Intraoperative neural monitoring (IONM) of the recurrent laryngeal nerve during thyroid surgery is used as a real-time guide. What is the MOST important action when continuous IONM shows a sudden loss of signal (LOS) from the RLN on the first side?

• A Continue with contralateral thyroidectomy as IONM findings do not alter surgical decision-making
• B Perform intraoperative laryngoscopy and continue if cords appear normal
• C Switch to non-nerve-sparing technique on the contralateral side to complete the operation quickly
• D Immediately abandon the procedure on that side and stage the contralateral side to prevent bilateral RLN injury ✓

Explanation

Loss of the electromyographic signal on the first side during IONM indicates likely mechanical RLN injury. The critical management decision is to stage the operation — defer completion of the contralateral thyroidectomy — to prevent bilateral RLN injury, which causes bilateral vocal cord paralysis, stridor, and emergency airway crisis. The European Laryngological Society consensus guidelines recommend this staged approach as the single most important benefit of continuous IONM in thyroid surgery.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.