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array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] ] ] "afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Comisión de Cabeza y Cuello y Base de Cráneo (SEORL CCC), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "SACYL.Complejo Asistencial de Zamora, Zamora, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Hospital de Torrevieja, Alicante, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Hospital Universitario Virgen Macarena, Sevilla, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Hospital Universitario de Móstoles, Móstoles, Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones sobre el uso de la neuromonitorización en cirugía de tiroides y paratiroides" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2358 "Ancho" => 2294 "Tamanyo" => 493896 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Recommendations on the use of neuromonitoring in thyroid and parathyroid surgery. Working method recommendations.</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">* The search was adapted to each of the data bases consulted.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">** Similar to other international surveys.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">17</span></a></p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Intraoperative neuromonitoring in thyroid and parathyroid surgery (TPTS) assesses the functional state of the laryngeal nerves (superior—SLN—and recurrent—RLN—) through the transformation into acoustic signal and electromiograph of the neuromuscular activity of the intrinsic muscles of the larynx after electric stimulus (directly or in the vagus nerve—VN—).</p><p id="par0010" class="elsevierStylePara elsevierViewall">In TPTS the IONM helps to identify the RLN in its dissection and predict possible laryngeal paralysis (LP) by providing information on its functional state on termination of surgery.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The laryngeal nerves may be injured through several mechanisms (sectioning, thermal mechanism, ligation, compression or traction).<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Thyroid surgery is associated with a relatively high proportion of changes in voice after surgery and a low prevalence of LP associated with variables such as the surgeon's experience or the performing of pre and postoperative laryngoscopy.<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">3,4</span></a> The prevalence of LP and voice changes in parathyroidectomy has been less reported since few specific studies exist on IONM in parathyroidectomy.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">IONM in TPTS has controversial aspects, especially due to the non significant reduction of LP or its cost and the confusion generated by the large number of publications concerning it.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In this regard, in 2016 the objective of the head and neck and skull base surgery commission was to design a document as guidance to the use of IONM in TPTS.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and Method</span><p id="par0035" class="elsevierStylePara elsevierViewall">The methodology of this study is summarised in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The group worked in 2 areas. One concerned the text document using bibliographical review and another consisted of 3 rounds of successive surveys with web forms (Google Forms) applying the Delphi method.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">6</span></a> The questions contained multiple choice answer options and open-ended questions. In each round all members of the group were anonymously made aware of the answers of the others. Consensus was established when over 50% of members reached a final agreement.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Document Limitations</span><p id="par0045" class="elsevierStylePara elsevierViewall">In general terms the text refers to thyroid surgery (although the concepts may be applied to parathyroidectomy), to RLN and to intermittent IONM—IONMi—(given the less widespread use of continuous IONM—IONMc—).</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">42 points of agreement were collected (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> in <a class="elsevierStyleCrossRef" href="#sec0090">Appendix A</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The high risk surgery criteria are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Seven sections were identified which were grouped into the topics discussed:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Indications</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0070" class="elsevierStylePara elsevierViewall">Team</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Technique, parameters of programming and registration</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0080" class="elsevierStylePara elsevierViewall">Signal loss behaviour</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0085" class="elsevierStylePara elsevierViewall">Laryngoscopy</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0090" class="elsevierStylePara elsevierViewall">Voice</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0095" class="elsevierStylePara elsevierViewall">Legal and ethical implications</p></li></ul></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Indications</span><p id="par0100" class="elsevierStylePara elsevierViewall">The use of the IONM is justified because it helps with visual identification of RLN, increasing the rate of identification,<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">7,8</span></a> facilitating dissection through successive checks,<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">1,3,4</span></a> with a high positive precision for assessing the functional status of the RLN at the end of surgery (99.26% overall precision, 78.38% positive predictive value and 99.85% negative predictive value),<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">1</span></a> guides decision making when there is a loss of signal,<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">4</span></a> may lower the rate of bilateral paralysis<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">9,10</span></a>—probably due to postponing the second lobectomy when the signal is lost in the first one in a elective total thyroidectomy (TT),<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">11</span></a>—may reduce the rate of transitory paralysisysis<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">12–15</span></a> (others do not find any difference<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">14,16</span></a>), increases the surgeon's confidence<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">17</span></a> and is useful for teaching.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">18</span></a> In contrast it has been argued that it does not reduce the rate of permanent paralysis<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">12,19,20</span></a> (in others it does<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">21</span></a>) and that it increases the cost.<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">22</span></a> The IONM has to be assessed not just with regards to the LP rate but from other viewpoints (financial, convenience, medical and legal, patient safety, teaching).<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">23</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">American Academy of Otolaryngology and Head and Neck Surgery</span> recommend carrying out IONM because it reduces the time in identifying RLN, the incidence of LP and helps to prevent bilateral LP.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">3</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Bilateral LP is rare<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">24</span></a> and it has been estimated that its incidence in patient series with IONM is lower than those in which only visual identification is made (2.43‰, 95% CI 1.55‰–3.5‰ and 5.18‰, 95% CI 2.53‰–8.7‰ respectively, with an absolute reduction of risk of 2.75‰, which suggests a necessary number of patients to treat of 364.13).<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">10</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In order to demonstrate a statistically significant reduction of the prevalence of paralysis with IONM compared with the single visual identification it would be necessary to carry out trials with over 150<span class="elsevierStyleHsp" style=""></span>000 nerves per arm.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">25</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">IONM is progressively included in the practice of TPTS<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">17</span></a> and preferably surgery where there is a high risk of paralysis, such as reinterventions,<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">17,26,27</span></a> cancer,<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">11,17,28</span></a> substernal extension,<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">11,17</span></a> in preoperative LP,<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">17,26,27</span></a> in Graves’ disease,<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">17</span></a> on patient request,<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">17</span></a> on patients with preoperative dysphonia,<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">17</span></a> in toxic nodular goitre,<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">17</span></a> in patients with a normal voice but who are referred with dysphonia,<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">17</span></a> in TT,<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">11</span></a> in central and lateral neck dissection,<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">11,17</span></a> if there was previous cervical surgery<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">11</span></a> and in thyroiditis.