） min（P＜0.05）,术后随访手术病人,对比饮水咳呛、发音低沉、手足麻木等症状,手足麻木症状两组差异无统计学意义（P＞0.05）,经胸骨甲状肌-胸骨舌骨肌入路组术后饮水咳呛、发音低沉并发症少于经环甲肌入路组（P＜0.05）。结论 经胸骨舌骨肌-胸骨甲状肌间隙入路对比应用环甲肌入路,喉上神经找出率高、寻找时间短,在上极的甲状腺肿瘤及腺体肥大的情况下应用此入路有助于暴露上极并保护喉上神经外支。     

Identification and surgical anatomy of the external branch of the superior laryngeal nerve

Injury to the external branch of the superior laryngeal nerve (EBSLN) during thyroid surgery can cause serious consequences for patients who depend on control of pitch and a clear and forceful voice, like singers or professional speakers. We used the Neurosign 100(R) nerve monitor to identify 157 nerves in 108 patients undergoing thyroid surgery. The EBSLN was successfully identified in 98.7 % of cases. The recording electrode could be placed either into the cricothyroid muscle or the vocal cord. The latter position proved superior if the recurrent laryngeal nerve had to be identified as well. 16 percent of the nerves crossed the branches of the superior thyroid artery at or below the upper pole of the gland, posing a "high risk" for intraoperative lesions. Our data confirm the results of smaller studies reporting this type of nerve course in 12 % to 14 % of patients. The present findings show a significant number of EBSLN to be in danger of injury when the superior thyroid artery is ligated during thyroid surgery. Neuromonitoring proofed to be a reliable method to identify the nerve, which is an important element in concepts to prevent its injury.     

The laryngeal mask airway for thyroid and parathyroid surgery

The role of the laryngeal mask airway for thyroid and parathyroid surgery was studied in 97 consecutive patients. In 50% the technique combined electrical stimulation of the recurrent laryngeal nerve with visualisation of vocal cord movement via a fibreoptic bronchoscope. Stimulation was required in 10% to assist in identifying recurrent laryngeal nerve position during difficult surgical dissection. In the remaining 40% stimulation was used to confirm nerve integrity and for teaching purposes. Tracheal intubation was required for seven patients but in only two of these was intubation unplanned. The incidence of postoperative recurrent laryngeal nerve dysfunction was zero. These data suggest that the technique offers a safe alternative in airway management and may provide advantages in terms of preservation of recurrent laryngeal nerve function.