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15 Intraoperative Neuromonitoring oftheRLNs During TOETVA Procedures
a
b
101
Fig. 15.16 An endoscopic image focusing on dissection and identication of the vagus nerve. (a) Initial step of preparation of the vagus nerve.
(b) Course of the vagus probe (from Chen etal. [9]; with permission)
tion is needed. Few case- series of c-IONM application in
TOETVA in humans have been reported. These limited evidences assessed that the use of C-IONM is reliable and safe
during transoral endoscopic thyroidectomies and may help
in the early detection of adverse electromyographic mutations, thus preventing the RLN injury. This procedure can be
challenging endoscopically, time-consuming, or even harmful to the nerve and vessels while positioning the accessory
and at removal of the electrode. Furthermore, C-IONM
accessory should be versatile because the position of the
vagus nerve in relation to the common carotid artery and the
internal jugular vein in humans is very changeable. In relation to the features of C-IONM electrodes available currently
for thyroid surgery, none of these seems to be easy to apply
in TOETVA.
Continuous neural stimulation was performed using the
delta electrode device. The stimulation was set at 0.7 mA
every 1 s. This enabled the ongoing assessment of stimulation waveform amplitude and latency EMG of the vocalis
muscle was checked, and the alarm was set to activate when
the EMG amplitude was decreased by 50% and latency was
prolonged by 10%.
102
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Ö. Makay et al.
a
b
Fig. 15.17 The picture represents an endoscopic view of the positioning of the delta electrode around the vagus nerve for continuous stimulation.
(a) Management how to put the delta electrode. (b) Final positioning of the delta electrode (from Chen etal. [9]; with permission)
IONM Limits inTOETVA
We suggest using increased current (3–10 mA) to facilitate mapping over the carotid sheath for VN stimulation.
Signicant limits of intraoperative neuromonitoring in transoral surgery are determined by:
Short duration of high-current stimulus (3–10 mA) can be
applied to facilitate indirect VN mapping/stimulation over
the lateral neck region.
(a) inability to appreciate the laryngeal twitch by digital pal-
pation (and endoscopic vision),
(b) difculty in stimulating the ipsilateral and contralateral
vagus nerve without further surgical dissection and prolonged operative time,
(c) difculty in the endotracheal tube position verication,
and
Most false LOS is due to EMG tube up displacement
(upwards) because the chin/neck is more exed (“sniff position”) than extended during TOETVA. The overall prevalence of EMG tube displacement in TOETVA is 15%. For
EMG tube displacement, because oral/nasal area is included
in the aseptic eld, it is less possible to re-check by the laryngoscope or berscope.
(d) limited operative area for IONM probe (Fig.15.18).
15 Intraoperative Neuromonitoring oftheRLNs During TOETVA Procedures
References
1. Anuwong A. Transoral endoscopic thyroidectomy vestibu-
lar approach: a series of the rst 60 human cases. World J Surg.
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2. Makay O, Dionigi G, Celik S. İzsiz Tiroidektomi Vestibüler
Yaklaşim ile Transoral Endoskopik Tiroidektomi TOETVA Atlası.
1st ed. İstanbul: İstanbul Tıp Kitabevleri; 2018.
3. Celik S, Makay O, Yoruk MD, Kocer IB, Ozdemir M, Kilic KD,
Tomruk C, Bilge O, Uyanikgil Y, Dionigi G. A surgical and
anatomo-histological study on transoral endoscopic thyroidectomy
vestibular approach (TOETVA). Surg Endosc. 2020;34:1088–102.
4. Zhang D, Fu Y, Dionigi G, Pontin A, Caruso E, Antonella P, Sun
H.Human cadaveric model for studying the preservation of mental
nerve during transoral endoscopic thyroidectomy. Surg Radiol Anat.
2020;42:55–62.
5. Zhang D, Famá F, Caruso E, Pinto G, Pontin A, Pino A, Mandolno
T, Gagliano E, Siniscalchi EN, De Ponte FS, Sun H, Dionigi G.How
to avoid and manage mental nerve injury in transoral thyroidectomy.
How to avoid and manage mental nerve injury in transoral thyroid-
ectomy. Surg Technol Int. 2019;35:101–6.
6. Zhang D, Mazzeo C, Dionigi G, et al. Nerve monitoring for
transoral thyroid surgery: why, how, and what to expect. Curr
Otorhinolaryngol Rep. 2019;7:225–31. https://doi.org/10.1007/
s40136- 019- 00251- z.
7. Zhang D, Sun H, Tufano R, Caruso E, Dionigi G, Kim HY.Recurrent
laryngeal nerve management in transoral endoscopic thyroidec-
tomy. Oral Oncol. 2020;108:104755. https://doi.org/10.1016/j.
oraloncology.2020.104755. Epub 2020 Jun 8.
