Recurrent Laryngeal Nerve Monitoring and Decision-Making in Advanced Thyroid Cancer

Invasive thyroid cancers present diagnostic and therapeutic dilemmas for the thyroid surgeon. Thyroid cancer invasion of adjacent structures, including the recurrent laryngeal nerves, larynx, trachea, and esophagus, necessitate careful preoperative evaluation of imaging and development of a tailored surgical and overall treatment plan. This must take into account tumor biology, possibility of preoperative neoadjuvant or postoperative adjuvant therapies, survival prognosis, distant metastasis status, and quality of life issues which can be associated with potential surgery. Recurrent laryngeal nerve monitoring, whether intermittent or continuous, is a critical component of intraoperative management of advanced thyroid cancer. Nerve monitoring provides real-time information that optimizes the surgeon’s ability to both completely extirpate disease and maintain nerve function. The surgeon must be intimately familiar with the nerve monitoring system, a learned skill which comes from both an overall high volume thyroid surgery clinical practice, as well as the use of nerve monitoring for both less complex and advanced surgeries. Special consideration must be given to cases of preoperative true vocal fold dysfunction or intraoperative loss of signal, including the possibility of unilateral or staged thyroid surgery, dependent upon the clinical context.