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">11</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">IONM work groups recommend its systemic use because it is not always possible to predict the degree of complexity in the preoperative period<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">1,4</span></a> and all the less so in bilateral surgery, in revision surgery and in cases of pre-existing paralysis.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">3</span></a></p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Intraoperative Neuromonitoring in Minimally Invasive Video Assisted Thyroidectomy</span><p id="par0130" class="elsevierStylePara elsevierViewall">Minimally invasive video assisted thyroidectomy was described by Miccoli in 1998, the most commonly endoscopic approach used being the treatment of modules under 4<span class="elsevierStyleHsp" style=""></span>cm due to their reproductibiltiy, outcome (cosmetic, less pain and postoperative recovery) and easy conversion to the open technique.<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">29</span></a> Despite the limited space of the approach (incision between 1.5 and 2<span class="elsevierStyleHsp" style=""></span>cm), the complexity of IONM was increased, since the stimulation probe was comfortably inserted and easily controlled through endoscopic imaging.<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">30</span></a> Although few studies exist on IONM in minimally invasive video assisted thyroidectomy, its use does not appear to affect rates of LP (transient or permanent), although it does reduce the time used in the search and dissection of the RLN.<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">31</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The technique is no different from that applied in open surgery. Electrodes are used, the surfaces of which are attached to the endotracheal tube (ETT). The thyroid lobe is laterally dissected and the middle thyroid vein is ligated, this is medially retracted, the carotid sheath is identified and the VN is stimulated with a 2<span class="elsevierStyleHsp" style=""></span>mA current directly or through the sheath to obtain a signal (V1) which verifies the functioning of the nerve. Dissection is continued and once the oesophageal tracheal furrow is reached, stimulation is made with 1<span class="elsevierStyleHsp" style=""></span>mA until the RLN has been located with obtainment of response (R1). Once the hemithyroid is resected, RLN and VN are stimulated using the same intensity as at the beginning of surgery, obtaining the corresponding electric responses (R2 and V2), which will help to verify nerve functioning.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Intraoperative Neuromonitoring in Thyroid Surgery Using Remote Approaches</span><p id="par0140" class="elsevierStylePara elsevierViewall">The knowledge and outcome from open thyroid surgery are not directly transferable to these approaches. Dissection of the gland is technically similar, but there are relevant differences in approach and instruments used. The current standard of endoscopy is the high definition image which may also be 3D (routine in robotics). This may minimise the risk on enabling better identification of structures. Advanced cutting and coagulation systems are also essential and systematically used. In the most widespread published series, of over 1000 patients intervened using robotic BABA—<span class="elsevierStyleItalic">Bilateral Axillo-Breast Approach</span>—, 2 cases of permanent LP were reported (.2%).<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">32</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The most common option is to use ETT surface electrodes.<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">33</span></a> According to the instrumentation and configuration of each operating theatre it is common to rotate the operating Table 180°. In underarm approaches the ipsilateral arm must be raised, and in all cases a wide subcutaneous breast dissection is made. In approaches without gas a large partition is also present. For all of these reasons there is a high risk of ETT movement, which should be appropriately fixed due to the risk of accidental extubation and poor positioning of the electrodes.</p><p id="par0150" class="elsevierStylePara elsevierViewall">There are no technical limitations for the use of IONM in thyroid surgery using remote approaches (RATS). There are long stimulation probes (up to 230<span class="elsevierStyleHsp" style=""></span>mm) which resolve the problem of distance up to the thyroid site.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Extensive literature already exists relating to RATS and there are several studies specifically aimed at IONM. Although in some initial publications there were no significant differences in the incidence of recurrent palsy in comparative studies,<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">34</span></a> posterior series referred to comparable results.<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">35</span></a> Lee et al. carried out a random prospective study in a group of 50 patients with papillary carcinoma of the thyroid using the robotic BABA approach, with and without IONM<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">36</span></a> and described a zero rate of recurrent paralysis and an absence of differences in the vocal analysis except a faster recovery of the vocal range in the monitored group. Another study refers to the monitoring of the external branch of the SLN, and showed its clinical viability in BABA.<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">37</span></a> Another laboratory study showed 2 cases of the use of the automatic usage of periodic stimulation of the vagus nerve in the transaxillary approach.<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">38</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">To sum up, the IONM in the CTAA is probably a measure of appropriate safety for surgery which is technically complex and which is forced to maintain very demanding safety standards.</p><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations from the work group</span>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0170" class="elsevierStylePara elsevierViewall">It is always recommended that IONMi be performed in thyroidectomy.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0175" class="elsevierStylePara elsevierViewall">In parathyroidectomy, the use of IONMi is recommended in cases considered to be high risk (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p></li></ul></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Equipment</span><p id="par0180" class="elsevierStylePara elsevierViewall">The basic elements of the IONM system are the monitor (where the stimulation and registration parameters are programmed), the connection box, the ground and return electrodes, the stimulation electrode, (intermittent—monopolar, bipolar—or continuation; fine tip or spherical tip), the registration electrodes (with surface attached to the ETT which have already been configured by the manufacturer or adhesives), the needle electrodes inserted into the thyroarytenoid muscles through the cricothyroid membrane—transligamentary—and others—endolaryngeal needle inserted through direct laryngoscopy or endolaryngeal electrodes in contact with the retrocricoid area.<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">4,39,40</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">The 2 most commonly used techniques and those referred to in the literature are the ones using surface electrodes in ETT and the transligamentary membrane.</p><p id="par0190" class="elsevierStylePara elsevierViewall">The transligamentary technique is useful when there is a signature failure with ETT, when surgery is unpredictably complex where IONM was unplanned with a risk involved in ETT exchange, in tracheal stenosis with no possibility of using ETT and in patients who have or who need tracheotomy.</p><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations from the work group</span>:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0200" class="elsevierStylePara elsevierViewall">The availability of neuromonitorisation equipment in the ENT services is considered necessary.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0205" class="elsevierStylePara elsevierViewall">The equipment must include:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">∘</span><p id="par0210" class="elsevierStylePara elsevierViewall">The possibility of configuring the stimulus and registration parameters.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">∘</span><p id="par0215" class="elsevierStylePara elsevierViewall">The capacity for information storage and reproduction.