Clinical outcomes of percutaneous versus peroral intraoperative neuromonitoring strategies in transoral endoscopic thyroidectomy vestibular approach: A retrospective analysis of 2,201 patients.

Abstract

Recurrent laryngeal nerve palsy remains a critical complication in transoral endoscopic thyroidectomy vestibular approach. While intraoperative neuromonitoring is employed, the optimal strategy for reducing vocal cord palsy remains a topic of debate. This large-scale, retrospective cohort study, based on a prospectively collected database, enrolled 2,201 patients who underwent transoral endoscopic thyroidectomy vestibular approach. We compared outcomes among 3 distinct groups: nonintraoperative neuromonitoring (n = 109), peroral intraoperative neuromonitoring (n = 582, year 2016-2019), and percutaneous intraoperative neuromonitoring (n = 1,510, year 2020-May 2025). The peroral and percutaneous groups were further analyzed according to the technique used: intermittent (intermittent intraoperative neuromonitoring) or combined (intermittent intraoperative neuromonitoring + continuous intraoperative neuromonitoring). End points were the incidence of vocal cord palsy and a multivariate analysis of independent risk factors for vocal cord palsy. The 2,092 intraoperative neuromonitoring patients (peroral and percutaneous) were analyzed in 4 subgroups: peroral intermittent intraoperative neuromonitoring (n = 481), peroral combined (intermittent intraoperative neuromonitoring + continuous intraoperative neuromonitoring, n = 101), percutaneous intermittent intraoperative neuromonitoring (n = 1,100), and percutaneous combined (intermittent intraoperative neuromonitoring + continuous intraoperative neuromonitoring, n = 410). Among these, the percutaneous combination (percutaneous-combined) group had a significantly lower temporary vocal cord palsy rate (0.2%) than all other groups (P < .05). This was attributed to higher technical success: percutaneous-combined intraoperative neuromonitoring achieved higher rates of persistent vagus nerve stimulation (99.7% vs 94.4%), a higher detection rate of imminent recurrent laryngeal nerve injury (4.4% vs 0.7%, P < .05), and a higher intraoperative signal recovery rate (88.9% vs 33.3%). Permanent vocal cord palsy was rare (n = 2), occurring only in the peroral groups. Critically, multivariate analysis confirmed that percutaneous combination intraoperative neuromonitoring was an independent protective factor against vocal cord palsy (odds ratio, 0.08; P = .02), whereas thyroid malignancy (odds ratio, 2.02; P = .02) and Graves disease/thyroiditis (odds ratio, 2.19; P = .03) were 2 independent risk factors. This large-scale study confirms that the percutaneous application of combined intermittent intraoperative neuromonitoring and continuous intraoperative neuromonitoring is a safe, feasible, and effective strategy for protecting the recurrent laryngeal nerve in the transoral endoscopic thyroidectomy vestibular approach. It is associated with reduced vocal cord palsy rates and can be considered a viable option, especially for individuals with high-risk thyroid diseases.