In Response to letter to the editor regarding International Neuromonitoring Study Group Guidelines 2018: Part II: Optimal Recurrent Laryngeal Nerve Management for Invasive Thyroid Cancer—Incorporation of Surgical, Laryngeal, and Neural Electrophysiologic Data

We would like to thank Dr. Haciyanli for his letter related to our recent publication “International Neuromonitoring Study Group Guidelines 2018: Part II: Optimal Recurrent Laryngeal Nerve Management for Invasive Thyroid Cancer Incorporation of Surgical, Laryngeal, and Neural Electrophysiologic Data.” Below is our response to his letter. It is true that surgery usually proceeds with the diseased side first. The specific algorithm (Fig. 3B) referred to is an algorithm for cases with a preoperatively nonfunctioning ipsilateral recurrent laryngeal nerve (RLN) with preoperative vocal cord paralysis (VCP). In such a scenario, the contralateral nerve is the only functioning nerve, so we recommend performing contralateral nerve dissection first. This allows the surgeon the duration of the case for possible recovery from loss of signal (LOS) if LOS is experienced on that side. Thus, the need for a tracheostomy at the end of surgery can be avoided. If the contralateral side is done second, that period of time for LOS recovery would not be available. Again, this applies to patients with a preoperatively nonfunctioning ipsilateral RLN. The second question relates to the algorithm in Figure 4, which describes management for cases with an ipsilateral functioning RLN with positive electromyography (EMG) requiring resection due to invasive disease. We recommend that the surgeon should dissect the ipsilateral RLN sufficient to diagnosis invasion and to confirm the need for RLN resection; the surgeon then confirms that despite that dissection, the RLNhas still maintained a good ipsilateral electrical signal. Thereafter, the surgeon should stop ipsilateral dissection and move to contralateral RLN dissection. If intraoperative neuromonitoring confirms that the contralateral RLN electrical function is preserved, the surgeon can go ahead and resect the ipsilateral nerve. If the contralateral RLN experiences LOS, the surgeon can wait for 20 minutes, and if LOS recovers, he/she can resect the ipsilateral nerve. In the event that the contralateral nerve continues to experience LOS, if the surgeon continues with ipsilateral nerve resection, he/she will risk bilateral VCP and will need to perform a tracheostomy. Hence, we recommend that the surgeon should stage the surgery and allow time for the contralateral RLN to recover, thereby avoiding a tracheostomy. In the Preoperative Patient Counselling and Education section of the article, we described the need for a preoperative discussion with thyroid surgery patients when intraoperative nerve monitoring is employed. It specifically mentions that it is essential to thoroughly discuss the possibility of staging the surgery with these patients during their preoperative visit. We are gratified that there is increasing discussion of intraoperative nerve monitoring in thyroid surgery and how it relates to optimal thyroid cancer care. We feel these guidelines help to provide a better understanding of the application of this technology for optimal RLN management for invasive thyroid cancer.