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">∘</span><p id="par0220" class="elsevierStylePara elsevierViewall">Automatic assessment of location and impedance of recording electrodes.</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">•</span><p id="par0225" class="elsevierStylePara elsevierViewall">A recording electrode with the surface attached to the ETT is recommended.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">•</span><p id="par0230" class="elsevierStylePara elsevierViewall">Sharp or spherical tip stimulation electrodes may be used depending on the surgeon's preference.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">•</span><p id="par0235" class="elsevierStylePara elsevierViewall">Monopolar stimulation electrodes are recommended.</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Technique, Programming and Registration Parameters<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">4</span></a></span><p id="par0240" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarises the data which have to be recorded in the IONM.<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">3,4,41</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0245" class="elsevierStylePara elsevierViewall">IONM<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">4,42,43</span></a> sequence:</p><p id="par0250" class="elsevierStylePara elsevierViewall">1. During induction of anaesthesia and intubation:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">a.</span><p id="par0255" class="elsevierStylePara elsevierViewall">Intubation with ETT with surface electrodes. Collaboration with anaestheology is important. The ETT diameter should be as large as possible with the electrodes positioned in the glottis area in contact with the vocal folds avoiding substances which make contact difficult (lubricants, saliva). Prevent the electrode of the ETT from twisting or getting trapped.</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">b.</span><p id="par0260" class="elsevierStylePara elsevierViewall">IONM equipment switched on.</p></li></ul></p><p id="par0265" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">i.</span><p id="par0270" class="elsevierStylePara elsevierViewall">Select thyroid screen.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">ii.</span><p id="par0275" class="elsevierStylePara elsevierViewall">Configure the stimulation and registration parameters:</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">iii.</span><p id="par0280" class="elsevierStylePara elsevierViewall">Stimulus of 0.5–3<span class="elsevierStyleHsp" style=""></span>mA (1<span class="elsevierStyleHsp" style=""></span>mA is recommended, with posterior adjustment).</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">iv.</span><p id="par0285" class="elsevierStylePara elsevierViewall">Registration threshold ≥100<span class="elsevierStyleHsp" style=""></span>μV.</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">v.</span><p id="par0290" class="elsevierStylePara elsevierViewall">Electrode impedance ≤5<span class="elsevierStyleHsp" style=""></span>kΩ with a difference between both sides of <1<span class="elsevierStyleHsp" style=""></span>kΩ.<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">vi.</span><p id="par0295" class="elsevierStylePara elsevierViewall">Other parameters (with advanced configuration): volume of the sound, tone of warning, voice, maximum spread, visualisation of transitory events, latency view, detection of artefacts, monopolar or bipolar stimulation, period of rejection of artefacts of the actual electrical impulse (usually 1.2<span class="elsevierStyleHsp" style=""></span>ms) and duration of stimulus (the most common configuration in IONMi is monopolar with frequency of 4 pulses and impulse duration of 100<span class="elsevierStyleHsp" style=""></span>s<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">43</span></a>). For safety reasons, a warning must be configured when a stimulus of 3<span class="elsevierStyleHsp" style=""></span>mA is reached.</p></li></ul></p><p id="par0300" class="elsevierStylePara elsevierViewall">2. After intubation:<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">a.</span><p id="par0305" class="elsevierStylePara elsevierViewall">Positioning of the patient. The hyperextension of the neck may change the position of the tube displacing it up to 33<span class="elsevierStyleHsp" style=""></span>mm and electrode impedance must therefore be confirmed. Respiratory variations of the base line (30–70<span class="elsevierStyleHsp" style=""></span>μV indicate good positioning).</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">b.</span><p id="par0310" class="elsevierStylePara elsevierViewall">Positioning of the earth electrodes (green, more remote positioning) and stimulus return (red, next to the larynx).</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">c.</span><p id="par0315" class="elsevierStylePara elsevierViewall">Connection of the electrodes to the connection box (earth, return and ETT) and to monitor.</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">d.</span><p id="par0320" class="elsevierStylePara elsevierViewall">Confirmation of the electrode impedance ≤5<span class="elsevierStyleHsp" style=""></span>kΩ which indicates how the system works.</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">e.</span><p id="par0325" class="elsevierStylePara elsevierViewall">Keep a distance from the electric systems, place filter in the electrical scalpel wires.</p></li></ul></p><p id="par0330" class="elsevierStylePara elsevierViewall">3. In the surgical field at the start of the intervention:<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">a.</span><p id="par0335" class="elsevierStylePara elsevierViewall">Connection of the stimulation electrode to the connection box.</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">b.</span><p id="par0340" class="elsevierStylePara elsevierViewall">Confirmation of the system on the VN (V1). Check the degree of relaxation (recording of the level of blocking in the adductor muscle of the thumb).<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">43</span></a> Stimulation of the VN may be performed directly, on the carotid artery or on the angle between the carotid and jugular vein without having to perform dissection through a small pouch in the fascia, with a supraliminal stimulus of up to 3<span class="elsevierStyleHsp" style=""></span>mA with a spherical tip stimulation probe of 2.3<span class="elsevierStyleHsp" style=""></span>mm which enables there to be pressure on the carotid, jugular or VN without injuring them.<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">44</span></a> The recording has to be ≥100<span class="elsevierStyleHsp" style=""></span>μV<span class="elsevierStyleHsp" style=""></span> with dual-phase wave and throbbing sound.</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">c.</span><p id="par0345" class="elsevierStylePara elsevierViewall">Visual identification of the RLN (it is the standard pattern, preferably in relation to the inferior thyroid artery) and functional confirmation (register R1). Identification may be made in 3 reference points: in its emergence of the mediastinum, its relationship with the inferior thyroid artery or its relation with the Berry ligament. When there are doubts or difficulties the IONM helps in the location and identification of the RLN using successive confirmations (mapping).</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">d.</span><p id="par0350" class="elsevierStylePara elsevierViewall">Once lobectomy has been terminated, a functional confirmation of the RLN (R2 registration) is made.</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">e.</span><p id="par0355" class="elsevierStylePara elsevierViewall">Confirmation of the system with final stimulus on the VN (V2) which confirms the integrity of RLN function and differentiates lesion type 1 (segmentary, with distal signal in RLN and absence of proximal signal in VN) of type 2 (global, with absence of distal and proximal signal).<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">4,45</span></a> Final V2 confirmation increases the predictive value.</p></li></ul></p><p id="par0360" class="elsevierStylePara elsevierViewall">The parameters of the signal are summarised in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. Latency, width and duration would vary depending on the studies, nerve stimulated, the side, the disease and the method of registration.<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">26,41</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0365" class="elsevierStylePara elsevierViewall">Defects may occur in the signal which are analysed in the section called “signal loss behaviour” (absence, loss or reduction of intensity or increase of latency) or excess signal.</p><p id="par0370" class="elsevierStylePara elsevierViewall">Excess signal is a false positive which may be due to a stimulus made on a nerve or vessel bridge, on the trachea, to interferences (electric, bipolar scalpel) or that the ETT has moved with respiratory movements, where the registration was not dualphased, had no relationship with the stimulus applied and lacked latency.<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">46</span></a> The correct signal may be obtained by lowering the stimulus to 0.8<span class="elsevierStyleHsp" style=""></span>mA or increasing the threshold (up to 200<span class="elsevierStyleHsp" style=""></span>μV).</p><p id="par0375" class="elsevierStylePara elsevierViewall">Signal losses may occur without LP (false positive, see the section on “signal loss behaviour”) and signal with LP (false negative) recordings.