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Minimal Invasive Resection of Large Retrosternal Thyroid Goiter

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Systematic Postdissection Vagal Stimulation and Surgical Strategy During Thyroidectomy.

Nadia H Van Den Berg¹, James Griffin¹, Patrick Sheahan^1,2

¹Department of Otolaryngology-Head & Neck Surgery, South Infirmary Victoria University Hospital, Cork, Ireland.

JAMA Otolaryngology-- Head & Neck Surgery

|May 7, 2026

Summary

Systematic V2 stimulation during intraoperative neuromonitoring (IONM) significantly improves sensitivity for detecting vocal cord palsy after thyroidectomy. This method is crucial for preventing bilateral vocal cord palsy by guiding surgical decisions.

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Identification and Protection of the Recurrent Laryngeal Nerve during Transoral Robotic Thyroidectomy

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Area of Science:

Otolaryngology
Surgical Neurology
Endocrinology

Background:

Intraoperative neuromonitoring (IONM) is vital for preventing vocal cord palsy during thyroidectomy.
The International Nerve Monitoring Study Group recommends a specific sequence for recurrent laryngeal nerve (RLN) stimulation.
The utility of V2 (postdissection vagus nerve) stimulation in identifying postoperative vocal cord palsy requires further investigation.

Purpose of the Study:

To evaluate the sensitivity of V2 stimulation compared to R2 stimulation alone for detecting postoperative vocal cord palsy.
To assess the role of systematic V2 stimulation in minimizing the risk of bilateral vocal cord palsy after total thyroidectomy.

Main Methods:

Retrospective cross-sectional study of patients undergoing thyroidectomy with IONM (V1, R1, R2, V2 sequence).
Comparison with a historical cohort using selective vagal nerve stimulation.
Primary outcome: vocal mobility on postoperative day 1; analysis of sensitivity, specificity, PPV, and NPV.

Main Results:

V2 stimulation demonstrated 100% sensitivity for detecting postoperative vocal cord palsy, compared to 57.9% for R2 stimulation.
9 cases with intact R2 and absent V2 response showed 77.8% impaired vocal mobility.
Systematic V2 stimulation showed higher sensitivity (100%) for IONM compared to selective vagal nerve stimulation (83.3%) in prior studies.

Conclusions:

IONM without systematic V2 stimulation has inferior sensitivity in detecting vocal cord palsy.
Systematic V2 stimulation is a more sensitive method for identifying potential nerve injury during thyroidectomy.
Systematic V2 stimulation should be considered the criterion standard to reduce the risk of bilateral vocal cord palsy.