Prospective analysis of the efficacy of continuous
intraoperative nerve monitoring during thyroidectomy,
parathyroidectomy, and parotidectomy
JOSEPH BRENNAN, MD, FACS, ERIC J. MOORE, MD, and KURT J. SHULER, MD, FACS, Lackland Air Force Base, Texas, and
Travis Air Force Base, California
OBJECTIVE: Continuous intraoperative electromyo-
graphic monitoring was prospectively performed in
all parotidectomies, thyroidectomies, and parathy-
roidectomies over approximately 5 years to assess
the efficacy of this technology.
STUDY DESIGN AND SETTING: Continuous intraoper-
ative nerve monitoring with perioperative nerve
assessment was performed. The postresection mini-
mal stimulation level of the nerves was determined
to evaluate if this level would predict nerve function
postoperatively.
RESULTS: Forty-four parotidectomies and 70 thy-
roid/parathyroid operations were performed with
140 nerves at risk (44 facial, 96 recurrent laryngeal).
The incidence of temporary facial paralysis was
15.9% (7 of 44) and the incidence of permanent
paralysis was 0%. The incidence of temporary re-
current laryngeal nerve paralysis in terms of nerves
at risk was 1.0% (1 of 96), and the incidence of per-
manent recurrent laryngeal nerve paralysis was 0%.
All patients with normally functioning facial and
recurrent laryngeal nerves postoperatively had min-
imal stimulation levels less than or equal to 0.4 mA.
CONCLUSION: Continuous intraoperative nerve
monitoring was associated with extremely low rates
of temporary and permanent nerve paralysis in our
From the Department of Otolaryngology–Head and Neck Surgery (Dr
Brennan), Wilford Hall Medical Center, Lackland Air Force Base,
and the Department of Otolaryngology–Head and Neck Surgery
(Drs Moore and Shuler), David Grant Medical Center, Travis Air
Force Base.
The opinions or assertions of the authors contained herein are the pri-
vate views of the authors and are not to be construed as official or
as reflecting the views of the Department of the Army or the
Department of Defense.
Presented at the Annual Meeting of the American Academy of
Otolaryngology–Head and Neck Surgery, Washington, DC,
September 24-27, 2000.
Reprint requests: Joseph Brennan, MD, FACS, Chairman, Department
of Otolaryngology–Head and Neck Surgery, Wilford Hall Medical
Center, 59th MDW/MMKR, 2200 Bergquist Dr, Suite 1, Lackland
Air Force Base, TX 78236-5300; e-mail, JosephBrennan@
59MDW.WHMC.AF.MIL
0194-5998/2001/$35.00 + 0 23/1/115402
doi:10.1067/mhn.2001.115402
series of 140 nerves at risk as compared to the rates
documented in the literature. (Otolaryngol Head
Neck Surg 2001;124:537-43.)
T he standard of care during routine parotidectomy is
the preservation of the seventh cranial nerve, which was
first described by Thomas Carwardine in 1907.1 The
incidence of temporary facial nerve paralysis after
nerve-sparing parotidectomy has been reported as high
as 71%.2 The incidence of permanent total or partial
paralysis after parotidectomy will range as high as
5.6%.3 The morbidity of temporary or permanent facial
paralysis can be significant; corneal exposure and blind-
ness are the most feared sequelae. The surgeon must
have the experience and ability to identify the facial
nerve in several anatomic locations if he or she is
unsuccessful at the usual site of identification near the
stylomastoid foramen.
Iatrogenic injury to the recurrent laryngeal nerve is
one of the most common and most feared complications
that occur during thyroid and parathyroid surgery. The
incidence of temporary recurrent laryngeal paralysis
after primary surgery (excluding reoperations) ranges as
high as 7.1% and permanent paralysis is as high as
3.6%.4,5 However, this rate of vocal cord paralysis may
approach 14% in patients with higher risk surgeries
including subsequent operations and total thyroidec-
tomies for malignant conditions.6-8 The most common
cause of lawsuits in endocrine surgery is iatrogenic
injury to the recurrent laryngeal nerve (RLN).9
Consequently, the ability to identify and protect the
RLN during thyroidectomy and parathyroidectomy is
critical to the success of the surgery.