</p><p id="par0380" class="elsevierStylePara elsevierViewall">Possible causes of false negative are:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">•</span><p id="par0385" class="elsevierStylePara elsevierViewall">Type 1 lesion (segmentary) or the RLN in which distal stimulus is obtained without there being a V2 signal.</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">•</span><p id="par0390" class="elsevierStylePara elsevierViewall">Damage resulting after the last stimulus (in IONMi).</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">•</span><p id="par0395" class="elsevierStylePara elsevierViewall">Delayed neuroapraxia.</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">•</span><p id="par0400" class="elsevierStylePara elsevierViewall">Damage caused by the ETT in posterior branches of the RLN which lead to the interarytenoid vein.</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">•</span><p id="par0405" class="elsevierStylePara elsevierViewall">Vocal immobility due to non neuromuscular causes.</p></li></ul></p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Precision of the Test</span><p id="par0410" class="elsevierStylePara elsevierViewall">IONM precision depends on technical aspects (stimulation and registration parameters, type of reference electrode, point of stimulation application—directly on the nerve or near it—, nerve stimulated—RLN, SLN, VN—type of stimulus—intermittent or continues—), the execution of the technique (visual identification of the RLN, obtainment of V1 and V2 references, sequence of references), of the experience in performing IONM (correct interpretation of the signal) and laryngoscopy (performing or not performing laryngoscopy and whether when performing it the detection of transient preoperative and postoperative paralysis increases).<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">47,48</span></a></p><p id="par0415" class="elsevierStylePara elsevierViewall">Obtainment of a V1 and V2 signal increases the precision of the IONMi, particularly in loss of signal due to lesion type 1 or in the case of the non recurrent inferior laryngeal nerve. Non recurrent inferior laryngeal nerve is more common on the right side (up to 3.6%), exceptional on the left side (.04%); IONM helps to correctly differentiate the motor branches of the sympathetic trunk fascicles,<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">49</span></a> and using proximal stimulation on the VN (obtainment of the signal) and distal nerve (absences of the signal), allowing for the intraoperative establishment of the presence of the non recurrent inferior laryngeal nerve.<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">50</span></a></p><p id="par0420" class="elsevierStylePara elsevierViewall">The function of the SLN through IONMi is based on palpation of the cricothyroid muscle with a twitch present in all patients and in the electromiographical recording by glottis contraction present in 70%–80% of patients (anastomosis with RLN through Galen's anastomosis).<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">51</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Continuous Intraoperative Neuromonitoring<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">28,52–55</span></a></span><p id="par0425" class="elsevierStylePara elsevierViewall">Perhaps its best name would be IONM with “repetitive stimulation in pulses” since stimulation is not actually continuous.<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">56</span></a></p><p id="par0430" class="elsevierStylePara elsevierViewall">The stimulation electrodes applied to the VN may be open (S Shaped, Anchor or V3), semi-closed (Delta or Saxophone) or closed (APS—automated periodic stimulation—).<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">56</span></a></p><p id="par0435" class="elsevierStylePara elsevierViewall">Reference threshold programming recommended is of 100<span class="elsevierStyleHsp" style=""></span>μV and stimulus of 1<span class="elsevierStyleHsp" style=""></span>mA with 10 stimuli of 100<span class="elsevierStyleHsp" style=""></span>ms duration.<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">55</span></a></p><p id="par0440" class="elsevierStylePara elsevierViewall">It is possible that the IONMi will not detect a lesion of the RLN between one stimulation and another<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">28</span></a> with the result that the main advantage of IONMc is surveillance of RLN function in real time during mobilisation and dissection of the gland detecting events which may lead to an injury, helping the surgeon prevent or correct risk manoeuvres (traction, heat).<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">28,53,54</span></a> Latency and amplitude are monitored and the events are classified into mild (reduction of breadth by 50%–70% and rise in latency of 5%–10%), severe (reduction of breadth>70% and increase of latency>10%) and loss of the signal when a response of <100<span class="elsevierStyleHsp" style=""></span>μV<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">28,53</span></a> is obtained.</p><p id="par0445" class="elsevierStylePara elsevierViewall">The IONMc leads to the recognition of dysfunction which occurs during the RLN traction and modifies the said manoeuvres to prevent the loss of the signal, and help to identify the functional recovery of the nerve which occurs when ≥50% of baseline breadth is restored. We therefore recommend postponing the second lobectomy if this recovery has not taken place in the first side operated on in an electiveTT.<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">56</span></a></p><p id="par0450" class="elsevierStylePara elsevierViewall">IONMc precision is 99.5% in the prediction of the functional status of the RLN and is therefore useful in decision making during surgery and to prevent its injury.<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">54</span></a></p><p id="par0455" class="elsevierStylePara elsevierViewall">Recommendations by the work group:<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">•</span><p id="par0460" class="elsevierStylePara elsevierViewall">RLN identification must be performed visually.</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">•</span><p id="par0465" class="elsevierStylePara elsevierViewall">At the very least the RLN must be monitored.</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">•</span><p id="par0470" class="elsevierStylePara elsevierViewall">Stimulation on the RLN in IONMi must be performed at the beginning and end in all cases (R1-R2).</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">•</span><p id="par0475" class="elsevierStylePara elsevierViewall">Stimulation on the VN in IONMi must be performed at the beginning and end in all cases (V1-V2).</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">•</span><p id="par0480" class="elsevierStylePara elsevierViewall">Registration of the superior layngeal nerve is not considered essential at the beginning (S1) and at the end (S2).</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">•</span><p id="par0485" class="elsevierStylePara elsevierViewall">If visual identification of the RLN is impossible, functional identification is considered valid using IONM (R-V)</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">•</span><p id="par0490" class="elsevierStylePara elsevierViewall">IONMc is considered useful in thyroid surgery in cancer with suspicion of extrathyroid extension, reinterventions or neck dissection.</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">•</span><p id="par0495" class="elsevierStylePara elsevierViewall">IONMc is considered useful in parathyroid surgery associated with the above mentioned thyroid surgery and in reinterventions.</p></li></ul></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Guidelines for Loss of Signal</span><p id="par0500" class="elsevierStylePara elsevierViewall">Signal loss is considered to have occurred when after stimulus<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">4</span></a>:<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">•</span><p id="par0505" class="elsevierStylePara elsevierViewall">There is no signal.</p></li><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">•</span><p id="par0510" class="elsevierStylePara elsevierViewall">The signal is <100<span class="elsevierStyleHsp" style=""></span>μV with stimuli of 1 to 2<span class="elsevierStyleHsp" style=""></span>mA (up to 3<span class="elsevierStyleHsp" style=""></span>mA on the VN).</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">•</span><p id="par0515" class="elsevierStylePara elsevierViewall">Checks are made with the area dry.</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">•</span><p id="par0520" class="elsevierStylePara elsevierViewall">There is no twitch.</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">•</span><p id="par0525" class="elsevierStylePara elsevierViewall">There is no laryngeal contraction using laryngoscopy.</p></li></ul></p><p id="par0530" class="elsevierStylePara elsevierViewall">The possible causes of signal loss are:</p><p id="par0535" class="elsevierStylePara elsevierViewall">1. False positive:<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">•</span><p id="par0540" class="elsevierStylePara elsevierViewall">The most common is the maladjustment of the ETT (rotated or displaced distally or proximally) or that it is small in diameter.