2024 FSA Podium and Poster Abstracts

P045: BILATERAL VOCAL CORD PARALYSIS POST-TOTAL THYROIDECTOMY: THE IMPACT OF INTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING (IONM)
Joshua R Stanton, DO; Jonathan Nieves, MD; Lisa Tomasello, MD; HCA east Florida Westside Hospital Anesthesiology Residency Program

A 67-year-old female with a past medical history of hypertension, hyperlipidemia, and hyperthyroidism presented for surgery secondary to a multinodular goiter. A preoperative CT scan also showed mild tracheal deviation. The patient was brought to the operating room where standard ASA monitors were applied. Induction of general anesthesia was achieved with midazolam, fentanyl, lidocaine, Propofol, and succinylcholine. The patient was intubated non-traumatically via direct laryngoscopy. Of note, preoperatively the surgical team elected not to use Intraoperative neuro monitoring via a NIMs endotracheal tube. Upon completion of the surgery, the patient met the extubation criteria and was following commands. The patient was extubated with the surgical team in the room. The patient was placed on a simple face mask and brought to the post-anesthesia care unit. A mild strider was noted on arrival at PACU. Anesthesia was recalled to the patient’s bedside shortly thereafter to evaluate the patient’s respiratory pattern. On observation, the patient appeared to be using respiratory muscles and had stridorous upper respiratory sounds. The patient was given racemic epinephrine and labs were drawn to include an ABG which showed hypercarbia with a PC02 of 59. The surgeon was made aware of the situation and the decision was made to re-intubate before any further decompensation. The patient was given 80mg of Propofol and a video laryngoscopy was inserted showing bilateral adducted vocal cords. An endotracheal tube was successfully placed and the patient was transferred to the intensive care unit for further management.

This case report examines bilateral vocal cord paralysis post-total thyroidectomy and evaluates the impact of intraoperative neurophysiological monitoring (IONM) on preventing such injuries. Meta-analyses and clinical studies reveal IONM's significant reduction in recurrent laryngeal nerve injury incidence, preventive role in unilateral and bilateral thyroidectomy cases, and negligible effect on operative times, highlighting its crucial role in enhancing patient safety and surgical outcomes in thyroid surgery.