Intraoperative neuromonitoring (IONM) during thyroidectomy shows a drop in signal amplitude of the recurrent laryngeal nerve (RLN) by >50% after the first lobe is removed. According to international guidelines (INMSG), what is the recommended next step?

• A Immediately complete the contralateral side to minimize operative time
• B Abandon the contralateral dissection; stage the surgery ✓
• C Apply bipolar cautery closer to the nerve to improve signal
• D Convert to hemithyroidectomy only and accept incomplete resection

Explanation

The International Neural Monitoring Study Group (INMSG) guidelines recommend abandoning the contralateral thyroid dissection (staged thyroidectomy) when IONM detects a loss of signal (LOS) or amplitude drop >50% after the first side. This prevents bilateral RLN injury, which causes bilateral cord paralysis, stridor, and need for tracheostomy. The patient returns for the second stage after 6–12 weeks when nerve recovery is confirmed by laryngoscopy. This decision-making protocol using IONM has significantly reduced the risk of bilateral RLN palsy.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.