<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">57</span></a></p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">•</span><p id="par0545" class="elsevierStylePara elsevierViewall">Bad contact with the larynx due to saliva, blood or lubricant.</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">•</span><p id="par0550" class="elsevierStylePara elsevierViewall">Connection failure.<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">57</span></a></p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">•</span><p id="par0555" class="elsevierStylePara elsevierViewall">Badly programmed parameters (threshold too high, latency too short and initial artefact of the actual stimulus therefore recorded or stimulus insufficient for performance—optimum in mapping 2<span class="elsevierStyleHsp" style=""></span>mA and during dissection 1<span class="elsevierStyleHsp" style=""></span>mA—).</p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">•</span><p id="par0560" class="elsevierStylePara elsevierViewall">Low sound volume.</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">•</span><p id="par0565" class="elsevierStylePara elsevierViewall">Activity of muscle relaxant activity.<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">57</span></a></p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">•</span><p id="par0570" class="elsevierStylePara elsevierViewall">Deficiency of pseudocholinesterase (serum cholinesterase or type II).</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">•</span><p id="par0575" class="elsevierStylePara elsevierViewall">Bad contact of stimulation probe (blood, fascias).</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">•</span><p id="par0580" class="elsevierStylePara elsevierViewall">Malfunctioning of stimulation probe.</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">•</span><p id="par0585" class="elsevierStylePara elsevierViewall">Artefacts and interferences.</p></li><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">•</span><p id="par0590" class="elsevierStylePara elsevierViewall">Fatigue from repeated stimuli.</p></li></ul></p><p id="par0595" class="elsevierStylePara elsevierViewall">2. True positive:<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">•</span><p id="par0600" class="elsevierStylePara elsevierViewall">Lesion of stimulated nerve (type 1—localised—or type 2—diffuse—).<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">8</span></a></p></li></ul></p><p id="par0605" class="elsevierStylePara elsevierViewall">When signal is loss or the signal is <100<span class="elsevierStyleHsp" style=""></span>μV, we would recommend checking (verification list):<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0330"><p id="par0610" class="elsevierStylePara elsevierViewall">1st Position of the ETT (laryngoscopy).</p></li><li class="elsevierStyleListItem" id="lsti0335"><p id="par0615" class="elsevierStylePara elsevierViewall">2nd Contact of ETT, earth and return electrodes.</p></li><li class="elsevierStyleListItem" id="lsti0340"><p id="par0620" class="elsevierStylePara elsevierViewall">3rd Connections (box).</p></li><li class="elsevierStyleListItem" id="lsti0345"><p id="par0625" class="elsevierStylePara elsevierViewall">4th Programmed parameters in the monitor (threshold, latency, stimulus, volume).</p></li><li class="elsevierStyleListItem" id="lsti0350"><p id="par0630" class="elsevierStylePara elsevierViewall">5th Relaxation of the patient.</p></li><li class="elsevierStyleListItem" id="lsti0355"><p id="par0635" class="elsevierStylePara elsevierViewall">6th Stimulation probe (status, contact, well dried surgical site).</p></li><li class="elsevierStyleListItem" id="lsti0360"><p id="par0640" class="elsevierStylePara elsevierViewall">7th Contralateral V signal</p></li><li class="elsevierStyleListItem" id="lsti0365"><p id="par0645" class="elsevierStylePara elsevierViewall">8th Laryngoscopy with stimulation in RLN or VN.</p></li><li class="elsevierStyleListItem" id="lsti0370"><p id="par0650" class="elsevierStylePara elsevierViewall">9th Twitch with supraliminal stimuli (3–4<span class="elsevierStyleHsp" style=""></span>mA).</p></li></ul></p><p id="par0655" class="elsevierStylePara elsevierViewall">After anterior confirmations<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">9</span></a> on the first side of an elective TT we may wait for the signal to be restored after 20–30<span class="elsevierStyleHsp" style=""></span>min (fatigue, neuroapraxia, relaxants),<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">58</span></a> if there is recovery ≥0% of the signal (in IONMc) may be valued to continue with the second lobectomy or postpone it, and if paralysis has been confirmed on the contralateral side the IONM means that extuabation may be scheduled.<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">59</span></a></p><p id="par0660" class="elsevierStylePara elsevierViewall">The strategy in the case of signal loss in the first side or with previous contralateral paralysis may be summarised in the algorithm <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0665" class="elsevierStylePara elsevierViewall">Recommendations from the work group:<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">•</span><p id="par0670" class="elsevierStylePara elsevierViewall">If a neuromonitoring signal is not initially obtained after following the verification list it is recommended that the intervention be continued and that it be notified as a safety incident.</p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">•</span><p id="par0675" class="elsevierStylePara elsevierViewall">If there is a loss of signal in the first side in an elective TT it is recommended that the verification list be followed, if there continues not to be a signal, to postpone the second lobectomy.</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">•</span><p id="par0680" class="elsevierStylePara elsevierViewall">If the decision is to postpone the second lobectomy and it is verified in the postoperative period that there is PL we recommend that the second lobectomy be planned according to the diagnosis obtained in the first one, the diagnosis obtained in the second one, symptomatology, comorbidity, therapeutic alternatives and the patient's opinion.</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">•</span><p id="par0685" class="elsevierStylePara elsevierViewall">If a loss of signal occurs with the known contralateral LP, after having followed the verification list we would recommend to proceed with monitored laryngoscopy, reintubation when there are signs of laryngeal respiratory failure and tracheotomy when intubation is not possible.</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">•</span><p id="par0690" class="elsevierStylePara elsevierViewall">Immediate surgical treatment in the larynx in a LP is not recommended.</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Laryngoscopy</span><p id="par0695" class="elsevierStylePara elsevierViewall">Laryngoscopy should always be performed in the preoperative and postoperative period because the precision of the IONM will depend on the ability to detect the LP in the preoperative period (from 3.5% to 6.5% of patients with nodular goitre<a class="elsevierStyleCrossRefs" href="#bib0635"><span class="elsevierStyleSup">60,61</span></a>) and in the postoperative period (to detect transient paralysis and false negatives).<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">4,24,47,48</span></a> The detection of paralysis in studies with routine laryngoscopy duplicate those carried out for patients with voice disorders and probably both transient paralysis and permanent paralysis are being under diagnosed.<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">3,62</span></a></p><p id="par0700" class="elsevierStylePara elsevierViewall">In the preoperative period laryngoscopy would be performed when programming surgery and repeated when a voice problem arises prior to surgery.</p><p id="par0705" class="elsevierStylePara elsevierViewall">Postoperative laryngoscopy may be performed immediately after extubation (with flexible fibroscopy or AirTraq<span class="elsevierStyleSup">®</span>), in the medium term postoperative period (24–72<span class="elsevierStyleHsp" style=""></span>h), in the late postoperative period (>1 month) and during follow-up after LP or dysphonia (up to 9–12 months follow-up<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">63</span></a>).</p><p id="par0710" class="elsevierStylePara elsevierViewall">Flexible laryngoscopy is recommended due to easy execution, reproductibility and because video recording may be allowed<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">64</span></a> with greater performance compared to examining with a mirror.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">3</span></a> The video stroboscopy leads to a more detailed examination in patients with voice disorders or with LP.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">3</span></a> Video laryngeal troboscopy is the technique of choice for assessing a possible compromise of the external branch of the SLN.<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">65</span></a></p><p id="par0715" class="elsevierStylePara elsevierViewall">Recommendations from the work group:<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">•</span><p id="par0720" class="elsevierStylePara elsevierViewall">Laryngoscopy must always be performed before and after intervention.