Intraoperative monitoring and identification of both
the RLN and the facial nerve have been described dur-
ing the past 2 decades.1,4,5,10-12 No prospective random-
ized study has proven the efficacy of intraoperative
monitoring in reducing the incidence of temporary and
permanent nerve injury. Nevertheless, multiple authors
have recommended the use of this technology, especially
during more difficult cases including additional surg-
eries. Intraoperative facial and RLN monitoring will
provide instant and continuous feedback regarding the
537

538 BRENNAN et al
Table 1. House-Brackmann facial nerve grading
system
Grade level Description of paralysis Function (%)
I Normal 100
II Slight 80
III Moderate 60
IV Moderately severe 40
V Severe 20
VI Total 0 Mucoepidermoid carcinoma
location and functional status of the nerves at risk dur-
ing dissection. This valuable feedback may decrease the
risk and incidence of iatrogenic injury to the RLN,
recurrent laryngeal and facial nerves.
METHODS AND MATERIAL
David Grant Medical Center is a 180-bed tertiary referral
center with patients being referred from the western United
States, the Pacific basin, and Europe. David Grant Medical
Center is the second largest Air Force teaching hospital and
the Otolaryngology–Head and Neck Surgery service is com-
prised of 3 board-certified surgeons. General surgery residents
routinely rotate on this service, and there are no subspecialty
(otolaryngology) residents in our hospital. Over a 5-year peri-
od between October 1994, and June 2000, all patients under-
going thyroidectomy, parathyroidectomy, or parotidectomy by
the Head and Neck service at our teaching hospital were
entered into this study. The data were prospectively collected
and there was no specific patient selection (all patients were
included in the study). The study was designed to determine
the incidence of RLN paralysis and facial nerve paralysis
occurring with continuous intraoperative nerve monitoring
during the above procedures. This incidence of nerve paraly-
sis would then be compared with the reported rates of nerve
paralysis as documented in the literature.
All patients having thyroidectomy, parathyroidectomy, and
parotidectomy performed by the Otolaryngology–Head and
Neck Surgery service between October 1994 and June 2000
were enrolled in this study. The data that were prospectively
collected included the patient names, social security numbers,
age, sex, and the date of surgery. The attending surgeon and
the resident surgeon were also recorded, and it was noted
whether the resident surgeon acted as the primary surgeon as
opposed to simply being the first assistant. The pathologic
diagnosis, the procedure performed, the length of follow-up,
perioperative complications, and disease recurrence or spread
were also recorded.
The parotid operations performed at our institution include
superficial, total, and radical parotidectomy. The staff sur-
geons do not perform subtotal parotidectomy, during which
less than a superficial lobectomy is performed and the facial
Otolaryngology–
Head and Neck Surgery
May 2001
Table 2. Parotid gland pathology
Number of patients
Pathology (n = 47)
Pleomorphic adenoma 17
Warthin’s tumor 10
Squamous cell carcinoma 7
Oncocytoma 3
Lymphepithelial cyst 2
2
Chronic parotitis 2
Lymphoma 1
Basal cell carcinoma 1
Metastatic renal cell carcinoma 1
Adenocarcinoma 1
nerve is not completely identified. The House-Brackmann
facial nerve grading system (Table 1) was used to evaluate the
facial nerve function of these patients both preoperatively and
postoperatively.13 The functional status of the facial nerve was
assessed by at least 2 staff surgeons and assigned a grade
ranging from Grade I or normal to Grade VI or total flaccid
paralysis.13 Intraoperatively, the Nerve Integrity Monitoring
System (NIM-2, Xomed-Treace) was used to perform contin-
uous electromyographic (EMG) monitoring of the facial
nerve. Two monopolar EMG electrodes were placed in the
orbicularis oculi and orbicularis oris muscles preoperatively.
