REVIEW ARTICLE

ANZJSurg.com

Recurrent laryngeal nerve injury in thyroid surgery: a review

Nathan James Hayward, Simon Grodski, Meei Yeung, William R. Johnson and Jonathan Serpell
Department of Breast, Endocrine and General Surgery, The Alfred, Melbourne, Victoria, Australia

Key words Abstract

intraoperative monitoring, recurrent laryngeal nerve,
recurrent laryngeal nerve palsy, thyroidectomy, vocal
cord paralysis.
Correspondence
Dr Nathan James Hayward, C/- Department of Breast,
Endocrine and General Surgery, The Alfred Hospital,
Level 6, Main Block, 55 Commercial Road, Prahran, Vic.
3181, Australia. Email: nathan.hayward1@gmail.com
N. J. Hayward BMedSci, MBBS (Hons); S. Grodski
MBBS (Hons), FRACS; M. Yeung MBBS, FRACS;
W. R. Johnson MBBS, FRACS; J. Serpell MD, FRACS.
Accepted for publication 4 June 2012.
doi: 10.1111/j.1445-2197.2012.06247.x
Recurrent laryngeal nerve palsy (RLNP) is an important and potentially catastrophic
complication of thyroid surgery. Permanent RLNP occurs in 0.3–3% of cases, with
transient palsies in 5–8%. A literature review and analysis of recent data regarding
RLNP in thyroid surgery was performed, with particular focus on the identification of
high-risk patients, the role of intraoperative identification and dissection of the nerve,
and the role of intraoperative neuromonitoring (IONM) and optimal perioperative
nerve assessment. In conjunction with the review, data from the Monash University/
Alfred Hospital Endocrine Surgery Unit between January 2007 and October 2011 were
retrospectively analysed, including 3736 consecutive nerves at risk (NAR). The
current literature and our data confirm that patients undergoing re-operative thyroid
surgery and thyroid surgery for malignancies are at increased risk of RLNP. Intraop-
erative visualization and capsular dissection of the RLN remain the gold standard for
intraoperative care during thyroid surgery for reducing RLNP risk. IONM should not
be used as the sole mechanism for identifying and preserving the nerve, although it can
be used to aid in the identification and dissection of the nerve, and may aid in nerve
protection in high-risk cases including cancer surgery and re-operative surgery.

Introduction
Recurrent laryngeal nerve palsy (RLNP) is a long recognized and
potentially catastrophic complication of thyroid surgery. Damage
to a recurrent laryngeal nerve (RLN) with resultant paralysis
of the sole abducting muscle (posterior cricoarytenoid) of the vocal
cords can cause symptoms ranging from almost undetectable
hoarseness in unilateral lesions to stridor and acute airway obstruc-
tion in bilateral damage.1–3 RLNP following thyroid surgery is
one of the leading reasons for medico-legal litigation against
surgeons.4
Post-operative RLNP is a rare complication of thyroid surgery in
expert hands. Over the years, surgical strategy has advanced from
non-visualization and avoidance of the RLN to the modern surgical
technique of capsular dissection and direct visualization of the
RLN.5 Permanent post-operative RLNP occurs in approximately
0.3–3% of cases2,6–9 and transient palsies in 3–8% of cases.1,2,7,9,10
Rates of RLNP are most accurately described in terms of ‘nerves at
risk’ (NAR) and are dependent on the type of surgery and nature of
disease.11
We analysed our data from the Monash University/Alfred Hospi-
tal Endocrine Surgery Unit between January 2007 and October
2011. A total of 2422 thyroid resection procedures were included,
with a total of 3736 NAR (Table 1).
Pre- and post-operative RLN evaluation was performed via fibre-
optic nasoendoscopy (FNE) in the majority of cases. Fifty-three
RLNP occurred during this period, consisting of 6 permanent and 47
temporary palsies. Overall, post-thyroid surgery RLNP incidence is
0.16% and 1.25% for permanent and transient RLNP, respectively.
Of the 53 RLNP in this series, there were two cases of bilateral
involvement, both transient. No patient required tracheostomy.
We present an analysis of the literature and our own data to
provide an update on RLN injury in thyroid surgery. In particular, we
look at potential risk factors for RLN injury, including re-operative
surgery, malignancy, extent of surgery, surgeon experience, side of
surgery, retrosternal goitre and pathology. We also examine the
current gold standard of capsular dissection, intraoperative visuali-
zation and dissection of the RLN, as well as the role of adjuncts such
as intraoperative neuromonitoring (IONM).
Risk factors for RLNP in thyroid surgery
There are considerable data identifying specific patients and proce-
dures with higher risk of RLNP in thyroid surgery.
Re-operative surgery
Patients undergoing secondary or re-operative thyroid operations are
at increased risk of RLN injury. It is estimated that the risk of