</p></li><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">•</span><p id="par0725" class="elsevierStylePara elsevierViewall">Flexible laryngoscopy is recommended.</p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">•</span><p id="par0730" class="elsevierStylePara elsevierViewall">Preoperative laryngoscopy must be performed when surgery is scheduled if there are doubts about the situation changing, or if dysphonia has occurred at any time prior to surgery.</p></li><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">•</span><p id="par0735" class="elsevierStylePara elsevierViewall">Immediate post-surgical laryngoscopy after extubation must be performed if there are signs of a suspicion of bilateral LP.</p></li><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">•</span><p id="par0740" class="elsevierStylePara elsevierViewall">In the case of unilateral LP must be performed every 8–12 weeks.</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">•</span><p id="par0745" class="elsevierStylePara elsevierViewall">Postoperative laryngoscopy in the medium postoperative period (24–72<span class="elsevierStyleHsp" style=""></span>h) should be performed if the patient presents with dysphonia.</p></li><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">•</span><p id="par0750" class="elsevierStylePara elsevierViewall">Postoperative laryngoscopy in the latepostoperative period (4–6 weeks) should always be performed.</p></li><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">•</span><p id="par0755" class="elsevierStylePara elsevierViewall">Video documentation of the laryngoscopy exploration is recommended.</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Voice</span><p id="par0760" class="elsevierStylePara elsevierViewall">The prevalence of voice disorders in the general population is approximately 7.5%. 80% of patients present with a higher or lower degree of dysphonia after thyroidectomy and up to 4% may have persistent voice problems.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">3</span></a></p><p id="par0765" class="elsevierStylePara elsevierViewall">Phonation disorders after thyroidectomy may be due to injury of the laryngeal nerves, trauma during intubation and extubation, dysfunction of cricothyroid articulation, dysfunction of the extrinsic laryngeal muscles, laryngeal tracheal fixation or psychological reaction to surgical intervention.<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">66</span></a></p><p id="par0770" class="elsevierStylePara elsevierViewall">The majority of studies refer to the identification and function of the RLN and it has not been demonstrated that identification and IONM of the external branch of the SLN reduce the rate of injury.<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">65</span></a></p><p id="par0775" class="elsevierStylePara elsevierViewall">We recommend assessing the voice preoperatively, taking precautions for protection of the SLN during surgery (identification, obtainment of the IONM signal and twitch)<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">66</span></a> and recording whether there was a change in the voice between 2 weeks and 2 months after surgery.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">3</span></a></p><p id="par0780" class="elsevierStylePara elsevierViewall">In the preoperative and postoperative period the patient should be asked if they have noticed any changes in their tone of voice, the volume, quality or resistance of it<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">3</span></a> which may be documented using the <span class="elsevierStyleItalic">Voice Handicap Index</span> adapted into Spanish<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">67</span></a> or other tools (V-RQOL, GRBAS or CAPE-V).<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">3</span></a></p><p id="par0785" class="elsevierStylePara elsevierViewall">Recommendations from the work group:<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">•</span><p id="par0790" class="elsevierStylePara elsevierViewall">The patient should be asked if they had voice problems both pre and postoperatively.</p></li><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">•</span><p id="par0795" class="elsevierStylePara elsevierViewall">A pre and postoperative voice study is recommended.</p></li><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">•</span><p id="par0800" class="elsevierStylePara elsevierViewall">A voice questionnaire before and after surgery may be used.</p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Legal and Ethical Implications<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">45,66</span></a></span><p id="par0805" class="elsevierStylePara elsevierViewall">Attention should be focused on 2 aspects:<ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">1.</span><p id="par0810" class="elsevierStylePara elsevierViewall">Information and informed consent. Information on individual risks of injury or temporary or permanent dysfunction of the RLN and SLN, unilateral, bilateral or combined and its consequences on the respiratory pathway (blockage, tracheotomy), voice and swallowing. The patient must be informed on whether IONM will be used or not and in the case of non use, the reasons for this<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">66</span></a> If selective use is made of IONM the patient must be informed (i.e. “if it is presumed that the neuromonitor is effective for complex cases, the surgeon must be capable of saying why it is not used in all cases”).<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">66</span></a> The patient must be informed that situations of paralysis risk are unpredictable during the preoperative period.<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">45</span></a></p></li><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">2.</span><p id="par0815" class="elsevierStylePara elsevierViewall">Information on the limitations and usefulness of IONM. That its use is no guarantee of preventing nerve damage, LP from other causes or dysphonia without nerve injury (anatomical integrity of the nerves does not have to be associated with normal function). As with all technology using devices false negatives or false positives may arise where the results affect other variables such as anaesthesia or technical assistance.<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">66</span></a> The patients should be informed about the real use of IONM which is merely technical (helping to identify nerves during dissection, for taking decisions during surgery on the functional status of the RLN, and eventually on the SLN, on termination of surgery). Information should be given on the possibility of postponing the second lobectomy in an elective TT if the signal is lost in the first side operated on, to prevent potential bilateral paralysis.<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">45,66</span></a></p></li></ul></p><p id="par0820" class="elsevierStylePara elsevierViewall">Recommendations from the work group:<ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">•</span><p id="par0825" class="elsevierStylePara elsevierViewall">Information on the results of the neuromonitoring should be included in the patient's clinical record.</p></li><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">•</span><p id="par0830" class="elsevierStylePara elsevierViewall">If a survey is made no opinion should be given on the need for neuromonitoring because there are no conclusive results in the literature.</p></li><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">•</span><p id="par0835" class="elsevierStylePara elsevierViewall">The patient must be informed that problems may arise with their voice after thyrodectomy, even though there is no laryngeal paralysis.</p></li><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">•</span><p id="par0840" class="elsevierStylePara elsevierViewall">The patient must be informed of the possibility that, if there is a loss of signal in the first side, the second lobectomy may need to be postponed.</p></li></ul></p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusions</span><p id="par0845" class="elsevierStylePara elsevierViewall">Laryngeal or voice motility after TPTS depends on variables such as the technique used or the technology applied.</p><p id="par0850" class="elsevierStylePara elsevierViewall">IONMi helps in the location and identification of RLN, during its dissection and provides information on its functional status on termination of surgery.</p><p id="par0855" class="elsevierStylePara elsevierViewall">IONM precision depends on variables such as the technique used, the technology used and the training for correct execution and interpretation of the signal. The degree of difficulty is not always predictable and may arise during surgery. For this reason training is required so that the appropriate technique may be carried out and interpretation of the signal may be made in any situation, even in complex cases.</p><p id="par0860" class="elsevierStylePara elsevierViewall">Obtaining registration using final V2 stimulus increases precision.</p><p id="par0865" class="elsevierStylePara elsevierViewall">Due to its precisions, both IONMi and IONMc make it easier to take decisions when there is loss of signal in the first side operated on or when extubation is planned if there was previous contralateral paralysis.</p><p id="par0870" class="elsevierStylePara elsevierViewall">IONM helps to reduce the rate of bilateral LP, increasing patient safety.