The staff surgeons placed the electrodes, set up the system,
and monitored the function of the machine throughout the
case. No audiologist was needed to run this nerve monitor.
The setup time required for the nerve monitor was noted.
Finally, we recorded the minimal stimulation level in mA
needed to stimulate the facial nerve at the stylomastoid fora-
men at the end of the parotidectomy. It should be noted that
the nerve monitor is composed of 2 channels that allow inde-
pendent assessment of both the upper and lower divisions of
the facial nerve during the resection. A loud speaker and a
screen warns the surgeon of nerve stimulation with a simulta-
neous visible waveform and audible alarm.10
The thyroid procedures performed include total, comple-
tion-total, near-total, and subtotal thyroidectomy. The para-
thyroid procedure always included bilateral neck exploration
and possible thymic exploration with visualization of 4 or
more glands. RLN function was assessed in all patients under-
going the above procedures with flexible nasopharyngoscopy.
Flexible nasopharyngoscopy was performed both preopera-
tively and postoperatively in all patients in the Otolaryn-
gology–Head and Neck Surgery Clinic. Typically, the initial
assessment would be performed at the preoperative visit sched-
uled several days before surgery. The postoperative assessment
would be performed either on the floor as an inpatient or in the
clinic at the first postoperative visit. We do not use the sole cri-
teria of hoarseness or the quick assessment of cord function by
Otolaryngology–
Head and Neck Surgery
Volume 124 Number 5
Table 3. Facial nerve analysis
Incomplete paralysis
Procedure (n) Parotidectomy Temporary
Superficial (31) 4 (12.9%)*
Total (13) 3 (23.0%)*
Combined totals (44) 7 (15.9%)*
*House-Brackmann Grade II.
†House-Brackmann Grade VI.
the anesthesiologist after extubation to determine RLN func-
tion. Nasopharyngoscopy was always performed by the staff
otolaryngologist. The NIM-2 was used to perform continuous
intraoperative electromyographic monitoring of the RLN. A
commercially purchased reinforced endotracheal tube with 2
sets of paired wires placed laterally above the cuff was used.9
The bare stainless-steel wires were in contact with the vocalis
muscle and provided continuous EMG feedback throughout
the case. As with the facial nerve, stimulation of the RLN
caused both a visual wavetype and an audible alarm on the
nerve monitor. The minimal stimulation level in mA required
to stimulate the RLN at the end of the thyroidectomy or
parathyroidectomy was recorded. The incidence of RLN paral-
ysis was determined both by nerves at risk and by operations.
RESULTS
Over the past 5 1/2 years, 111 patients underwent 117
thyroidectomies, parathyroidectomies, and parotidec-
tomies by the Otolaryngology–Head and Neck service
at David Grant Medical Center. Similar operations per-
formed by other services, such as the General Surgery
Department, were not included in this study. Fifty-six
males and 55 females comprised the study population;
their ages ranged between 11 and 84 years. The data
were further stratified with respect to the nerves at risk
during surgery—the facial nerve and the RLN. All 117
operations were performed using continuous intraoper-
ative EMG monitoring of either the facial nerve or the
RLN. All 3 otolaryngology surgeons staffed general
surgery residents during these procedures, with the
senior surgeon (J.B.) staffing over 50% of the opera-
tions performed. All patients were followed by the staff
surgeons (range, 3 months to 66 months).