© 2012 The Authors

ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons ANZ J Surg 83 (2013) 15–21

16
Table 1 Thyroid procedures January 2007–October 2011
Operation Benign Cancer Total operations NAR
Hemithyroidectomy 863 143 1006 1006
Total thyroidectomy 1019 278 1297 2594
Re-operative unilateral 97 5 102 102
thyroidectomy
Re-operative bilateral 13 4 17 34
thyroidectomy
Totals 1993 429 2422 3736
Operation: procedure performed. Benign: number procedures benign diagno-
sis. Cancer: number procedures cancer diagnosis. Total operations: total
procedures including benign and cancer diagnosis. Nerves at risk (NAR):
number recurrent laryngeal nerves at risk in given procedure.
permanent RLNP is 2–30% for re-operative procedures.4,12–16 In
re-operative surgery, anatomical planes are distorted due to scarring
from the primary procedure, resulting in difficult RLN identification
and increased nerve traction.14 Disease and/or scarring may encase
the nerve, resulting in difficulty in dissection and placing the nerve
at greater risk.17 It is reported that re-operative surgery for both
benign and malignant disease is associated with increased risk.13,14,17
The Jatzko et al. study reported secondary operations for recurrent
benign goitre having an incidence of post-operative RLNP approach-
ing 8% compared with almost zero for primary surgery. This study
went on to report rates as high as 30% in re-operative procedures
where the nerve was unable to be identified intraoperatively.18 The
large prospective trial of Thomusch et al. reported a relative risk of
3.1 for RLNP in secondary compared with primary benign goitre
surgery.14 The study of Lo et al. is in keeping with this evidence, but
is expansive in analysing data from all histopathological diagnosis.
This study reports a 4% incidence of RLNP for re-operative thyroid
surgery compared with less than 1% for primary procedures.7 The
higher risk of RLNP is generally accepted in the context of dis-
ease.19,20 Our unit’s experience is in keeping with the literature. A
statistically significant increase in permanent RLNP occurred in
re-operative procedures compared with primary surgery, with rates
of 0.74% and 0.13%, respectively (P = 0.01). Similarly, transient
RLNP rates were 4.41% in re-operative surgery versus 1.13% for
primary surgery (P = 0.02).
Cancer surgery
Surgery for thyroid cancer places the RLN at greater risk of intra-
operative damage, often due to tumour invasion of the surrounding
soft tissue and at times the nerve itself. It is reported that the nerve
is invaded in up to 20% of cases.16 Dralle et al. reported permanent
RLNP in 1.52% of patients undergoing primary thyroid cancer
surgery compared with less than 0.5% (P < 0.001) in benign disease.
The RLNP rates are even greater in secondary malignancy surgery,
approaching 6%.13 The prospective study of Lo et al. also reports
statistically significant rates of RLNP in surgery for malignant
disease (5.26%) as opposed to benign disease (0.7%, P = 0.01).
These findings are supported in several other smaller studies, with
reported rates for RLNP in thyroid cancer operations ranging from
2% to 50%.1,6,7,13,21
Our data confirm increased incidence of temporary and permanent
RLNP in cancer versus benign disease surgery. The incidence of
14452197, 2013, 1-2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1445-2197.2012.06247.x by EBMG ACCESS - ETHIOPIA, Wiley Online Library on [30/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Hayward et al.