</p><p id="par0875" class="elsevierStylePara elsevierViewall">IONM may help to reduce the rate of transient LP.</p><p id="par0880" class="elsevierStylePara elsevierViewall">IONMi must be performed in all thyrodectomies and in high risk parathyroidectomies.</p><p id="par0885" class="elsevierStylePara elsevierViewall">IONMc has a higher capacity to predict nerve injury under circumstances with increased latency or a reduction of the breadth of the signal and may be useful in high risk surgery.</p><p id="par0890" class="elsevierStylePara elsevierViewall">IONM increases the surgeon's confidence during surgery.</p><p id="par0895" class="elsevierStylePara elsevierViewall">IONM is useful for teaching and helps in continuous professional training, identifying variants in anatomical pathways of the laryngeal nerves.</p><p id="par0900" class="elsevierStylePara elsevierViewall">IONM facilitates the recording of data for research.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflict of Interests</span><p id="par0905" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1063370" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1011607" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1063371" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Método" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1011608" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and Method" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Document Limitations" ] ] ] 6 => array:3 [ "identificador" => "sec0020" "titulo" => "Results" "secciones" => array:7 [ 0 => array:3 [ "identificador" => "sec0025" "titulo" => "Indications" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Intraoperative Neuromonitoring in Minimally Invasive Video Assisted Thyroidectomy" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Intraoperative Neuromonitoring in Thyroid Surgery Using Remote Approaches" ] ] ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Equipment" ] 2 => array:3 [ "identificador" => "sec0045" "titulo" => "Technique, Programming and Registration Parameters" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Precision of the Test" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Continuous Intraoperative Neuromonitoring" ] ] ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Guidelines for Loss of Signal" ] 4 => array:2 [ "identificador" => "sec0065" "titulo" => "Laryngoscopy" ] 5 => array:2 [ "identificador" => "sec0070" "titulo" => "Voice" ] 6 => array:2 [ "identificador" => "sec0075" "titulo" => "Legal and Ethical Implications" ] ] ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflict of Interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-06-04" "fechaAceptado" => "2017-06-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1011607" "palabras" => array:11 [ 0 => "Thyroidectomy" 1 => "Parathyroidectomy" 2 => "Neuromonitoring" 3 => "Recurrent laryngeal nerve" 4 => "Electromyography" 5 => "Patient safety" 6 => "Guidelines" 7 => "Larynx" 8 => "Voice" 9 => "Thyroid" 10 => "Parathyroid" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1011608" "palabras" => array:11 [ 0 => "Tiroidectomía" 1 => "Paratiroidectomía" 2 => "Neuromonitorización" 3 => "Nervio laríngeo recurrente" 4 => "Electromiografía" 5 => "Seguridad del paciente" 6 => "Guía de práctica clínica" 7 => "Laringe" 8 => "Voz" 9 => "Tiroides" 10 => "Paratiroides" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Thyroid and parathyroid surgery (TPTS) is associated with risk of injury to the recurrent laryngeal nerve, superior laryngeal nerve and voice changes. Intraoperative neuromonitoring (IONM), intermittent or continuous, evaluates the functional state of the laryngeal nerves and is being increasingly used. This means that points of consensus on the most controversial aspects are necessary.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To develop a support document for guidance on the use of IONM in TPTS.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Method</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Work group consensus through systematic review and the Delphi method.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Seven sections were identified on which points of consensus were identified: indications, equipment, technique (programming and registration parameters), behaviour on loss of signal, laryngoscopy, voice and legal implications.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">IONM helps in the location and identification of the recurrent laryngeal nerve, helps during its dissection, reports on its functional status at the end of surgery and enables decision-making in the event of loss of signal in the first operated side in a scheduled bilateral thyroidectomy or previous contralateral paralysis. The accuracy of IONM depends on variables such as accomplished technique, technology and training in the correct execution of the technique and interpretation of the signal. This document is a starting point for future agreements on TPTS in each of the sections of consensus.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducción</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La cirugía de tiroides y paratiroides (CTPT) se asocia a riesgo de lesión del nervio laríngeo recurrente, nervio laríngeo superior y cambios en la voz. La neuromonitorización intraoperatoria (NMIO), intermitente o continua, en CTPT evalúa el estado funcional de los nervios laríngeos y se utiliza progresivamente con más frecuencia. Esto obliga a adoptar puntos de acuerdo en los aspectos más controvertidos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Elaborar un documento de ayuda para orientar en la utilización de la NMIO en CTPT.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Método</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Consenso en grupo de trabajo mediante revisión sistemática y método Delphi.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se identificaron 7 secciones sobre las que se establecieron puntos de acuerdo: indicaciones, equipo, técnica (parámetros de programación y registro), conducta en pérdida de señal, laringoscopia, voz e implicaciones legales.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La NMIO ayuda en la localización e identificación del nervio laríngeo recurrente, ayuda durante su disección, informa sobre su estado funcional al finalizar la cirugía y permite tomar decisiones en caso de pérdida de señal en el primer lado operado en una tiroidectomía bilateral programada o si había parálisis contralateral previa. La precisión de la NMIO depende de variables como la técnica realizada, la tecnología utilizada y la formación para la correcta ejecución de la técnica e interpretación de la señal. El documento presentado es un punto de inicio para futuros acuerdos en CTPT en cada una de las secciones de consenso.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Método" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Pardal-Refoyo JL, Parente-Arias P, Arroyo-Domingo MM, Maza-Solano JM, Granell-Navarro J, Martínez-Salazar JM, et al. Recomendaciones sobre el uso de la neuromonitorización en cirugía de tiroides y paratiroides. Acta Otorrinolaringol Esp. 2018;69:231–242.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0915" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:</p> <p id="par0920" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0095" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2358 "Ancho" => 2294 "Tamanyo" => 493896 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Recommendations on the use of neuromonitoring in thyroid and parathyroid surgery. Working method recommendations.</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">* The search was adapted to each of the data bases consulted.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">** Similar to other international surveys.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">17</span></a></p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1660 "Ancho" => 3260 "Tamanyo" => 236351 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Recommendations on the use of neuromonitoring in thyroid and parathyroid surgery. Algorithm of decision in the case of loss of signal on the first side operated on in an elective total thryodectomy or in previous contralateral paralysis depending on laryngeal motility confirmed with laryngoscopy and neuromonitoring signal.</p> <p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">RF: Respiratory failure; S1: side one; S2: side two; p0L: preoperative laryngoscopy; pL1: postoperative laryngoscopy performed between the first and third day; pL2: postoperative laryngoscopy performed between the fourth and sixth week; pL3: successive postoperative laryngoscopies; IONM: intraoperative neuromonitoring; V2: neuromonitoring signal obtained by stimulating the vagus nerve after termination of lobectomy; IONM V1-V2 sequence obtained with initial V1 and final V2 vagus signal; V1-R1-R2-V2: sequence of IONM obtained in 4 steps (initial vagus, in recurrent laryngeal nerve and R1 and R2 and final vagus V2).</p> <p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">* Strong level of indication: when other therapeutic alternatives do not have such a high probability of cure as total thyroidectomy.</p> <p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">** Weak degree of indication: when other therapeutic alternatives have a similar probability of cure as total thyroidectomy.</p> <p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Taken and modified with the permission of Pardal-Refoyo et al.