Forty-seven parotid operations were performed in-
cluding 31 superficial, 13 total, and 3 radical parotidec-
tomies. Because 3 facial nerves were resected
intraoperatively, there were 44 facial nerves at risk dur-
ing these procedures. Table 2 demonstrates the pathology
results of the 47 parotid glands resected; pleomorphic
adenoma (17 specimens) and Warthin’s tumor (10 spec-
imens) were the most common diagnoses. Seven
BRENNAN et al 539
Total paralysis
Permanent Temporary Permanent
0 0 0
0 1 (7.7%)† 0
0 1 (2.3%)† 0
parotidectomies were performed in patients with squa-
mous cell carcinoma, either to ensure negative margins
with invasive skin lesions or to remove metastatic dis-
ease. In addition, 3 patients underwent neck dissections
with their parotid operations. Continuous EMG nerve
monitoring was used in all parotid resections. The nerve
integrity monitor and electrodes were set up by the sur-
geon in less than 3 minutes. Bipolar electrocautery and
sutures are used exclusively for hemostasis. Unipolar
electrocautery and the Shaw scalpel, which has been
shown to be an independent risk factor for facial paral-
ysis, were not used.14 The parotidectomy was begun
with subplatysmal elevation of the skin flaps. A 2-tunnel
parotidectomy technique was used. An inferior tunnel
separating the tail of the parotid gland from the stern-
ocleidomastoid muscle was created with identification
of the posterior belly of the digastric muscle, which lies
at the level of the facial nerve. Next, the superior tunnel
was created anterior to the tragus. As the superior tun-
nel is deepened, the tragal pointer and the tympanomas-
toid suture are identified. The 2 tunnels are then joined
as a single tunnel near the tympanomastoid suture,
which serves as the most constant landmark to the facial
nerve. The facial nerve is then identified near the stylo-
mastoid foramen approximately 6 to 8 mm below the
edge of the tympanomastoid suture. This technique was
successful in 46 of the 47 parotidectomies performed.
In 1 case, the nerve was not easily identified with this
technique, and retrograde dissection was performed
after identifying the marginal mandibular branch cross-
ing over the retrofacial vein.
Facial nerve function was assessed both preopera-
tively and postoperatively using the House-Brackmann
grading system.13 All 47 parotidectomy patients had a
grade I, or normally functioning nerve preoperatively.
The 3 patients with radical parotidectomy were excluded
from postoperative statistics since they obviously had
grade VI function after resection of the facial nerve. The
remaining 44 patients with preservation of the facial
nerve were then assessed using the House-Brackmann
scale. The incidence of temporary facial nerve paralysis
 Otolaryngology–
Head and Neck Surgery
540 BRENNAN et al May 2001

Table 4. Thyroid and parathyroid gland pathology hyperparathyroidism and 1 subtotal parathyroidectomy
Number of patients
for secondary hyperparathyroidism. All 8 parathyroidec-
Pathology (n = 70) tomy patients had successful resections with normal cal-
cium levels postoperatively. The most common
Multinodular goiter 24 pathologic diagnoses, as depicted in Table 4, was multin-
Papillary carcinoma 24
odular goiter in 24 patients and papillary carcinoma in 24
Primary hyperparathyroidism 7
Follicular carcinoma 4 patients. The incidence of temporary hypoparathyroidism
Follicular adenoma 4 requiring treatment was 1.6% (1 of 62) and the incidence
Hurthle cell adenoma 2 of permanent hypoparathyroidism was also 1.6% (1 of
Medullary thyroid carcinoma 2 62). The single case of permanent hypoparathyroidism
Parathyroid cyst 1
occurred in a patient with Grave’s disease who had a total
Graves disease (1) Coexisting papillary CA
Thymic cyst 1 thyroidectomy for papillary carcinoma. During the 70
Secondary hyperparathyroidism 1 thyroid and parathyroid operations, 96 RLN were at risk
(bilateral RLNs were at risk during total and near-total
thyroidectomies and parathyroidectomies). The special
endotracheal tube with electrodes was placed as usual by
was 15.9%; 7 of the 44 patients demonstrated nerve dys- the anesthesiologist during intubation. The surgeon then
function postoperatively (Table 3). One patient (2.3%, 1 placed the ground electrodes and set up the nerve moni-
of 44) had a grade VI or total paralysis postoperatively tor in less than 3 minutes.