permanent and transient RLNP in thyroid cancer surgery was 0.28%
and 1.82%, respectively. In thyroid operations performed for benign
disease, permanent RLNP occurred in 0.13%, with transient palsy in
1.12%. The increased incidence of transient RLNP in surgery for
thyroid cancer is statistically significant compared with benign
disease (P = 0.0001). However, the observed trend of increased
permanent RLNP in thyroid cancer surgery (0.28% versus 0.13%),
and benign disease was not statistically significant (P = 0.08). This
is likely due to the very small event rate in this group.
Extent of surgery
The extent of thyroid surgery has been investigated, and it is gener-
ally accepted that extended resections carry higher risk of RLNP.22
Erbil et al., in a retrospective study analysing 3250 patients, reported
a 12.6 times greater risk (P = 0.01) of RLNP in patients undergoing
extended thyroidectomy (lobectomy or total thyroidectomy) com-
pared with conservative surgery (sub-total resection) for thyroid
carcinoma and malignancy.1 These findings are supported by the
Dralle et al. study, where the risk of permanent RLNP was signifi-
cantly higher in those undergoing lobectomy versus subtotal resec-
tion (1.34% and 0.68%, respectively).13
Favourable long-term survival and low reoccurrence rates have
been demonstrated in total thyroidectomy and near-total thyroidec-
tomy for thyroid carcinoma, with less extensive/sub-total resections
not advocated.23,24 Near-total thyroidectomy (defined by leaving less
than 1 g of thyroid tissue adjacent to the RLN at the ligament of
Berry on one side) has been shown to have low instances of RLNP
and hypoparathyroidism and is commonly and safely practised in
many centres.25,26
Surgeon experience
There is a small group of studies investigating surgeon’s experience
as a risk factor for RLNP. Sosa et al. concluded that surgeons with a
caseload of greater than 100 thyroid operations per year are at a
significantly reduced risk of complications and have shorter inpa-
tient hospital stays. It was observed that the experienced surgeons
were performing a far greater proportion of ‘complex’ procedures
(malignancy and re-operative surgery). It is postulated that the true
effect of surgeon experience may be somewhat diluted by lower
caseload hospitals/surgeons referring more complex cases to spe-
cialist centres.27 Dralle et al. reported RLNP rates of 0.72% for
surgeons performing greater than 45 NAR procedures per year com-
pared with 1.06% in those with less than 45 NAR per year (P =
0.003), with both groups having similar surgery types and pathol-
ogy.13 These findings are, however, refuted in other studies, where no
difference in RLNP incidence is seen when a supervised trainee
performs the operation.14,28–30 These data demonstrate that surgical
trainees can safely perform thyroidectomy under supervision, and
suggest that inexperienced surgeons with no specialty training may
have increased RLNP incidence. There is evidence suggesting that
surgeon training has a greater bearing on morbidity rates than
caseload, with surgeons having undergone thyroid-specific specialty
training based on provincial areas (with reduced caseload) being
found to have similar RLNP rates as those surgeons based in met-
ropolitan endocrine surgery units with similar training.31
© 2012 The Authors
ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons

