Selective visualization of the recurrent laryngeal nerve during parathyroidectomy

Introduction: Direct visualization of the recurrent laryngeal nerve (RLN) is considered the gold standard for avoiding nerve injury during parathyroidectomy. We hypothesize that with routine intraoperative nerve monitoring (IONM), RLN visualization is not mandatory for safe parathyroidectomy. Methods: Following institutional review board approval, adult patients undergoing parathyroidectomy using IONM during a two-year period were reviewed. The RLN was only visualized if exposed during parathyroid gland dissection. Outcomes included the rate of nerve visualization and rates of RLN injury. Results: 240 of 479 (50.1 ​%) nerves at risk were visualized. There was loss of signal in three cases where the RLN was visually identified and none in non-visualized cases. The rates of temporary and permanent RLN injury were 0.99 ​% and 0 ​%, respectively. Conclusion: Routine IONM provides reassurance of nerve integrity in cases where the RLN is not visualized and an acceptably low rate of RLN injury is achieved with selective visualization.