after a total parotidectomy with a deep lobe tumor at the The 3 staff surgeons believe that the technique used
stylomastoid foramen. The remaining 6 patients (13.6%, for RLN identification is critical for the success of the
6 of 44) had grade II dysfunction with isolated weakness procedure. We used a medial dissection technique dur-
of the marginal branch in 3, the nasolabial area in 2, and ing which the dissection is based on the thyroid capsule
the eye in 1 patient (Table 3). As would be expected, the and all soft tissue is dissected off the thyroid capsule as
incidence of temporary paralysis was higher after total the tracheal-esophageal groove is exposed. As opposed
parotidectomy (23%, 3 of 13) than after superficial to the distal identification of the RLN in the carotid tri-
parotidectomy (12.9%, 4 of 31) (Table 3). Most impor- angle in the lateral approach, the medial approach will
tantly, all patients were followed by their staff surgeons identify the RLN more proximally near Berry’s liga-
to assess permanent facial nerve dysfunction. The inci- ment and the cricothyroid junction. We use bipolar elec-
dence of permanent facial nerve paralysis was 0% (Table trocautery almost exclusively, and we do not use an
3). The 7 patients with temporary paralysis regained esophageal stethoscope that may distort anatomy. After
complete function and had grade I performance of the raising the subplatysmal flaps and separating the strap
facial nerve. The 6 patients with isolated dysfunction muscles in the midline, the middle thyroid vein is ligated
(grade II) recovered within 3 months and the single and the carotid sheath is identified. If indicated, the isth-
patient with complete paralysis (grade VI) fully recov- mus is then cross-clamped across the medial contralat-
ered at 5 months postoperatively. The minimal stimula- eral lobe and suture ligated. Dissection is carried
tion level of the facial nerve trunk at the stylomastoid superiorly across the cricothyroid space isolating the
foramen ranged between 0.15 mA and 1.0 mA. The min- superior vessels medially (the vessels had previously
imal stimulation level did not predict the isolated nerve been isolated laterally during the carotid sheath dissec-
branch weakness since these 6 patients had levels tion). The superior vessels are then suture ligated indi-
between 0.2 and 0.5 mA, which is identical to the range vidually with a no-clamp technique on the thyroid
of normally functioning patients. However, the only capsule to protect the external branch of the superior
patient with a stimulation level greater than 0.5 mA was laryngeal nerve. Finally, the gland is rotated medially
the 1 patient with total postoperative paralysis (grade using sponges (no clamps or sutures are placed into the
VI), whose nerve stimulated at 1.0 mA. gland to cause bleeding), and the dissection is carried
Seventy thyroid and parathyroid operations were per- into the tracheoesophageal groove directly on the thy-
formed by the Otolaryngology/Head and Neck Service roid capsule. The RLN is identified proximally near
during the study period. The operations included 36 Berry’s ligament and the cricothyroid joint. The termi-
subtotal (lobectomy and isthmusectomy), 13 total, 8 nal branches of the inferior thyroid artery are ligated on
completion-total, and 5 near-total thyroidectomies. Three the capsule. The inferior parathyroid gland is typically
patients had neck dissections performed during the thy- identified near the junction of the inferior thyroid artery
roid procedures. In addition, 8 parathyroidectomies were and the RLN. The superior parathyroid gland, which
performed with 7 bilateral explorations for primary often has to be peeled off the thyroid capsule, is usually
Otolaryngology–
Head and Neck Surgery
Volume 124 Number 5
Table 5. Recurrent laryngeal nerve/parathyroid analysis
Paralysis
Procedure (n)Thyroidectomy Temporary
Subtotal (36) 0 0
Near-total (5) 0 0
Total (21) 1 (4.8%)*
Combined totals (62) 1 (1.6%)*
*Resolved fully at 6 months.
located near where the RLN enters the larynx at the
cricothyroid joint. After ligating the remaining soft tis-
sue attachments and inferior thyroid vein, the specimen
is removed and examined for soft tissue that may be
consistent with parathyroid tissue. Before closing, the
RLN is examined and stimulated to assess the minimal
stimulation level on the nerve integrity monitor.