Recurrent laryngeal nerve injury
Left versus right side
There are differences in the anatomy of the right and left RLN. The
left has a longer course, curving around ligamentum arteriosum at
the aortic arch and travels in the tracheo-oesophageal groove. The
right nerve rears around the subclavian artery and, as a consequence,
is normally anterolateral to the tracheo-oesophageal groove.8
Despite these differences, few studies report individual rates for
right and left RLN palsy. The Dionigi et al. study reported no domi-
nance of RLNP side32 and is supported by other studies.7,22 There
have been some reports implying the right nerve being injured more
regularly.33
Overall data confirm no difference in the laterality of nerve
injured. Within our series, excluding the two cases of bilateral
damage, of the remaining 51 RLNP, 24 involved the left RLN
(1.37% of 1742 NAR) and 27 the right RLN (1.35% of 1990 NAR).
There is no statistically significant difference in the laterality of
RLNP (P = 1.0).
Retrosternal goitre
Evidence regarding increased RLNP in primary retrosternal goitre
extension is scarce. It has been suggested that these patients may
have increased RLNP.13 However, evidence from a large case series
shows no increased risk of RLNP.34 It is well established that sec-
ondary surgery for retrosternal goitre carries increased risk.7,33
Within our data, 204 NAR were exposed in surgery for retrosternal
goitre, with one temporary and zero permanent RLNP. Given this
small incidence, it was deemed impossible to draw conclusions from
our data.
Graves’ disease
Historically, it has been suggested that surgery for Graves’ disease
carries increased RLNP risk; this is, however, refuted in several
studies, including ours where no significant difference in RLNP is
seen between any specific benign histological diagnoses.1,11,13
Intraoperative visualization and
dissection of the RLN
In the early 1900s, Lahey of Boston (1938) and Riddell of London
(1956) revolutionized thyroid surgery by advocating routine identi-
fication and dissection of the RLN.35 This method was not initially
endorsed, with early studies disputing the effect of routine identifi-
cation in protecting the RLN.36 There is now strong evidence advo-
cating routine intraoperative identification of the RLN.5,37,38 The
Jatzko et al. review incorporating 12 000 thyroid resections revealed
RLNP rates of 1.2% in cases where the nerve was identified versus
7.2% where it was not (P ⱕ 0.001).18 The study of Hermann et al.
including 27 000 NAR reported permanent RLNP rates of 0.4%
where the nerve was identified, as opposed to 1.1% where it was not
(P ⱕ 0.001).39 More contemporary studies are in keeping with this
finding.1,9,13,14,39 Dralle et al., in the large multi-centre, multivariate
study analysing close to 30 000 NAR, definitively identified visual
RLN identification and dissection as the gold standard for RLN
protection when comparing no nerve identification, visual identifi-
cation only and visual identification plus IONM.13
© 2012 The Authors
ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons
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17
Intraoperative identification and capsular dissection are crucial in
the preservation of the RLN. The final 2 cm of extralaryngeal RLN
where it is covered by the tubercle of Zuckerkandl and fascial layers
is a common anatomical site of injury.5,40,41 In this position, the RLN
is covered anterolaterally by a vascular fascial layer containing ter-
tiary branches of the inferior thyroid artery, and medially/posteriorly
sits on the true Berry’s ligament. Dissection of the RLN from these
two capsular layers is potentially the site of greatest traction on the
nerve, with sound anatomical understanding and careful dissection
important in preserving the RLN.41 Possible mechanisms of injury
include transection, clamping, ligation, traction, thermal injury (dia-
thermy) and ischaemia.42,43 Snyder et al. examined the mechanisms
of RLN injury and concluded that injury was more likely to occur in
visually intact nerves rather than accidental transection (which
accounts for approximately 0.3% of RLNP). It was concluded that
the majority of such injuries occur under traction, in the setting of an
anatomical variant such as extralaryngeal bifurcation, medial or
anterior displacement of the nerve, bifurcation of the nerve at the
inferior thyroid artery and non-recurrence. It was found that by far
the most common and troublesome variant was extralaryngeal bifur-
cation of the RLN and subsequent traction injury.44,45 The prospec-
tive trial of Sancho et al. noted extralaryngeal branching of the RLN
in 37.4% of nerves, with a mean branching distance from the larynx
of 21.5 mm. Transient vocal cord dysfunction was twice as common
in extralaryngeal-branched nerves (15.8% versus 8.1%, P = 0.022).46
The incidence and importance of this variant is confirmed in other
studies.8,47 We have recently demonstrated that the anterior branch of
an extralaryngeal bifurcated RLN carries the motor fibres for all
intrinsic laryngeal muscles.8 If unnoticed, this may lead to a poste-
rior branched limb of the nerve being considered the nerve in its
entirety, placing the anterior limb of the nerve at risk of injury.44,46,48
The role of IONM
In recent times, the use of IONM as an adjunct to RLN visual
identification and dissection has been safely applied and its efficacy
was analysed in reducing rates of RLNP in thyroid surgery.4,13,39 The
large multi-centre, prospective trial of Thomusch et al. reported
significantly lower rates of permanent and temporary RLNP in sub-
total resection for benign goitre using IONM and visual identifica-
tion compared with visualization alone.22 There is, however, little
support within the literature advocating the use of IONM to reduce
RLNP incidence. Several studies show a small reduction in RLNP
incidence using IONM, but fail to exhibit statistical significance
when compared with direct visualization alone.6,12,13,17,49–54 The one
published randomized control trial comparing IONM versus identi-
fication alone in bilateral thyroid surgery concluded that IONM
reduced rates of transient but not permanent palsies.55 The recent
meta-analysis by Higgins et al. analysed data from the 1 randomized
control trial, 7 comparative trials and 34 case series, including a total
of 64 699 NAR. No statistically significant difference in transient
(2.74% IONM versus 2.49% identification only; odds ratio (OR):
0.93, 95% confidence interval (CI): 0.76–1.12) or permanent RLNP
(0.75% IONM versus 0.58% identification only; OR: 0.50, 95% CI:
0.15–1.75) was reported.56