8. Zhang D, Wang C, Wang T, Du R, Li K, Yang M, Xue G, Dionigi
Fig. 15.18 Signicant limits of intraoperative neuromonitoring in
transoral surgery are determined by the limited operative area for
IONM probe (from Zhang etal. [6]; with permission)
G, Sun H.Clinical experience of use of percutaneous continuous
nerve monitoring in robotic bilateral axillo-breast thyroid sur-
gery. Front Endocrinol. 2022;12:817026. https://doi.org/10.3389/
fendo.2021.817026.
9. Chen HK, Chen CL, Wen KS, et al. Application of transoral con-
tinuous intraoperative neuromonitoring in natural orice trans-
luminal endoscopic surgery for thyroid disease: a preliminary
study. Surg Endosc. 2018;32:517–25. https://doi.org/10.1007/
s00464- 017- 5656- 0.
103
Index
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A
Abducens nerve, 2
Airway, 15
Amplitude, 32
Anesthesia, 92
Anxiety, 15
Artifacts, 100, 101
Artifactual isolated amplitude, 102
Artifactual isolated latency, 103
Artifactual repeated amplitude drops and latency, 104
Automatic periodic stimulation (APS) accessory, 122
B
Bilateral recurrent laryngeal nerve injury, 6, 17
C
C2 Explore, 12
Cadwell, 12
CadX, 12
Carotid vessels, 41
Cascade IOMAX, 12
Cascade Surgical Studio (CSS), 12
Cephalic manner, 119
Combined EMG event, 101
Communicating “anastomoses”
extra-laryngeal anastomosis, 7
Galen’s anastomosis, 7
Compound muscle action potential (CMAP), 14
Continuous intraoperative neuromonitoring (CIONM), 31, 91, 92, 96,
122–124
Continuous neural stimulation, 123
Cranial nerve (CN), 1
abducens nerve, CN VI, 2
communicating “anastomoses”
extra-laryngeal anastomosis, 7
Galen’s anastomosis, 7
facial nerve, CN VII
anatomy, 3
function, 3
glossopharyngeal nerve, CN IX, 3
hypoglossal nerve, 7
oculomotor nerve, CNIII, 2
olfactory nerve, CNI, 1
optic nerve, CNII, 1
phrenic nerve, 8
spinal accessory nerve, 7
trigeminal nerve, CN V, 2
trochlear nerve, CN IV, 2
vagus nerve, CN X
anatomy, 3, 4
branches, 4–7
function, 4
Cricothyroid muscle, 119
D
Denitive global loss of signal, 108
Dominant side, 91–92
E
Electromyography (EMG), 16, 103
Electrophysiological equipment, 11
Cadwell
CadX, 12
Cascade IOMAX, 12
Cascade Surgical Studio, 12
Inomed, 12
Medtronic
NIM 3.0 system, 11
NIM TriVantage, 11
NIM Vital, 11
Endotracheal tube (ETT), 21, 32, 48, 92
External branch of the superior laryngeal nerve (EBSLN), 6, 7, 25
and dissection, in TOETVA, 119
intraoperative neurophysiological monitoring for, 59
thyroid and parathyroid surgery
avoiding injury, 41
diagnosis, 42
frequency of, 43
intraoperative monitoring, 42, 43
normative features, 44
prognostic parameters of, 44
surgical anatomy, 41
External image of stimulation, 122
Extra-laryngeal anastomosis, 7
F
Facial nerve
anatomy, 3
function, 3
Fasciculations, 81
G
Galen’s anastomosis, 7
Glossopharyngeal nerve, 3
Glottic movement, 25
Ground electrodes, 81
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. L. Shifrin et al. (eds.), Atlas of Intraoperative Cranial Nerve Monitoring in Thyroid and Head and Neck Surgery,
https://doi.org/10.1007/978-3-031-24613-5
105
106
Index
H
Head and neck procedures, 17
Hypoglossal nerve, 7, 81, 82, 84
I
Informed consent, 92
Internal branch of the superior laryngeal nerve (IBSLN), 6
Intraoperative nerve monitoring (IONM), 13–15, 19
anesthesia emergence, 17
for external branch of the superior laryngeal nerve, 59
for hypoglossal nerve, 81, 82, 84
intraoperative management, 16, 17
limitations, 21
for phrenic nerve, 85, 88
preoperative assessment, 15
preventing vocal fold injury, 20, 21
rationale for, 19, 20
of RLNs during, 47
C-IONM, advanced monitoring with, 122, 123
during TOETVA 2, 118
EBSLN approach, 119
guidance with percutaneous stimulating probe, 121
limits, 124
operative strategy with dissecting and stimulating instruments,
121, 122
steps in, 119, 120
TOETVA procedures, 111, 117
with long stimulating probe, 120, 121
safety of, 21
for spinal accessory nerve, 77
standard algorithm for, 122
team, 13
thyroid and parathyroid surgery, 91
CIONM, prerequisites for, 91, 92
education, role in, 26