During the 70 thyroidectomies and parathyroidec-
tomies, 96 RLNs were at risk. The RLNs are identified
bilaterally in all total thyroidectomies, near-total thy-
roidectomies, and parathyroid explorations. All 96 nerves
were visually identified during these procedures and
were successfully stimulated with the nerve monitor at
the end of the case. The incidence of temporary RLN
paralysis was 1.0% in terms of nerves at risk (1 in 96) or
1.6% in terms of thyroid cases performed (1 of 62) (Table
5). The single case of temporary RLN paralysis occurred
in a patient with multifocal papillary carcinoma who had
17 positive lymph nodes in the neck and paratracheal
area. He was found to have his ipsilateral RLN, which
was functioning normally preoperatively, to be encased
in carcinoma. The papillary carcinoma was peeled off the
nerve, and the patient was noted to have ipsilateral vocal
cord paralysis on postoperative examination. The inci-
dence of permanent RLN paralysis with 96 nerves at risk
was 0% (Table 5). This same patient was noted on his 6-
month follow-up visit to have normal and symmetric
vocal cord function during nasopharyngoscopy.
As noted previously, David Grant Medical Center is
a large United States Air Force teaching hospital in
which general surgery residents rotate on the Otolaryn-
gology/Head and Neck Surgery service. There are no
subspecialty (such as otolaryngology) residents in the
hospital. Over 90% of the cases had a resident scrubbed
in and approximately 50% of the cases had a senior-
level (postgraduate year 3 to 5) resident acting as pri-
mary surgeon and performing the case with staff
supervision. The cost of the nerve electrodes for the
parotidectomy was $57 and the cost of the reinforced
endotracheal tube for thyroidectomy/parathyroidectomy
was $190. The length of patient follow-up ranged be-
BRENNAN et al 541
Hypoparathyroidism
Permanent Temporary Permanent
0 0
0 0
0 1 (4.8%) 1 (4.8%)
0 1 (1.6%) 1 (1.6%)
tween approximately 3 months and 66 months. Even
though no patients have had recurrent parotid, thyroid,
or parathyroid disease, this short follow-up time pre-
cludes definitive assessment of disease recurrence.
DISCUSSION
The efficacy of continuous intraoperative monitoring
of the facial nerve and the RLN remains controversial.
There have been no prospective randomized studies
demonstrating that intraoperative nerve monitoring will
decrease the incidence of temporary and permanent
nerve paralysis. The mechanisms of intraoperative nerve
injury include division, laceration, traction, pressure,
crush, electrical, ligature entrapment, ischemia, and suc-
tion trauma.4 Most surgeons believe that the identifica-
tion and visualization of the nerves at risk will lessen the
likelihood of nerve injury.4 Nerve identification in certain
types of operations may be very difficult. These difficult
cases include reoperations, cancer excisions, anatomic
distortion with large tumors, anatomic anomalies (nonre-
current laryngeal nerve), and a history of irradiation or
inflammation.1,11 Unfortunately, the surgeon can not
always predict when the surgery will be “difficult.”11
Continuous EMG nerve monitoring may better enable
the surgeon to differentiate neural from nonneural tissue
and to protect the nerve throughout the case.11
Continuous EMG monitoring causes no nerve damage as
opposed to the disposable nonpulsed direct stimulators
that may result in temporary nerve paralysis.4
Temporary and permanent facial nerve paralysis
after parotidectomy is not uncommon. The incidence of
temporary nerve paralysis typically ranges between
20% and 71%, with a higher incidence after reopera-
tions and total parotidectomy.3,4,10 The most common
site of temporary nerve paralysis is the marginal man-
dibular nerve.15 The morbidity of temporary facial
paralysis may be significant, especially if the dysfunc-
tion involves the orbicularis oculi muscle. More impor-
tantly, the incidence of permanent facial paralysis after
parotidectomy typically ranges between 2% and 5%.1-4,10
Terrel et al12 showed that continuous intraoperative

542 BRENNAN et al
monitoring significantly decreased the incidence of tem-
porary facial nerve paralysis from 62% to 43%, although
the rates of permanent paralysis were not significantly
different. Several other studies showed no differences in
paralysis rates using continuous intraoperative nerve
monitoring, although these studies were retrospective
and excluded “high-risk” tumors including deep-lobe,
recurrent, and large (over 4 cm) tumors.1,10 Despite these