18
There are some instances where evidence for IONM use is
stronger, suggesting that it can aid in the identification of the nerve,
correlating with decreased complication rates.12,49,55,57 The large
International Intraoperative Monitoring Study Group strongly advo-
cate the use of IONM, applying its use to aid in the initial identifi-
cation, dissection and prognostication of post-operative function.58
Dralle et al. identified that surgeons undertaking a ‘low volume’ of
thyroid surgery benefitted from IONM in reducing RLNP rates when
compared with ‘high volume’ counterparts.35 The support for IONM
appears stronger when used in ‘high-risk’ procedures. This is par-
ticularly apparent in re-operative thyroid procedures and malignancy
surgery. In these instances, a trend for slightly reduced RLNP rates
is observed, although not to statistically significant levels in all
instances.12,13,17,45,59 The Yarbrough et al. study exclusively analysed
re-operative thyroid procedures and showed no difference in RLNP
rates between monitored and unmonitored groups.17 There is some
evidence suggesting that IONM may reduce palsy rates in Hashimo-
to’s and Graves’ disease.13
The use of IONM is yet to be universally supported by thyroid
surgeons, with a recent survey reporting regular usage rates of
approximately 20–40%.60 There is though a definite trend that sur-
geons will be more inclined to use IONM in ‘high-risk’ operations,
which may significantly alter the interpretation of results, particu-
larly in retrospective and non-randomized trials.6,12,60
Various studies have looked at the validity of IONM in accu-
rately detecting RLNP intraoperatively. Most studies conclude
that IONM can be reliably used to predict normal cord function
where nerve signal is intact and therefore has a high negative pre-
dictive value, on the order of 92–100%.4,14,61 This is particularly
the case when the identified nerve responds to less than 0.5 mA of
stimulation.62 Conversely, little information is gained when the
IONM signal is lost/absent. The outcomes for these patients are
extremely variable, with extremely poor positive predictive value
(reported ranges from 10% to 70%). Intraoperative loss of signal
may indicate nerve injury or incorrect electrode placement/
equipment failure; it is therefore strongly suggested that IONM
not be used as the sole method of RLN identification and
preservation.4,14,55,57,61,63
There is a lack of high-level evidence (i.e. level A, randomized
control trials) to elucidate the true RLN sparing effect of IONM.
This is partly due to the rarity of RLNP in specialized institutions
and additionally due to the reluctance of many centres to participate
in randomization.13,56 Because of the rarity of RLNP, it is calculated
that to achieve significant study power, recruitment of over 40 000
patients to each arm of randomized study focusing on thyroid cancer
would be required to unveil a true effect, and over 9 million patients
if examining benign disease.12,13,58 Another suggested limitation in
interpreting studies is the lack of a standardized approach to IONM
set-up and use.13 Chiang et al. constructed a standardized ‘four step’
IONM set-up procedure which when adhered to significantly
reduced IONM signal loss, confirming the importance of diligent
equipment set-up.4 Other studies have investigated nerve stimulation
with concurrent posterior cricoarytenoid palpation, reporting
encouraging results in predicting RLNP.64 This is, however, refuted
as having an unsatisfactorily high false-negative rate and is yet to be
confirmed as a useful adjunct.63
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Hayward et al.
Data from the Monash University/Alfred Hospital Endocrine
Surgery Unit in using IONM were analysed. Within the specified
time frame and including all histological diagnoses, a total of 2861
NAR were exposed when using IONM, compared with 875 NAR
without. Temporary RLNP occurred in 1.43% of NAR when using
IONM, compared with 0.68% without. The difference in these
RLNP rates is not statistically significant (P = 0.054). Permanent
RLNP occurred in 0.10% and 0.34% of NAR for groups using
IONM versus without IONM, respectively. The difference in these
rates also failed to reach statistical significance (P = 0.14). We
suspect that these results may be influenced by selection bias, with a
tendency to use IONM in more difficult cases. Our experience with
IONM is in keeping with the literature, with no significant difference
in RLNP rates when comparing thyroid surgery with the use of
IONM versus without IONM.
Perioperative evaluation of RLN function
RLN assessment is inadequate in the majority of large studies to
accurately detect and report RLNP.7,65 Preoperative assessment of
RLN function is becoming more commonly advocated to allow
greater accuracy in post-surgery reporting.43 Randolph and Kamani
recently reported 70% of all invasive thyroid disease and 0.3% of
benign disease having preoperative defective vocal cord opposi-
tion.64 Other studies reported one-third of all patients will have
some degree of preoperative vocal cord hypomobility on examina-
tion.66,67 In instances of preoperative cord deficit being caused by
benign goitre, it is reported that 89% will recover full function
after surgery.68 Pre-intubation laryngoscopy and subsequent assess-
ment has revealed that vocal fold injury can occur in approxi-
mately 30% of endotracheal intubations and 4% of post-operative
RLNP are attributable to intubation injury.69 Accurate preoperative
assessment and consideration of other causes of dysfunction
including hyperaemia related to gastro-oesophageal reflux,
Reinke’s oedema and chronic laryngitis is crucial to reporting true
surgical RLNP rates.66,70 It is widely accepted that clinical evalu-
ation of voice function is an unacceptable means of identifying
RLNP, particularly in unilateral lesions that commonly remain
asymptomatic.32,71
The assessment of RLN function may be performed in a variety of
ways, the most commonly used methods include indirect laryngos-
copy, FNE and videostroboscopy. The large systematic review of
Jeannon et al. reported significant differences in RLNP reporting
when comparing assessment modalities and advocated FNE to be
considered the ‘gold standard’ in diagnosing perioperative RLNP,
owing to superior visualization, being generally well tolerated and
widely available.2 FNE also permits the observer to electronically
record images, with retrospective analysis allowing diagnosis of
subtle palsies.71
Dionigi et al. evaluated the optimal time for post-operative naso-
laryngoscopy to accurately determine RLN dysfunction. Following
surgery patients were examined with FNE in post-operative recovery
(day 0), the day following surgery (day 1) and again at 2 weeks
following surgery (day 14). RLNP was identified in 6.4%, 6.7% and
4.8%, respectively for these time intervals. The difference between
day 0 and day 1 examination failed to reach statistical significance;
© 2012 The Authors
ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons

