Comparison of a Handheld Device vs Endotracheal Tube–Based Neuromonitoring for Recurrent Laryngeal Nerve Stimulation

Abstract

Objective To measure the effect of thyroidectomy difficulty on intraoperative neuromonitoring false loss of signal (LOS) and to compare intraoperative endotracheal tube–based neuromonitoring (ETNM) and Checkpoint palpation-based direct stimulation (pDS) signals with postoperative laryngoscopy. We hypothesized that pDS has higher a positive predictive value for postdissection confirmation of recurrent laryngeal nerve function than ETNM and that this difference is accentuated with increasing thyroidectomy difficulty. Study Design Prospective single-arm cross-sectional study comparing ETNM and pDS for patients undergoing hemi-, total, or completion thyroidectomy from July 2018 to March 2020. Setting Single-surgeon series at a tertiary care hospital. Methods Percentage concordance and positive and negative predictive values were measured. Each thyroidectomy was assigned a validated thyroidectomy difficulty score, and recorded recurrent laryngeal nerve signals were compared with postoperative vocal fold mobility. Results Percentage concordance was 90.09%. Positive and negative predictive values were 0.19 (95% CI, 0.09-0.31) and 1.0 for ETNM and 0.59 (95% CI, 0.35-0.82) and 1.0 for pDS. The difference in positive predictive value was significant (0.40 [95% CI, 0.33-0.47], P < .001). False LOS rates for ETNM and pDS were 13.19% versus 3.30% (9.89% [95% CI, 1.80%-18.62%], P = .0155), 44.11% versus 0% (44.11% [95% CI, 25.80%-60.54%], P < .001), and 73.33% versus 13.33% (60% [95% CI, 24.76%-78.46%], P = .001) for the second through fourth thyroidectomy difficulty score quartiles, respectively. False LOS with ETNM was linearly correlated with increasing difficulty ( R2 = 0.97). Conclusion ETNM was subject to high rates of postdissection false LOS that increased with thyroidectomy difficulty score. pDS is a reliable alternative that has higher positive predictive value than ETNM, particularly in more challenging cases such as those with posteriorly fixed thyroid cancers and fibrotic glands. Evidence level 2.