findings, those same authors stated that nerve monitoring
was “very helpful” during routine parotid surgery.1 We
agree that the nerve monitor may be extremely helpful in
identifying the nerve, especially in the “difficult”
parotidectomy cases. Furthermore, the continuous visible
and audiologic feedback of nerve stimulation throughout
the case better enables the surgeon to more “gently” dis-
sect and protect the nerve. We believe this feedback is
especially valuable to the novice resident surgeon who is
gaining familiarity with nerve anatomy. Our temporary
and permanent incidence of facial nerve paralysis is
below that typically described in the literature after
parotidectomy. Unfortunately, the lack of a control group
without monitoring during parotid resections prevents the
definitive analysis of the efficacy of intraoperative nerve
monitoring during these cases. The minimal stimulation
level of the facial nerve at the end of the parotidectomy
was not predictive of incomplete postoperative facial
paralysis (grade II) involving isolated nerve branches
such as the marginal mandibular nerve. However, our
single case of complete facial paralysis (grade VI) was
the only case in which the minimal stimulation level
exceeded 0.5 mA. This isolated case suggests that mini-
mal stimulation levels of the facial nerve exceeding 0.5
mA at end of the parotidectomy may predict complete
facial nerve paralysis postoperatively.
One of the most dreaded complications after thyroid
and parathyroid surgery is RLN paralysis. Establishing
the true rate of RLN dysfunction has been difficult
because many surgeons report their rate of injury with-
out performing preoperative and postoperative laryn-
goscopy. It is impossible to accept these frequently
published series that do not document laryngeal exami-
nations because they undoubtedly underestimate their
true incidence of RLN paralysis.4 The incidence of tem-
porary RLN paralysis ranges between 0.4% and
13%.4,11,16-18 More importantly, the incidence of per-
manent RLN paralysis ranges between 0% and
3.6%.4,11,16-19 Series that document preoperative and
postoperative laryngeal examinations have rates of per-
manent RLN paralysis typically between 1% and
3%.11,17,19 As would be expected, those series docu-
menting extraordinarily low rates of RLN injury below
1% do not perform laryngeal examinations for true
vocal cord function.7,18 These series “evaluate” RLN
Otolaryngology–
Head and Neck Surgery
May 2001
paralysis by asking the patient if they have hoarseness
or by having the anesthesiologist perform laryngoscopy
when the patient is awakening from general anesthesia.4
Both of these methods are relatively useless in accu-
rately diagnosing laryngeal dysfunction.4 With RLN
paralysis, the ipsilateral true vocal cord is generally in
the paramedian position. During phonation, some tens-
ing of the true vocal cord occurs due to the action of the
intact cricothyroid and interarytenoid muscles. Conse-
quently, not all patients with RLN paralysis experience
hoarseness. Furthermore, as the normal true vocal cord
compensates to meet the paralyzed cord, the expected
symptoms of hoarseness, vocal fatigue, and breathiness
may become nonexistent.4 A typical example of such a
study was a retrospective review of 1192 thyroidec-
tomies that showed a permanent RLN paralysis rate of
0.5%.18 Another study of 132 patients having reopera-
tion for thyroid and parathyroid disease showed a rate
of permanent RLN paralysis of 0%.7 Both studies relied
on the presence of “hoarseness” or an anesthesiologist’s
extubation examination to determine the function of the
RLN and preoperative and postoperative laryngoscopy
was not performed.7,18 Needless to say, these type of
studies are absolutely worthless in predicting their rates
of permanent and temporary RLN paralysis. Preopera-
tive and postoperative laryngoscopy must be performed
to accurately assess vocal cord function during thy-
roidectomy and parathyroidectomy. Videostroboscopy,
which will identify more subtle laryngeal dysfunction
including superior laryngeal nerve injury, is more
expensive and more time-consuming to perform.4 Mini-
mal stimulation levels of the RLN at the end of the case
were less than or equal to 0.4 mA in all patients with
normally functioning nerves postoperatively. The mini-
mal stimulation level of the single patient with RLN
paralysis was 0.5 mA. Minimal stimulation levels of the
RLN greater than or equal to 0.5 mA may correlate with
RLN paralysis postoperatively.