Recurrent laryngeal nerve injury
however, RLNP detection on day 14 was significantly reduced com-
pared with examination on post-operative day 0 or day 1. It is
therefore concluded that FNE assessment on day 0 or day 1 post-
thyroidectomy is the recommended time frame to detect the majority
of RLNP, including those mild lesions that require follow-up but
would not be detected on outpatient follow-up 2 weeks following
surgery.32 With this in mind, and due to practicality and patient
comfort, it is suggested that FNE examination on day 1 post-thyroid
surgery be adopted as a common practice. FNE pre- and post-thyroid
surgery is a useful audit tool, allowing immediate feedback and
therefore potentially enhancing surgical technique, which may lead
to better patient outcomes in the longer term.
There is considerable evidence that partial lesions commence the
healing process within the first few days post-operatively, with
normal nerve function present within a few weeks.32,72 There is,
however, considerable conjecture regarding the definition of ‘tran-
sient’ palsy. It is thought that two-thirds of transient palsies will
recover within 4 weeks.46 Dionigi et al. reported that 89% of all
partial palsies were resolved within 12 months.32 Several groups
support diagnosis of permanent RLNP after 12 months of serial
examination with ongoing dysfunction.7,32,56,63 However, Streuer
et al. reported RLN function restitution up to 2 years following
intraoperative injury.9
Conclusions
The literature and our data confirm that patients undergoing
re-operative thyroid surgery and thyroid surgery for cancer are at
increased risk of RLNP. There is no significant difference in later-
ality of nerve injured or in rates between histological diagnoses. The
literature suggests that extended resection and possibly low surgeon
caseload are also risk factors. Pre- and post-operative laryngoscopy
(optimally via FNE) is advocated for RLN assessment. Intraopera-
tive visualization and capsular dissection of the RLN is the gold
standard for intraoperative care during thyroid surgery for reducing
risk of RLNP. Abnormal traction forces leading to RLNP are fre-
quently the result of RLN anatomical variants, including extralaryn-
geal branching of the nerve. The benefit of IONM in aiming to
reduce RLNP for routine thyroid surgery is not well defined. IONM
should not be used as the sole mechanism for identifying and pre-
serving the nerve, although it can be used to aid in the identification
and dissection of the nerve, and may reduce risk of injury in ‘high-
risk’ cases including malignancy and re-operative surgery. If using
IONM, a standardized approach is recommended to reduce
equipment-related error. In the post-operative period, FNE assess-
ment within 24 h of surgery is advocated. Any post-operative RLNP
requires ongoing serial examination. It is reasonable to diagnose
permanent palsy following 12 months of RLN dysfunction.
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