Continuous Intraoperative Nerve Monitoring during Thyroid Surgery: Realistic Utility

Objectives: Intraoperative nerve monitoring (IONM) with intermittent stimulation, can predict recurrent laryngeal nerve injury after the damage has been already done; on the other hand, continuous IONM (CIONM) via stimulation of the vagus nerve (VN) by the automated periodic stimulation (APS) electrode, should permit more reliable monitoring of the nerve's functional integrity during surgery. Methods: The advantages CIONM offers over its intermittent counterpart are indeed related to its ability to provide accurate and real-time feedback to enable the surgeon to act before damage has been inflicted on the nerve. Furthermore, these characteristics do not compromise safety and effectiveness of the surgical procedure. Results: The indications for its use have been progressively expanding, despite the still living surrounding skepticism, and recurrent thyroid disease, thyroidectomy with neck dissection, pre-existing unilateral vocal cord paralysis, previous neck treatment and high risk for intraoperative hemorrhage, represent the main situations with strong indications for CIONM use. Conclusions: This article provides a detailed description of this effective, patient's safety tool. Here we enclose IONM with APS technical and practical steps, in order to give the idea of a clear awareness of its benefits and to encourage surgeons to widen their skills and knowledge about its potential use.