Our rates of temporary and permanent RLN paraly-
sis are lower than the rates documented in series with
appropriate perioperative laryngeal exams. As with
parotidectomy, we believe that intraoperative nerve
monitoring is helpful during thyroid and parathyroid
operations for the same reasons. However, as with all
operations, the surgical technique is critical since the
most common cause of RLN injury is a surgical error.
We favor the medial to lateral dissection technique dur-
ing which the RLN is identified proximally near the
cricothyroid joint after a pericapsular dissection. The
most constant location of the RLN is near the cricothy-
roid joint; it is easily identified in this location.
Furthermore, by dissecting all tissue off the capsule of
the thyroid gland, we hopefully will preserve the blood
Otolaryngology–
Head and Neck Surgery
Volume 124 Number 5
supply to the parathyroid glands and minimize the inci-
dence of postoperative hypoparathyroidism. The advo-
cates of the lateral to medial dissection identify the
RLN more distally in the RLN triangle which is an
inverted triangle bounded by the inferior thyroid gland
superiorly, the common carotid artery laterally, and the
trachea-esophagus medially.4 The nerve is then fol-
lowed proximally by dissecting the soft tissue over the
RLN to the cricothyroid joint. The advocates of this
technique point out that over 40% of RLNs will branch
before the cricothyroid joint and that this technique will
identify the RLN as a single trunk.4 However, since the
dissection is based on the RLN as opposed to the thy-
roid capsule, there may be additional soft tissue left
medial to the dissection that may jeopardize the
parathyroid blood supply. Regardless of technique,
most surgeons advocate the visual identification of the
RLN during surgery and several studies have docu-
mented a lower RLN paralysis rate with this approach.11
We believe that the “blind” technique with a pericapsu-
lar thyroid dissection without RLN identification is
potentially dangerous. Nevertheless, despite an exhaus-
tive intraoperative search, surgeons may not be able to
identify the RLN bilaterally in up to 36% of patients
undergoing thyroidectomy.20 Continuous intraoperative
EMG monitoring may assist in more accurately identi-
fying the RLN in such cases.
CONCLUSION
We prospectively collected data and determined our
rates of nerve paralysis with continuous intraoperative
nerve monitoring during parotidectomy, thyroidectomy,
and parathyroidectomy. We had no cases of permanent
facial nerve or recurrent laryngeal nerve paralysis during
the past 5 years with 140 nerves at risk during the resec-
tions. Minimal stimulation levels of the facial nerve and
RLN ≥0.5 mA intraoperatively may correlate with com-
plete nerve dysfunction postoperatively. However, the
predictive value of minimal stimulation levels needs fur-
ther evaluation since only 2 of our patients had complete
nerve paralysis postoperatively. All staff surgeons be-
lieved that continuous intraoperative electromyographic
monitoring was helpful and better enabled the resident
surgeon to more “gently” handle the nerve. Nevertheless,
the most crucial factor in nerve preservation is surgical
technique. Although nerve monitoring may be helpful, it
BRENNAN et al 543
is not the standard of care during parotid, thyroid, or
parathyroid surgery. Until a prospective, randomized trial
documents the efficacy of continuous intraoperative
monitoring in reducing permanent nerve paralysis, its use
can not be routinely recommended.
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544 BRENNAN et al May 2001