EMG data, evaluation of, 100, 101, 103
evidence basis, benet of, 27
history of, 25, 26
preoperative laryngeal examination, role of, 27
prevalence and patterns, 26
procedure, 92, 95, 96
and RLN invasion, 35, 36
standards of use and applications, 28
vocal cord paralysis, rates and impact of, 26, 27
types of, 21
for vagus nerve, 73
Intubation, 22
L
Laryngeal nerve monitoring endotracheal tubes, 15
Latency, 32
Long stimulation probe, 120
M
Maryland dissector, 117
Medial approach, 93
Mental nerve, 111, 115, 116
Monitored TOETVA, 121
Monopolar probes, 31
Motor unit action potentials (MUAPs), 14
N
Neck anatomy, 114
Neck dissection, 73, 77
Neck nerves, 1
Nerve integrity monitoring (NIM) endotracheal tubes, 16
Nerve Integrity Monitoring system (NIM-2), 25
Nerve-monitoring probe entry, 121
Neurological decit prevention, 85
Neuronal damage, 100
NIM 3.0 system, 11
NIM TriVantage, 11
NIM Vital, 11
Non-recurrent laryngeal nerve (NRLN), 5
Normative EMG, 33
O
Oculomotor nerve, 2
Olfactory nerve, 1
Optic nerve, 1
P
Paralysis, 81
Parathyroid surgery
CIONM, prerequisites for, 91, 92
education, role in, 26
EMG data, evaluation of, 100, 101, 103
evidence basis, benet of, 27
history of, 25, 26
neuromonitoring in, 36
preoperative laryngeal examination, role of, 27
prevalence and patterns, 26
procedure, 92, 95, 96
and RLN invasion, 35, 36
standards of use and applications, 28
vocal cord paralysis, rates and impact of, 26, 27
Phrenic nerve, 8, 85, 87–90
Platysma, 122
Positive EBSLN response, 61, 63, 65, 66, 69, 70
Pre-operative laryngeal examination (POLE), 15
R
Recurrent laryngeal nerve (RLN), 4–6, 19, 25
and dissection in TOETVA, 117
during TOETVA 2, 118–119
intraoperative neurophysiological monitoring
for, 35, 36, 47
and loss of signal, 34, 35
mechanisms of, 34
stimulation, 48, 49, 52–54
S
Signal recovery, 102
Special sensory pathway, 4
Special visceral efferent brachial motor pathway, 4
Spinal accessory nerve, 7, 77–79
Staged thyroidectomy, 103
Sternothyroid muscle, 43
Superior laryngeal nerve (SLN), 6
Superior thyroid artery, 42
Index
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107
T
Threshold, 32
Thyroid and parathyroid surgery, 19, 47, 59, 73
EBSLN monitoring during
avoiding injury, 41
diagnosis, 42
frequency of, 43
intraoperative monitoring, 42, 43
normative features, 44
prognostic parameters of, 44
surgical anatomy, 41
International RLN anatomic classication and estimated
prevalence, 28
IONM, 91
CIONM, prerequisites for, 91, 92
education, role in, 26
EMG data, evaluation of, 100, 101, 103
evidence basis, benet of, 27
history of, 25, 26
preoperative laryngeal examination,
role of, 27
prevalence and patterns, 26
procedure, 92, 95, 96
and RLN invasion, 35, 36
standards of use and applications, 28
vocal cord paralysis, rates and impact
of, 26, 27
phases of surgery, 28
RLN
algorithms, for management, 29
and loss of signal, 34, 35
mechanisms of, 34
normal anatomy, 28, 29
signal interpretation and troubleshooting, 32, 34
standard set-up, 30–32
Thyroidectomy, 20, 27, 47, 59, 73
Thyroid isthmus, 120
Transient global loss of signal, 106
Transient segmental loss of signal, 105
Transoral endoscopic thyroidectomy with vestibular approach
(TOETVA), 111
C-IONM, advanced monitoring with, 122, 123
guidance with percutaneous stimulating probe, 121
limits, 124
operative strategy with dissecting and stimulating instruments,
121, 122
RLN approach and dissection, 117–119
steps in, 119, 120
with long stimulating probe, 120, 121
Transoral surgery, 125
Trapezius muscle, 77
Trigeminal nerve, 2
Triggered EMG, 13, 14
Trochlear nerve, 2
Troubleshooting algorithm, 118
U
Uneventful EMG tracing, 100
V
Vagus nerve (VN), 25
anatomy, 3, 4
branches, 4–7
careful elevation of, 94
CIONM, 96
dissection and identication of, 123
function, 4
intraoperative neurophysiological monitoring for, 73
positive response, 73–75
Vestibular incisions, 112
Videolaryngoscopy, 32
Visceral motor pathway, 4
Visceral sensory pathway, 4
Vocal cord palsy, 108
Vocal cord paralysis, 26, 27, 91
Vocal fold injury, 20, 21
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