<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">59</span></a></p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">HBP: high blood pressure.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% Agreement \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">High risk in thyroid surgery</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Reintervention on the same side \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Advanced cancer, capsular rupture, infiltration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Goitre with endothorasic extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Large volume goitre \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Circumferential goitre \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Association with recurrent neck dissection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Association with lateral neck dissections (<span class="elsevierStyleSmallCaps">ii</span>, <span class="elsevierStyleSmallCaps">iii</span>, <span class="elsevierStyleSmallCaps">iv</span>, <span class="elsevierStyleSmallCaps">v</span>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span> Graves’ disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Thyroditis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Contralateral paralysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Associated comorbidity: HBP, obesity, cardiopathy, diabetes, anticoagulation, anti-aggregation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Any emergency surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Any member of the team inexpert (surgeon, instrumentalist, anaesthetist) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">High risk in parathyroid surgery</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Reintervention on the same side \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Negative location studies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Thyroid diseases associated with high risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Revision surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span> Bilateralexamination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Adenomas large in size \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Contralateral laryngeal paralysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Parathyroids which are difficult to locate intraoperatively (ectopias, intraglandular) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Associated comorbidity: HBP, obesity, cardiopathy, diabetes, anticoagulation, anti-aggregation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Any emergency surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Any member of the team inexpert (surgeon, instrumentalist, anaesthetist) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1812999.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Reproductibility Recommendations on the Use of Neuromonitoring in Thyroid and Parathyroid Surgery. Situations Considered by the Work Group to Induce High Risk of Laryngeal Paralysis in Thyroid and Parathyroid Surgery.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Lp: laryngoscopy; RLN: recurrent laryngeal nerve; SLN: superior laryngeal nerve; IONM: intraoperative neuromonitoring.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Information and informed consent document \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preoperative laryngoscopy (p0L) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preoperative voice assessment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vagus nerve stimulation prior to thyroid dissection (V1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RLN stimulation in initial identification (R1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RLN stimulation on termination of thyroid dissection and complete haemostasis (R2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SLN stimulation in identification (S1) (optional) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SLN stimulation in final dissection (S2) (optional) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stimulation of vagus nerve on termination of thyroidectomy and haemostasis (V2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Include the recording of the IONM in the patient's clinical history (recording of data and imaging for each side) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postoperative laryngoscopy (Lp1, Lp2, Lp3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postoperative voice assessment \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1813000.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Recommendations on the Use of Neuromonitoring in Thyroid and Parathyroid Surgery. Recommended References in Neuromonitoring.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">IONM: intraoperative neuromonitoring; RLN: recurrent laryngeal nerve; SLN: superior laryngeal nerve; VN: vagus nerve.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">VN \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RLN \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SLN \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Breadth (μV)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Both sides \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">750±279<span class="elsevierStyleHsp" style=""></span>μV<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1086±349<span class="elsevierStyleHsp" style=""></span>μV<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Right side \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">512<span class="elsevierStyleHsp" style=""></span>μV (168–1593)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">623<span class="elsevierStyleHsp" style=""></span>μV (207–1986)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Left side \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">460<span class="elsevierStyleHsp" style=""></span>μV (138–1241)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">719<span class="elsevierStyleHsp" style=""></span>μV (205–1767)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Latency (ms)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Both sides \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.96±0.69<span class="elsevierStyleHsp" style=""></span>ms<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.56±0.49<span class="elsevierStyleHsp" style=""></span>ms<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Right side \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.47±0.73<span class="elsevierStyleHsp" style=""></span>ms<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>3.91<span class="elsevierStyleHsp" style=""></span>ms (3.13–4.69)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.73<span class="elsevierStyleHsp" style=""></span>ms (1.95–3.91)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Left side \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.14±0.86<span class="elsevierStyleHsp" style=""></span>ms<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>5.90<span class="elsevierStyleHsp" style=""></span>ms (5–7.03)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.73<span class="elsevierStyleHsp" style=""></span>ms (1.95–3.91)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Duration (ms)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Right side \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.59<span class="elsevierStyleHsp" style=""></span>ms (6.64–11.72)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.42<span class="elsevierStyleHsp" style=""></span>ms (5.47–10.16)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Left side \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.38<span class="elsevierStyleHsp" style=""></span>ms (7.42–11.72)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.42<span class="elsevierStyleHsp" style=""></span>ms (5.47–9.77)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1812998.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Expressed as mean and its standard deviation. <span class="elsevierStyleItalic">Source</span>: Lorenz et al.<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">26</span></a></p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Expressed as median and its range (P10-P90). <span class="elsevierStyleItalic">Source</span>: Dionigi et al.<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">41</span></a></p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Recommendations on the Use of Neuromonitoring in Thyroid and Parathyroid Surgery. 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Review article
Recommendations on the Use of Neuromonitoring in Thyroid and Parathyroid Surgery
Recomendaciones sobre el uso de la neuromonitorización en cirugía de tiroides y paratiroides
José Luis Pardal-Refoyoa,b,
, Pablo Parente-Ariasa,c, Marta María Arroyo-Domingoa,d, Juan Manuel Maza-Solanoa,e, José Granell-Navarroa,f, Jesús María Martínez-Salazarg, Ramón Moreno-Lunaa,e, Elvylins Vargas-Yglesiasa,h
Autor para correspondencia
a Comisión de Cabeza y Cuello y Base de Cráneo (SEORL CCC), Spain
b SACYL.Complejo Asistencial de Zamora, Zamora, Spain
c Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
d Hospital de Torrevieja, Alicante, Spain
e Hospital Universitario Virgen Macarena, Sevilla, Spain
f Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
g Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain
h Hospital Universitario de Móstoles, Móstoles, Madrid, Spain